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Li L, Teng J, Kou N, Yue Y, Wang H. ANCA-associated vasculitis and lung cancer: an immunological perspective. Clin Exp Med 2024; 24:208. [PMID: 39230721 PMCID: PMC11374858 DOI: 10.1007/s10238-024-01475-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2024] [Accepted: 08/20/2024] [Indexed: 09/05/2024]
Abstract
Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a severe autoimmune disease that often involves the upper and lower respiratory tracts. In recent years, numerous studies have found a significant increase in the incidence of cancer among AAV patients, but the association between lung cancer and AAV remains inconclusive, with relatively low clinical attention. This review summarizes the current literature on the risk of lung cancer in patients with ANCA-associated vasculitis (AAV), detailing the potential mechanisms by which AAV may contribute to lung cancer, and further elucidates the inherent carcinogenic risks of immunosuppressants.There is a correlation between AAV and lung cancer, which is related to T cell senescence and damage, as well as the abnormal expression of cytokines such as IL-6 and IL-10. In AAV patients, the use of cyclophosphamide and azathioprine (AZA) alone has a clear carcinogenic risk, with frequent use of CYC potentially posing a high risk for lung cancer. Although TNF inhibitors (TNFi) combined with CYC have carcinogenic risks, there is insufficient evidence to link them directly to an increased risk of lung cancer. For patients at high risk for lung cancer, the judicious use of immunosuppressants, timely computed tomography (CT), and lung cancer screening can reduce the risk of lung cancer in AAV patients.
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Affiliation(s)
- Longzhao Li
- Respiratory Disease Center, Dongzhimen Hospital, Beijing University of Chinese Medicine, No.116 Cuiping West Road, Tongzhou District, 101121, Beijing, China
- Beijing University of Traditional Chinese Medicine, Beijing, China
| | - Jun Teng
- Respiratory Disease Center, Dongzhimen Hospital, Beijing University of Chinese Medicine, No.116 Cuiping West Road, Tongzhou District, 101121, Beijing, China
- Beijing University of Traditional Chinese Medicine, Beijing, China
| | - Na Kou
- Respiratory Disease Center, Dongzhimen Hospital, Beijing University of Chinese Medicine, No.116 Cuiping West Road, Tongzhou District, 101121, Beijing, China
| | - Yuan Yue
- Respiratory Disease Center, Dongzhimen Hospital, Beijing University of Chinese Medicine, No.116 Cuiping West Road, Tongzhou District, 101121, Beijing, China
| | - HongWu Wang
- Respiratory Disease Center, Dongzhimen Hospital, Beijing University of Chinese Medicine, No.116 Cuiping West Road, Tongzhou District, 101121, Beijing, China.
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Yoshii R, Kajiwara K, Uemura N, Matsushita K, Nakamura T, Tomita M, Mukoyama M. The successful treatment of microscopic polyangiitis associated with non-tuberculous mycobacterial-pulmonary disease. CEN Case Rep 2024; 13:271-276. [PMID: 38066231 PMCID: PMC11294296 DOI: 10.1007/s13730-023-00839-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 11/06/2023] [Indexed: 08/02/2024] Open
Abstract
While the incidence and prevalence of non-tuberculous mycobacterial-pulmonary disease (NTM-PD) are increasing and microscopic polyangiitis (MPA) is common in East Asian countries, case reports of MPA associated with NTM-PD are limited. A 72-year-old male receiving treatment for NTM-PD with antibiotics was referred to our hospital with fever and arthralgia that developed a few months previously. A blood test revealed the presence of the myeloperoxidase antineutrophil cytoplasmic antibody (MPO-ANCA) and renal impairment. Based on a pathological examination of renal tissue, which showed crescentic glomerulonephritis, the patient was diagnosed with MPA. Due to acute kidney injury and strongly positive MPO-ANCA, pulse steroid therapy was initiated followed by intravenous rituximab (RTX). The patient also received plasmapheresis (14 sessions). Renal dysfunction was reversed. MPA associated with NTM-PD is extremely rare and, thus, there is currently no established treatment. Our patient was diagnosed with MPA based on the findings of renal biopsy while receiving treatment for NTM-PD. RTX and plasmapheresis combined with systemic glucocorticoid therapy were initiated before these clinical conditions had fully recovered. Although MPA secondary to NTM-PD may be more refractory to treatment than primary MPA in the presence of a very low interferon-gamma (IFN-γ) level, this case was successfully treated with steroids, RTX, and plasmapheresis.
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Affiliation(s)
- Ryuichi Yoshii
- NHO Kumamoto Medical Center, 1-5 Ninomaru, Kumamoto, Kumamoto, Japan.
| | - Kengo Kajiwara
- NHO Kumamoto Medical Center, 1-5 Ninomaru, Kumamoto, Kumamoto, Japan
| | - Naomichi Uemura
- NHO Kumamoto Medical Center, 1-5 Ninomaru, Kumamoto, Kumamoto, Japan
| | - Koki Matsushita
- NHO Kumamoto Medical Center, 1-5 Ninomaru, Kumamoto, Kumamoto, Japan
| | - Tomohumi Nakamura
- NHO Kumamoto Medical Center, 1-5 Ninomaru, Kumamoto, Kumamoto, Japan
| | - Masao Tomita
- NHO Kumamoto Medical Center, 1-5 Ninomaru, Kumamoto, Kumamoto, Japan
| | - Masashi Mukoyama
- Kumamoto University Hospital, 1-1-1 Honjo, Kumamoto, Kumamoto, Japan
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Masiak A, Jassem E, Dębska-Ślizień A, Bułło-Piontecka B, Kowalska B, Chmielewski M. Co-existence of ANCA-associated vasculitides with immune-mediated diseases: a single-center observational study. Rheumatol Int 2024; 44:1521-1528. [PMID: 38914775 PMCID: PMC11222238 DOI: 10.1007/s00296-024-05631-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Accepted: 05/28/2024] [Indexed: 06/26/2024]
Abstract
BACKGROUND Antineutrophil cytoplasmic antibody-associated vasculitides (AAV) is a group of systemic necrotizing small vessel autoimmune diseases, with microscopic polyangiitis (MPA) and granulomatosis with polyangiitis (GPA) being the two most common. The co-existence of AAV with different immune-mediated diseases (autoimmune disesases - AID) might affect the clinical presentation of the primary disease. The purpose of the study was to assess the co-existence of AAV with AID and to investigate whether it affects the characteristics and the course of AAV. METHODS A retrospective single-center study was performed to identify patients with a diagnosis of MPA or GPA and concomitant AID, and to investigate their clinical features and characteristics. The group consisted of consecutive unselected AAV patients treated at a large university-based hospital, since 1988 with follow-up until 2022. RESULTS Among 284 patients diagnosed either with GPA (232) or MPA (52), 40 (14,1%) had co-existing AIDs. The most frequent were: Hashimoto thyroiditis (16 cases), rheumatoid arthritis (8 cases), followed by psoriasis (6 cases), pernicious anemia (3 cases), and alopecia (3 cases). Patients with autoimmune comorbidities had a significantly longer time between the onset of symptoms and the diagnosis (26 vs. 11 months, p < 0.001). Laryngeal involvement (20.0% vs. 9.0%, p = 0,05), peripheral nervous system disorders (35.0% vs. 13.9%, p < 0.001), and neoplasms (20.0% vs. 8.6%, p = 0,044) were more common in patients with AID comorbidities, compared to subjects without AID. In contrast, renal involvement (45.0% vs. 70.9%, p = 0.001) and nodular lung lesions (27.5% vs. 47.5%, p = 0.044) were significantly less frequent in patients with co-morbidities. Following EUVAS criteria, patients with autoimmune co-morbidities had a generalized form of the disease without organ involvement (52.5% vs. 27.2%, p = 0.007), while the others had a higher percentage of generalized form with organ involvement (38.3% vs. 20.0%, p = 0.007). CONCLUSIONS The coexistence of AAV with different autoimmune diseases is not common, but it might affect the clinical course of the disease. Polyautoimmunity prolonged the time to diagnosis, but the AAV course seemed to be milder. Particular attention should be paid to the increased risk of cancer in these patients. It also seems reasonable that AAV patients should receive a serological screening to exclude the development of overlapping diseases.
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Affiliation(s)
- Anna Masiak
- Department of Rheumatology, Clinical Immunology, Geriatrics and Internal Medicine, Medical University of Gdansk, Gdańsk, Poland.
| | - Ewa Jassem
- Department of Pulmonology and Allergology, Medical University of Gdansk, Gdańsk, Poland
| | - Alicja Dębska-Ślizień
- Department of Nephrology, Transplantology and Internal Diseases, Medical University of Gdansk, Gdańsk, Poland
| | - Barbara Bułło-Piontecka
- Department of Nephrology, Transplantology and Internal Diseases, Medical University of Gdansk, Gdańsk, Poland
| | - Bożena Kowalska
- Department of Otolaryngology, Medical University of Gdansk, Gdańsk, Poland
| | - Michał Chmielewski
- Department of Rheumatology, Clinical Immunology, Geriatrics and Internal Medicine, Medical University of Gdansk, Gdańsk, Poland
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Bilgin E, Demirci Yıldırım T, Özdemir Ulusoy B, Öğüt TS, Karabacak M, Sadioğlu Çağdaş Ö, Yıldırım R, Güven DC, Akleylek C, Ediboğlu E, Kutu ME, Özgür D, Kardaş RC, Bölek EÇ, Sandal Uzun G, Özsoy Z, Sarıyıldız E, Ayan G, Armağan B, Erden A, Kılıç L, Erbasan F, Alibaz-Öner F, Aşıcıoğlu E, Yazıcı A, Bilge NŞ, Küçük H, Çelik S, Bes C, Akar S, Yılmaz N, Kaşifoglu T, Cefle A, Direskeneli H, Yazısız V, Dizdar Ö, Omma A, Önen F, Karadağ Ö. Unveiling cancer risk in ANCA-associated vasculitis: result from the Turkish Vasculitis Study Group (TRVaS). Intern Emerg Med 2024; 19:1025-1034. [PMID: 38553624 PMCID: PMC11186896 DOI: 10.1007/s11739-024-03577-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 03/05/2024] [Indexed: 05/31/2024]
Abstract
To investigate cancer incidence in patients with ANCA-associated vasculitis (AAV), compare it with the age/sex-specific cancer risk of the Turkish population, and explore independent risk factors associated with cancer. This multicenter, incidence case-control study was conducted using the TRVaS registry. AAV patients without cancer history before AAV diagnosis were included. Demographic and AAV-related data of patients with and without an incident cancer were compared. Standardized cancer incidence rates were calculated using age-/sex-specific 2017 Turkish National Cancer Registry data for cancers (excluding non-melanoma skin cancers). Cox regression was performed to find factors related to incident cancers in AAV patients. Of 461 AAV patients (236 [51.2%] male), 19 had incident cancers after 2022.8 patient-years follow-up. Median (IQR) disease duration was 3.4 (5.5) years, and 58 (12.6%) patients died [7 with cancer and one without cancer (log-rank, p = 0.04)]. Cancer-diagnosed patients were older, mostly male, and more likely to have anti-PR3-ANCA positivity. The cumulative cyclophosphamide dose was similar in patients with and without cancer. Overall cancer risk in AAV was 2.1 (SIR) ((1.3-3.2), p = 0.004); lung and head-neck [primary target sites for AAV] cancers were the most common. In Cox regression, male sex and ≥ 60 years of age at AAV diagnosis were associated with increased cancer risk, while receiving rituximab was associated with decreased cancer risk. Cancer risk was 2.1 times higher in AAV patients than the age-/sex-specific cancer risk of the Turkish population population, despite a high rate of rituximab use and lower dose of cyclophosphamide doses. Vigilance in cancer screening for AAV patients covering lung, genitourinary, and head-neck regions, particularly in males and the elderly, is vital.
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Affiliation(s)
- Emre Bilgin
- Faculty of Medicine, Division of Rheumatology, Hacettepe University, Ankara, Turkey
- Hacettepe Vasculitis Research Center, Ankara, Turkey
| | - Tuba Demirci Yıldırım
- Faculty of Medicine, Division of Rheumatology, Dokuz Eylul University, İzmir, Turkey
| | | | - Tahir Saygın Öğüt
- Faculty of Medicine, Division of Rheumatology, Akdeniz University, Antalya, Turkey
| | - Murat Karabacak
- Faculty of Medicine, Division of Rheumatology, Marmara University, Istanbul, Turkey
| | | | - Reşit Yıldırım
- Faculty of Medicine, Division of Rheumatology, Eskişehir Osmangazi University, Eskişehir, Turkey
| | - Deniz Can Güven
- Division of Medical Oncology, Elazığ Fethi Sekin City Hospital, Elazığ, Turkey
| | - Cansu Akleylek
- Faculty of Medicine, Division of Rheumatology, Demiroğlu Bilim University, Istanbul, Turkey
| | - Elif Ediboğlu
- Faculty of Medicine, Division of Rheumatology, Katip Çelebi University, İzmir, Turkey
| | - Muhammet Emin Kutu
- Division of Rheumatology, Bakırköy Sadi Konuk City Hospital, Istanbul, Turkey
| | - Duygu Özgür
- Division of Rheumatology, Başakşehir Çam Sakura City Hospital, Istanbul, Turkey
| | - Rıza Can Kardaş
- Faculty of Medicine, Division of Rheumatology, Gazi University, Ankara, Turkey
| | - Ertuğrul Çağrı Bölek
- Faculty of Medicine, Division of Rheumatology, Hacettepe University, Ankara, Turkey
- Hacettepe Vasculitis Research Center, Ankara, Turkey
| | - Güllü Sandal Uzun
- Faculty of Medicine, Division of Rheumatology, Hacettepe University, Ankara, Turkey
- Hacettepe Vasculitis Research Center, Ankara, Turkey
| | - Zehra Özsoy
- Faculty of Medicine, Division of Rheumatology, Hacettepe University, Ankara, Turkey
- Hacettepe Vasculitis Research Center, Ankara, Turkey
| | - Emine Sarıyıldız
- Faculty of Medicine, Division of Rheumatology, Hacettepe University, Ankara, Turkey
- Hacettepe Vasculitis Research Center, Ankara, Turkey
| | - Gizem Ayan
- Faculty of Medicine, Division of Rheumatology, Hacettepe University, Ankara, Turkey
- Hacettepe Vasculitis Research Center, Ankara, Turkey
| | - Berkan Armağan
- Division of Rheumatology, Ankara City Hospital, Ankara, Turkey
| | - Abdulsamet Erden
- Faculty of Medicine, Division of Rheumatology, Gazi University, Ankara, Turkey
| | - Levent Kılıç
- Faculty of Medicine, Division of Rheumatology, Hacettepe University, Ankara, Turkey
- Hacettepe Vasculitis Research Center, Ankara, Turkey
| | - Funda Erbasan
- Faculty of Medicine, Division of Rheumatology, Akdeniz University, Antalya, Turkey
| | - Fatma Alibaz-Öner
- Faculty of Medicine, Division of Rheumatology, Marmara University, Istanbul, Turkey
| | - Ebru Aşıcıoğlu
- Faculty of Medicine, Division of Rheumatology, Marmara University, Istanbul, Turkey
| | - Ayten Yazıcı
- Faculty of Medicine, Division of Rheumatology, Kocaeli University, Kocaeli, Turkey
| | - Nazife Şule Bilge
- Faculty of Medicine, Division of Rheumatology, Eskişehir Osmangazi University, Eskişehir, Turkey
| | - Hamit Küçük
- Faculty of Medicine, Division of Rheumatology, Gazi University, Ankara, Turkey
| | - Selda Çelik
- Division of Rheumatology, Bakırköy Sadi Konuk City Hospital, Istanbul, Turkey
| | - Cemal Bes
- Division of Rheumatology, Başakşehir Çam Sakura City Hospital, Istanbul, Turkey
| | - Servet Akar
- Faculty of Medicine, Division of Rheumatology, Katip Çelebi University, İzmir, Turkey
| | - Neslihan Yılmaz
- Faculty of Medicine, Division of Rheumatology, Demiroğlu Bilim University, Istanbul, Turkey
| | - Timucin Kaşifoglu
- Faculty of Medicine, Division of Rheumatology, Eskişehir Osmangazi University, Eskişehir, Turkey
| | - Ayse Cefle
- Faculty of Medicine, Division of Rheumatology, Kocaeli University, Kocaeli, Turkey
| | - Haner Direskeneli
- Faculty of Medicine, Division of Rheumatology, Marmara University, Istanbul, Turkey
| | - Veli Yazısız
- Faculty of Medicine, Division of Rheumatology, Akdeniz University, Antalya, Turkey
| | - Ömer Dizdar
- Faculty of Medicine, Division of Medical Oncology, Hacettepe University, Ankara, Turkey
| | - Ahmet Omma
- Division of Rheumatology, Ankara City Hospital, Ankara, Turkey
| | - Fatoş Önen
- Faculty of Medicine, Division of Rheumatology, Dokuz Eylul University, İzmir, Turkey
| | - Ömer Karadağ
- Faculty of Medicine, Division of Rheumatology, Hacettepe University, Ankara, Turkey.
- Hacettepe Vasculitis Research Center, Ankara, Turkey.
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Han XY, Li ZY, Zhao MH, Little MA, Chen M. Malignancy is increased in patients with antineutrophil cytoplasmic antibody-associated vasculitis in China. Arthritis Res Ther 2024; 26:113. [PMID: 38822382 PMCID: PMC11140968 DOI: 10.1186/s13075-024-03345-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 05/24/2024] [Indexed: 06/03/2024] Open
Abstract
OBJECTIVE It has been reported that in western countries malignancy risk was higher in patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) compared with that in the general population. In the current study, we investigated the incidence, spectrum and risk factors of malignancy in Chinese AAV patients. METHODS AAV patients diagnosed from 1995 to 2021 in Peking University First Hospital with a follow-up more than 12 months were recruited. Standardized incidence ratios (SIR) were calculated to describe the risk of malignancy, adjusted for sex, age and follow-up time. RESULTS A total of 552 AAV patients were recruited, among which 23 patients had malignancies either preceding or concurrent with AAV diagnosis, and 43 of the remaining 529 patients developed malignancies within 4.3 ± 4.2 years post AAV diagnosis (SIR: 2.24; 95% CI: 1.68-2.99; p < 0.001). Among these 66 patients, twenty different sites of malignancy were observed, lung cancer being most frequent. To get exactly expected malignancies for the calculation of SIR, 529 patients without preceding or concurrent malignancies were included in the following analysis. Lung cancer was still the leading malignancy diagnosis (SIR: 5.01; 95% CI: 3.29-7.62), followed by malignancies in the kidney, bladder, ureter and prostate. Male gender (HR:2.84; 95%CI:1.36-5.96; p = 0.006) and older age (per year, HR:1.04; 95%CI:1.00-1.07; p = 0.038) were significantly associated with increased risk of malignancy. For patients with malignancy developed beyond 5 years after the diagnosis of AAV, a significantly higher malignancy risk was observed in those with a cumulative cyclophosphamide dose over 20.0 g (SIR: 11.54; 95% CI: 4.77-27.93; p < 0.001). Within the first 2 years after the diagnosis of AAV, the risk of malignancy was still significantly higher than that in the general population, but the cumulative cyclophosphamide dose was not significantly associated with malignancy occurrence in this subgroup of patients. CONCLUSIONS Malignancy risk is higher in Chinese AAV patients than that in the general population, with a different malignancy spectrum from western countries. Both the use of cyclophosphamide and AAV per se might be associated with higher incidence of malignancy occurrence.
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Affiliation(s)
- Xiang-Yu Han
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, 100034, China
| | - Zhi-Ying Li
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, 100034, China.
| | - Ming-Hui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, 100034, China
| | - Mark A Little
- Trinity Kidney Centre, Trinity Translational Medicine Institute, Trinity College Dublin, Irish Centre for Vascular Biology, Trinity College Dublin, Dublin, Ireland
| | - Min Chen
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, 100034, China
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Sharma P, Zonozi R, Geetha D. ANCA-Associated Vasculitis. ADVANCES IN KIDNEY DISEASE AND HEALTH 2024; 31:194-205. [PMID: 39004459 DOI: 10.1053/j.akdh.2024.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 04/19/2024] [Accepted: 04/24/2024] [Indexed: 07/16/2024]
Abstract
ANCA-associated vasculitis (AAV) is a necrotizing, small-to-medium vessel vasculitis associated with significant morbidity and mortality. AAV is a systemic autoimmune disease affecting kidneys, eyes, sinuses, peripheral nerves, skin, and upper and lower respiratory tracts. AAV tends to present in characteristic phenotypes categorized clinically as granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic GPA (EGPA). Kidney involvement is a common feature of AAV, and has important implications on disease prognosis and management. Existing therapies have been refined and improvements in our understanding of the pathophysiology of AAV has led to approval of novel therapies. In this review, we provide an overview of epidemiology, disease mechanisms, clinical presentation and review therapeutic strategies for induction and maintenance of remission.
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Affiliation(s)
- Purva Sharma
- Division of Kidney Disease and Hypertension, Northwell Health, The Glomerular Disease Center at Northwell Health.
| | - Reza Zonozi
- Nephrology Associates of Northern Virginia, Fairfax, VA; Inova Fairfax Hospital, Falls Church, VA
| | - Duvuru Geetha
- Division of Nephrology, Johns Hopkins University School of Medicine
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Potentas-Policewicz M, Szolkowska M, Blasinska K, Gawryluk D, Sobiecka M, Fijolek J. Lung cancer in older patients with granulomatosis with polyangiitis: a report of three cases. BMC Pulm Med 2024; 24:193. [PMID: 38649886 PMCID: PMC11034167 DOI: 10.1186/s12890-024-03024-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 04/18/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND Granulomatosis with polyangiitis (GPA) is characterized by necrotizing granulomatous inflammation with necrotizing vasculitis predominantly affecting small to medium vessels. The survival rates have drastically improved; however, GPA can be lethal, with older patients having a worse prognosis and higher mortality than younger patients. Moreover, the incidence of various cancers has been reported to increase in patients with GPA. We aimed to discuss possible associations between GPA and lung cancer and emphasize the associated diagnostic challenges. CASE PRESENTATION We encountered three older patients with chronic GPA who developed lung cancer during long-term follow-up. Two of the patients had a smoking history, with one having silicosis and the other having chronic obstructive pulmonary disease. Furthermore, all of them had radiation exposure from repeated radiography/computed tomography. All the patients had confirmed GPA, and vasculitis relapse was first suspected when new lung lesions were noted during follow-up. However, they had no new clinical symptoms, and serum ANCA titer increased only in one patient. All the patients received standard immunosuppressive treatment but eventually died. CONCLUSIONS Lung cancer is uncommon in patients with GPA; however, the similarity between the imaging findings of lung cancer and GPA may pose a diagnostic challenge. Clinicians should be particularly vigilant when treating older patients with an increased risk of cancer, as they are often asymptomatic or have poorly apparent clinical features.
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Affiliation(s)
| | - Malgorzata Szolkowska
- Department of Pathology, National Tuberculosis and Lung Diseases Research Institute, Warsaw, Poland
| | - Katarzyna Blasinska
- Department of Radiology, National Tuberculosis and Lung Diseases Research Institute, Warsaw, Poland
| | - Dariusz Gawryluk
- The Third Department of Pneumonology and Oncology, National Tuberculosis and Lung Diseases Research Institute, Warsaw, Poland
| | - Malgorzata Sobiecka
- The First Department of Pneumonology, National Tuberculosis and Lung Diseases Research Institute, Warsaw, Poland
| | - Justyna Fijolek
- The Third Department of Pneumonology and Oncology, National Tuberculosis and Lung Diseases Research Institute, Warsaw, Poland.
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8
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Li JJ, Chen L, Zhao Y, Yang XQ, Hu FB, Wang L. Data mining and safety analysis of traditional immunosuppressive drugs: a pharmacovigilance investigation based on the FAERS database. Expert Opin Drug Saf 2024; 23:513-525. [PMID: 38533933 DOI: 10.1080/14740338.2024.2327503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 10/13/2023] [Indexed: 03/28/2024]
Abstract
OBJECTIVE The purpose of this study aimed to explore the new and serious adverse events(AEs) of Tacrolimus(FK506), cyclosporine(CsA), azathioprine(AZA), mycophenolate mofetil(MMF), cyclophosphamide(CTX) and methotrexate(MTX), which have not been concerned. METHODS The FAERS data from January 2016 and December 2022 were selected for disproportionality analysis to discover the potential risks of traditional immunosuppressive drugs. RESULTS Compared with CsA, FK506 has more frequent transplant rejection, and is more related to renal impairment, COVID-19, cytomegalovirus infection and aspergillus infection. However, CsA has a high infection-related fatality rate. In addition, we also found some serious and rare AE in other drugs which were rarely reported in previous studies. For example, AZA is closely related to hepatosplenic T-cell lymphoma with high fatality rate and MTX is strongly related to hypofibrinogenemia. CONCLUSION The AEs report on this study confirmed that the results were basically consistent with the previous studies, but there were also some important safety signals that were inconsistent with or not mentioned in previous published studies. EXPERT OPINION The opinion section discusses some of the limitations and shortcomings, proposing the areas where more effort should be invested in order to improve the safety of immunosuppressive drugs.
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Affiliation(s)
- Juan-Juan Li
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Ministry of Education, Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Chengdu, Sichuan, China
- Department of Pharmacy, Guangyuan Central Hospital, Guanyuan, Sichuan, China
| | - Li Chen
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Ministry of Education, Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Chengdu, Sichuan, China
| | - Yang Zhao
- Department of Pharmacy, Guangyuan Central Hospital, Guanyuan, Sichuan, China
| | - Xue-Qin Yang
- Department of Pharmacy, Guangyuan Central Hospital, Guanyuan, Sichuan, China
| | - Fa-Bin Hu
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Ministry of Education, Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Chengdu, Sichuan, China
- Department of Pharmacy, Jinniu Maternity and Child Health Hospital of Chengdu, Chengdu, Sichuan, China
| | - Li Wang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Ministry of Education, Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Chengdu, Sichuan, China
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Thet Z, Lam AKY, Ng SK, Aung SY, Han T, Ranganathan D, Newsham S, Borg J, Pepito C, Khoo TK. Comparison of skin cancer risk between renal transplant recipients and patients with glomerular diseases in rural Queensland. Aust J Rural Health 2024; 32:249-262. [PMID: 38646861 DOI: 10.1111/ajr.13081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 11/09/2023] [Accepted: 01/07/2024] [Indexed: 04/23/2024] Open
Abstract
INTROUDCTION There is increased risk of skin cancer in patients with gloermular disease or those with renal transplant. OBJECTIVES To compare the risk of skin cancer between kidney recipients (KTRs) and patients with glomerular disease (GD). DESIGN The cohort comprised patients with KTRs (n = 61) and GD (n = 51) in Central and Central West Queensland, Australia. A quantitative cohort study was undertaken to study the risk of skin cancer in rural communities between two subgroups of patients with kidney diseases in relationship to immunosuppression. Statistical analyses of the differences in incidence of skin cancers between the two groups were done by chi-square test, Fisher's exact test, independent t-test and McNemar's test. FINDINGS KTRs with non-melanoma skin carcinoma (NMSC) increased significantly after treatment with immunosuppressants (pre-transplantation, n = 11 [18.0%], post-transplantation, n = 28 [45.9%]; p < 0.001). There were no differences in number of patients with NMSC observed in the GD group (pre-diagnosis, n = 6 [11.8%], post-diagnosis, n = 7 [13.7%]; p = 1.000). Compared to the risks at 1 year post-immunosuppressants, the incidence of NMSC of KTRs increased significantly at 3 years (20.3% vs. 35.4%, p < 0.001) and 5 years (20.3% vs. 62.2%, p < 0.001) post-immunosuppressants, whereas the increased incidence of NMSC was observed only at 5 years (2.1% vs. 11.8%, p = 0.012) in the GD cohort. The mean cumulative number of NMSC in KTRs increased significantly at 3 years (p = 0.011), and 5 years (p = 0.001) post-immunosuppressants, compared to the risks at 1 year post-immunosuppressants, however, no differences were noted in the GD cohort. DISCUSSION Immunosuppressants increased the risk of NMSC in KTRs. The increased risk is likely dependent on the intensity and duration of immunosuppressants. CONCLUSION In patients with a high risk of NMSC, reducing skin cancer risk should be considered in conjunction with the optimisation of treatment.
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Affiliation(s)
- Zaw Thet
- School of Medicine and Dentistry, Griffith University, Gold Coast, Queensland, Australia
- Department of Nephrology, Central Queensland Hospital and Health Service, Rockhampton, Queensland, Australia
| | - Alfred King-Yin Lam
- School of Medicine and Dentistry, Griffith University, Gold Coast, Queensland, Australia
- Faculty of Medicine, University of Queensland, Herston, Queensland, Australia
- Pathology Queensland, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Shu-Kay Ng
- School of Medicine and Dentistry, Griffith University, Gold Coast, Queensland, Australia
| | - Soe Yu Aung
- Faculty of Medicine, University of Queensland, Herston, Queensland, Australia
- Department of Oncology, Central Queensland Hospital and Health Service, Rockhampton, Queensland, Australia
| | - Thin Han
- Department of Nephrology, Central Queensland Hospital and Health Service, Rockhampton, Queensland, Australia
- Faculty of Medicine, University of Queensland, Herston, Queensland, Australia
| | - Dwarakanathan Ranganathan
- School of Medicine and Dentistry, Griffith University, Gold Coast, Queensland, Australia
- Department of Nephrology, Metro North Hospital and Health Service, Herston, Queensland, Australia
| | - Stephanie Newsham
- Department of Nephrology, Central Queensland Hospital and Health Service, Rockhampton, Queensland, Australia
| | - Jennifer Borg
- Department of Nephrology, Central Queensland Hospital and Health Service, Rockhampton, Queensland, Australia
| | - Christine Pepito
- Department of Nephrology, Central Queensland Hospital and Health Service, Rockhampton, Queensland, Australia
| | - Tien K Khoo
- School of Medicine and Dentistry, Griffith University, Gold Coast, Queensland, Australia
- School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia
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10
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Cui H, Zhang W, Zhang L, Qu Y, Xu Z, Tan Z, Yan P, Tang M, Yang C, Wang Y, Chen L, Xiao C, Zou Y, Liu Y, Zhang L, Yang Y, Yao Y, Li J, Liu Z, Yang C, Jiang X, Zhang B. Risk factors for prostate cancer: An umbrella review of prospective observational studies and mendelian randomization analyses. PLoS Med 2024; 21:e1004362. [PMID: 38489391 PMCID: PMC10980219 DOI: 10.1371/journal.pmed.1004362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 03/29/2024] [Accepted: 02/16/2024] [Indexed: 03/17/2024] Open
Abstract
BACKGROUND The incidence of prostate cancer is increasing in older males globally. Age, ethnicity, and family history are identified as the well-known risk factors for prostate cancer, but few modifiable factors have been firmly established. The objective of this study was to identify and evaluate various factors modifying the risk of prostate cancer reported in meta-analyses of prospective observational studies and mendelian randomization (MR) analyses. METHODS AND FINDINGS We searched PubMed, Embase, and Web of Science from the inception to January 10, 2022, updated on September 9, 2023, to identify meta-analyses and MR studies on prostate cancer. Eligibility criteria for meta-analyses were (1) meta-analyses including prospective observational studies or studies that declared outcome-free at baseline; (2) evaluating the factors of any category associated with prostate cancer incidence; and (3) providing effect estimates for further data synthesis. Similar criteria were applied to MR studies. Meta-analysis was repeated using the random-effects inverse-variance model with DerSimonian-Laird method. Quality assessment was then conducted for included meta-analyses using AMSTAR-2 tool and for MR studies using STROBE-MR and assumption evaluation. Subsequent evidence grading criteria for significant associations in meta-analyses contained sample size, P values and 95% confidence intervals, 95% prediction intervals, heterogeneity, and publication bias, assigning 4 evidence grades (convincing, highly suggestive, suggestive, or weak). Significant associations in MR studies were graded as robust, probable, suggestive, or insufficient considering P values and concordance of effect directions. Finally, 92 selected from 411 meta-analyses and 64 selected from 118 MR studies were included after excluding the overlapping and outdated studies which were published earlier and contained fewer participants or fewer instrument variables for the same exposure. In total, 123 observational associations (45 significant and 78 null) and 145 causal associations (55 significant and 90 null) were categorized into lifestyle; diet and nutrition; anthropometric indices; biomarkers; clinical variables, diseases, and treatments; and environmental factors. Concerning evidence grading on significant associations, there were 5 highly suggestive, 36 suggestive, and 4 weak associations in meta-analyses, and 10 robust, 24 probable, 4 suggestive, and 17 insufficient causal associations in MR studies. Twenty-six overlapping factors between meta-analyses and MR studies were identified, with consistent significant effects found for physical activity (PA) (occupational PA in meta: OR = 0.87, 95% CI: 0.80, 0.94; accelerator-measured PA in MR: OR = 0.49, 95% CI: 0.33, 0.72), height (meta: OR = 1.09, 95% CI: 1.06, 1.12; MR: OR = 1.07, 95% CI: 1.01, 1.15, for aggressive prostate cancer), and smoking (current smoking in meta: OR = 0.74, 95% CI: 0.68, 0.80; smoking initiation in MR: OR = 0.91, 95% CI: 0.86, 0.97). Methodological limitation is that the evidence grading criteria could be expanded by considering more indices. CONCLUSIONS In this large-scale study, we summarized the associations of various factors with prostate cancer risk and provided comparisons between observational associations by meta-analysis and genetically estimated causality by MR analyses. In the absence of convincing overlapping evidence based on the existing literature, no robust associations were identified, but some effects were observed for height, physical activity, and smoking.
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Affiliation(s)
- Huijie Cui
- Department of Epidemiology and Biostatistics, Institute of Systems Epidemiology, and West China-PUMC C. C. Chen Institute of Health, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Wenqiang Zhang
- Department of Epidemiology and Biostatistics, Institute of Systems Epidemiology, and West China-PUMC C. C. Chen Institute of Health, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Li Zhang
- Department of Epidemiology and Biostatistics, Institute of Systems Epidemiology, and West China-PUMC C. C. Chen Institute of Health, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yang Qu
- Department of Epidemiology and Biostatistics, Institute of Systems Epidemiology, and West China-PUMC C. C. Chen Institute of Health, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zhengxing Xu
- Department of Epidemiology and Biostatistics, Institute of Systems Epidemiology, and West China-PUMC C. C. Chen Institute of Health, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zhixin Tan
- Department of Epidemiology and Biostatistics, Institute of Systems Epidemiology, and West China-PUMC C. C. Chen Institute of Health, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Peijing Yan
- Department of Epidemiology and Biostatistics, Institute of Systems Epidemiology, and West China-PUMC C. C. Chen Institute of Health, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Mingshuang Tang
- Department of Epidemiology and Biostatistics, Institute of Systems Epidemiology, and West China-PUMC C. C. Chen Institute of Health, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Chao Yang
- Department of Epidemiology and Biostatistics, Institute of Systems Epidemiology, and West China-PUMC C. C. Chen Institute of Health, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yutong Wang
- Department of Epidemiology and Biostatistics, Institute of Systems Epidemiology, and West China-PUMC C. C. Chen Institute of Health, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Lin Chen
- Department of Epidemiology and Biostatistics, Institute of Systems Epidemiology, and West China-PUMC C. C. Chen Institute of Health, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Chenghan Xiao
- Department of Maternal, Child and Adolescent Health, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Yanqiu Zou
- Department of Epidemiology and Biostatistics, Institute of Systems Epidemiology, and West China-PUMC C. C. Chen Institute of Health, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yunjie Liu
- Department of Epidemiology and Biostatistics, Institute of Systems Epidemiology, and West China-PUMC C. C. Chen Institute of Health, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ling Zhang
- Department of Iatrical Polymer Material and Artificial Apparatus, School of Polymer Science and Engineering, Sichuan University, Chengdu, China
| | - Yanfang Yang
- Department of Epidemiology and Biostatistics, Institute of Systems Epidemiology, and West China-PUMC C. C. Chen Institute of Health, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yuqin Yao
- Department of Occupational and Environmental Health, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Jiayuan Li
- Department of Epidemiology and Biostatistics, Institute of Systems Epidemiology, and West China-PUMC C. C. Chen Institute of Health, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zhenmi Liu
- Department of Maternal, Child and Adolescent Health, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Chunxia Yang
- Department of Epidemiology and Biostatistics, Institute of Systems Epidemiology, and West China-PUMC C. C. Chen Institute of Health, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xia Jiang
- Department of Epidemiology and Biostatistics, Institute of Systems Epidemiology, and West China-PUMC C. C. Chen Institute of Health, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Nutrition and Food Hygiene, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Ben Zhang
- Hainan General Hospital and Hainan Affiliated Hospital, Hainan Medical University, Haikou, China; West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
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11
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Hellmich B, Sanchez-Alamo B, Schirmer JH, Berti A, Blockmans D, Cid MC, Holle JU, Hollinger N, Karadag O, Kronbichler A, Little MA, Luqmani RA, Mahr A, Merkel PA, Mohammad AJ, Monti S, Mukhtyar CB, Musial J, Price-Kuehne F, Segelmark M, Teng YKO, Terrier B, Tomasson G, Vaglio A, Vassilopoulos D, Verhoeven P, Jayne D. EULAR recommendations for the management of ANCA-associated vasculitis: 2022 update. Ann Rheum Dis 2024; 83:30-47. [PMID: 36927642 DOI: 10.1136/ard-2022-223764] [Citation(s) in RCA: 132] [Impact Index Per Article: 132.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 02/21/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND Since the publication of the EULAR recommendations for the management of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) in 2016, several randomised clinical trials have been published that have the potential to change clinical care and support the need for an update. METHODS Using EULAR standardised operating procedures, the EULAR task force undertook a systematic literature review and sought opinion from 20 experts from 16 countries. We modified existing recommendations and created new recommendations. RESULTS Four overarching principles and 17 recommendations were formulated. We recommend biopsies and ANCA testing to assist in establishing a diagnosis of AAV. For remission induction in life-threatening or organ-threatening AAV, we recommend a combination of high-dose glucocorticoids (GCs) in combination with either rituximab or cyclophosphamide. We recommend tapering of the GC dose to a target of 5 mg prednisolone equivalent/day within 4-5 months. Avacopan may be considered as part of a strategy to reduce exposure to GC in granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA). Plasma exchange may be considered in patients with rapidly progressive glomerulonephritis. For remission maintenance of GPA/MPA, we recommend rituximab. In patients with relapsing or refractory eosinophilic GPA, we recommend the use of mepolizumab. Azathioprine and methotrexate are alternatives to biologics for remission maintenance in AAV. CONCLUSIONS In the light of recent advancements, these recommendations provide updated guidance on AAV management. As substantial data gaps still exist, informed decision-making between physicians and patients remains of key relevance.
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Affiliation(s)
- Bernhard Hellmich
- Klinik für Innere Medizin, Rheumatologie und Immunologie, Medius Kliniken, Akademisches Lehrkrankenhaus der Universität Tübingen, Kirchheim unter Teck, Germany
| | | | - Jan H Schirmer
- Rheumatology & Clinical Immunology and Cluster of Excellence Precision Medicine in Chronic Inflammation, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Alvise Berti
- CIBIO, Universita degli Studi di Trento, Trento, Italy
- Rheumatology, Santa Chiara Hospital, Trento, Italy
| | - Daniel Blockmans
- Department of Internal Medicine, University Hospital of Leuven, Leuven, Belgium
| | - Maria C Cid
- Department of Autoimmune Diseases, Hospital Clinic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Julia U Holle
- Rheumazentrum Schleswig-Holstein Mitte, Neumuenster, Germany
| | - Nicole Hollinger
- Klinik für Innere Medizin, Rheumatologie und Immunologie, Medius Kliniken, Akademisches Lehrkrankenhaus der Universität Tübingen, Kirchheim unter Teck, Germany
| | - Omer Karadag
- Division of Rheumatology, Department of Internal Medicine, Vasculitis Research Center, Hacettepe University School of Medicine, Anakra, Turkey
| | - Andreas Kronbichler
- Department of Internal Medicine IV, Medical University, Innsbruck, Austria
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Mark A Little
- Trinity Health Kidney Centre, Trinity College Dublin, Dublin, Ireland
| | - Raashid A Luqmani
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMs), University of Oxford, Oxford, UK
| | - Alfred Mahr
- Klinik für Rheumatologie, Kantonspital St Gallen, St Gallen, Switzerland
| | - Peter A Merkel
- Division of Rheumatology, Department of Medicine, Division of Epidemiology, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Aladdin J Mohammad
- Department of Medicine, University of Cambridge, Cambridge, UK
- Department of Clinical Sciences, Lund University & Department of Rheumatology, Skåne Hospital, Lund, Sweden
| | - Sara Monti
- Department of Internal Medicine and Therapeutics, Università di Pavia, Pavia, Italy
- Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Chetan B Mukhtyar
- Vasculitis Service, Rheumatology Department, Norfolk and Norwich University Hospital NHS Trust, Norwich, UK
| | - Jacek Musial
- 2nd Department of Internal Medicine, Jagiellonian University Medical College, Kraków, Poland
| | | | - Mårten Segelmark
- Division of Nephrology, Department of Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Y K Onno Teng
- Centre of Expertise for Lupus-, Vasculitis-, and Complement-Mediated Systemic Autoimmune Diseases (LuVaCs), Department of Internal Medicine, Section Nephrology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Benjamin Terrier
- National Referral Center for Rare Systemic Autoimmune Diseases, Université Paris Descartes, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Gunnar Tomasson
- Department of Epidemiology and Biostatistics, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Department of Rheumatology and Centre for Rheumatology Research, University Hospital Reykjavik, Reykjavik, Iceland
| | - Augusto Vaglio
- Nephrology Unit, Meyer Children's Hospital, and Department of Biomedical, Experimental and Clinical Science, University of Florence, Florence, Italy
| | - Dimitrios Vassilopoulos
- 2nd Department of Medicine and Laboratory, Clinical Immunology-Rheumatology Unit, National and Kapodistrian University of Athens, School of Medicine, Hippokration General Hospital, Athens, Greece
| | - Peter Verhoeven
- Dutch Patient Vasculitis Organization, Haarlem, The Netherlands
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
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12
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Gorial FI, Awadh NI, Shaheen NW, Dheyaa A, Ali ZH, Wajdi N. Emergence of acute promyelocytic leukemia in a patient with granulomatosis with polyangiitis during treatment with cyclophosphamide: a rare case report. Reumatismo 2023; 75. [PMID: 38115775 DOI: 10.4081/reumatismo.2023.1593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 10/01/2023] [Indexed: 12/21/2023] Open
Abstract
Granulomatosis with polyangiitis (GPA) is a rare autoimmune disease that affects multiple organs and causes inflammation, necrosis, and vasculitis in small blood vessels. Treatment for GPA involves achieving and maintaining remission. In recent studies, cyclophosphamide-based regimens have been linked to comorbidity hazards, including an increased risk of malignancies, especially hematological ones. Acute myeloid leukemia is the main hematologic malignancy that can complicate GPA. In this context, we report the case of a middle-aged woman with GPA who developed acute promyelocytic leukemia (APL) during maintenance with cyclophosphamide. She was treated with all-trans retinoic acid at 50 mg/day and arsenic trioxide at 10 mg/day, along with steroids. This case highlights the unique emergence of APL in a GPA patient during cyclophosphamide therapy. A single case has previously been reported on the development of APL in a patient with GPA while using azathioprine monotherapy for 2 years.
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Affiliation(s)
- F I Gorial
- Rheumatology Unit, Department of Medicine, College of Medicine, University of Baghdad.
| | - N I Awadh
- Rheumatology Unit, Department of Internal Medicine, Baghdad Teaching Hospital.
| | | | - A Dheyaa
- Rheumatology Unit, Department of Internal Medicine, Baghdad Teaching Hospital.
| | - Z H Ali
- College of Medicine, University of Baghdad.
| | - N Wajdi
- College of Medicine, University of Baghdad.
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13
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Sumichika Y, Yokose K, Sato S, Saito K, Yoshida S, Matsumoto H, Temmoku J, Fujita Y, Matsuoka N, Yashiro-Furuya M, Asano T, Ohkawara H, Watanabe H, Migita K. Development of Acute Promyelocytic Leukemia in a Patient with Granulomatosis with Polyangiitis: A Case Report. TOHOKU J EXP MED 2023; 259:107-112. [PMID: 36436925 DOI: 10.1620/tjem.2022.j098] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Granulomatosis with polyangiitis (GPA) is a rare disorder of unknown etiology, which is characterized by necrotizing granulomatous inflammation of the upper respiratory system and kidneys. Immunosuppressive treatment (cyclophosphamide or azathioprine with glucocorticoids) improved the outcome of GPA, however, latent comorbidity (cancers and hematologic malignancies) has become more prevalent in recent years. Here, we present a first case of the patient with GPA complicated by acute promyelocytic leukemia (APL) successfully treated with molecular-targeted therapy. A 77-year-old female was referred to our hospital for nasal obstruction, hearing loss, and fever. Otorhinolaryngological investigation revealed otitis media, and head computed tomography (CT) showed paranasal mucosal thickening with septal perforation. Chest CT showed cavitary granulomatous lesions in both lungs. Biopsy of the nasal mucosa revealed granulomatous lesions, and the patient was finally diagnosed with GPA. Oral administration of prednisolone 50 mg/day was initiated, and oral azathioprine (50 mg/day) was added. After 26 months of azathioprine initiation, pancytopenia developed and azathioprine was stopped. Then sudden elevated levels of blasts appeared in the hemogram (blasts 11%). She was diagnosed with APL via bone marrow examination which revealed plenty of faggot cells with Auer rods and chromosomal mutation. The patient was started on all-trans retinoic acid 60 mg/day following arsenic trioxide 7 mg/day in consideration of elderly onset. Complete remission was achieved and oral prednisolone was successfully reduced to 15 mg/day without a major relapse of GPA. Because GPA can be complicated by APL even during maintenance treatment using azathioprine, careful monitoring should be performed in such patients.
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Affiliation(s)
- Yuya Sumichika
- Department of Rheumatology, Fukushima Medical University School of Medicine
| | - Kohei Yokose
- Department of Rheumatology, Fukushima Medical University School of Medicine
| | - Shuzo Sato
- Department of Rheumatology, Fukushima Medical University School of Medicine
| | - Kenji Saito
- Department of Rheumatology, Fukushima Medical University School of Medicine
| | - Shuhei Yoshida
- Department of Rheumatology, Fukushima Medical University School of Medicine
| | - Haruki Matsumoto
- Department of Rheumatology, Fukushima Medical University School of Medicine
| | - Jumpei Temmoku
- Department of Rheumatology, Fukushima Medical University School of Medicine
| | - Yuya Fujita
- Department of Rheumatology, Fukushima Medical University School of Medicine
| | - Naoki Matsuoka
- Department of Rheumatology, Fukushima Medical University School of Medicine
| | | | - Tomoyuki Asano
- Department of Rheumatology, Fukushima Medical University School of Medicine
| | - Hiroshi Ohkawara
- Department of Hematology, Fukushima Medical University School of Medicine
| | - Hiroshi Watanabe
- Department of Rheumatology, Fukushima Medical University School of Medicine
| | - Kiyoshi Migita
- Department of Rheumatology, Fukushima Medical University School of Medicine
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14
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Habibi MA, Alesaeidi S, Zahedi M, Hakimi Rahmani S, Piri SM, Tavakolpour S. The Efficacy and Safety of Rituximab in ANCA-Associated Vasculitis: A Systematic Review. BIOLOGY 2022; 11:biology11121767. [PMID: 36552276 PMCID: PMC9774915 DOI: 10.3390/biology11121767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 11/25/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022]
Abstract
Background and aim: Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a rare multisystem autoimmune disease developed by autoantibody production against human neutrophilic granulocytes, including proteinase-3 (PR3) and myeloperoxidase (MPO). The management of AAV patients is difficult due to the multiorgan involvement, high rate of relapse, and complications of immunosuppressive agents that make it challenging. This study aims to investigate the efficacy and safety of rituximab (RTX) therapy in patients with granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA) subtypes. Method: The PubMed/Medline database was searched for any studies related to RTX therapy in ANCA-associated vasculitis (GPA and MPA subtypes), from inception to 1 August 2022, and proceeded in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Results: Our search resulted in 1082 initial records. After the elimination of review papers, irrelevant studies, and non-English records, 223 articles were included, and the data related to the efficacy and safety of RTX therapy were extracted. Several randomized and non-randomized studies showed that RTX is an effective treatment option for patients with AAV. Most of the studies showed the very effective effect of RTX in controlling disease in AAV patients, including pediatrics, adults, and elderlies, although RTX cannot completely prevent relapse. However, maintenance therapy helps delay the disease's relapse and causes sustained remission. Not only the licensed dose (375 mg/m2 intravenous per week for 4 weeks) could induce disease remission, but studies also showed that a single infusion of RTX could be effective. Although RTX could resolve many rare manifestations in AAV patients, there are few reports showing treatment failure. Additionally, few sudies have reported the unexpeted worsening of the disease after RTX administration. Generally, RTX is relatively safe compared to conventional therapies, but some serious adverse effects, mainly infections, cytopenia, hypogammaglobinemia, malignancy, and hypersensitivity have been reported. Conclusions: RTX is an effective and relatively safe therapeutic option for AAV. Studies on the evaluation of the safety profiles of RTX and the prevention of severe RTX-related side effects in AAV patients are required.
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Affiliation(s)
- Mohammad Amin Habibi
- Clinical Research Development Center, Qom University of Medical Sciences, Qom 3719964797, Iran
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran P.O. Box 982166757001, Iran
| | - Samira Alesaeidi
- Rheumatology Research Center, Tehran University of Medical Sciences, Tehran P.O. Box 982188220065, Iran
| | - Mohadeseh Zahedi
- Clinical Research Development Center, Qom University of Medical Sciences, Qom 3719964797, Iran
| | - Samin Hakimi Rahmani
- Clinical Research Development Center, Qom University of Medical Sciences, Qom 3719964797, Iran
| | - Seyed Mohammad Piri
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran P.O. Box 982166757001, Iran
| | - Soheil Tavakolpour
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA 02215, USA
- Correspondence: ; Tel.: +1-(617)-906-2978
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15
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Folci M, Ramponi G, Solitano V, Brunetta E. Serum ANCA as Disease Biomarkers: Clinical Implications Beyond Vasculitis. Clin Rev Allergy Immunol 2022; 63:107-123. [PMID: 34460071 DOI: 10.1007/s12016-021-08887-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2021] [Indexed: 01/13/2023]
Abstract
Usually associated with autoimmune diseases, anti-neutrophil cytoplasmic antibodies are also detected in other conditions, such as infections, malignancies, and after intake of certain drugs. Even if the mechanisms of production and their pathogenic role have not been fully elucidated yet, ANCA are widely recognized as a clinically alarming finding due to their association with various disorders. While ANCA target several autoantigens, proteinase-3, and myeloperoxidase are the ones proved to be most frequently related to chronic inflammation and tissue damage in murine models. Albeit these autoantibodies could be present as an isolated observation without any implications, ANCA are frequently used in clinical practice to guide the diagnosis in a suspect of small vessel vasculitis. Conditions that should prompt the clinician to test ANCA status range from various forms of lung disease to renal or peripheral nervous system impairment. ANCA positivity in the presence of an autoimmune disease, especially rheumatoid arthritis, or connective tissue diseases, is frequently correlated with more clinical complications and treatment inefficacy, even in the absence of signs of vasculitis. For this reason, it has been postulated that ANCA could represent the final expression of an immune dysregulation rather than a pathogenic event responsible for organs damage. Recently, it has also been proposed that ANCA specificity (PR3 or MPO) could possibly define ANCA-associated vasculitides better than clinical phenotype. This review aims at summarizing the latest advancements in the field of ANCA study and clinical interpretation.
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Affiliation(s)
- Marco Folci
- Humanitas Clinical and Research Center - IRCCS, Milan, Italy.
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.
| | | | - Virginia Solitano
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Enrico Brunetta
- Humanitas Clinical and Research Center - IRCCS, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
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Li X, Huang M, Liu J. ANCA-Associated Vasculitis With Anti-GBM Disease and Two Types of Tumors: A Case Report. Front Med (Lausanne) 2022; 8:810680. [PMID: 35127765 PMCID: PMC8814105 DOI: 10.3389/fmed.2021.810680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Accepted: 12/20/2021] [Indexed: 11/22/2022] Open
Abstract
Introduction Anti-neutrophil cytoplasm antibody (ANCA)-associated-vasculitis and anti-glomerular basement membrane (GBM) disease are types of autoimmune diseases that are characterized by the presence of circulating autoantibodies. Most patients with these diseases experience sudden onset, rapid progress, and poor prognosis. The purpose of the present article is to report a case of ANCA-associated vasculitis with anti-GBM disease and two types of tumors. Case Report A 63-year-old Chinese woman who underwent resection for rectal cancer 6 years before and for lung adenocarcinoma 4 years before, presented with fever and nasal obstruction, for the past 2 months and chondritis of an ear for the past 1 month. The patient failed to respond to an anti-infection treatment at local and higher-level hospitals with the first episode of “recurrent sinusitis and fever.” Later, systemic symptoms such as fatigue, numbness of the limbs, and auricular chondritis gradually aggravated, followed by an increase in inconspicuous hematuria, proteinuria, and serum creatinine level. After admission, the GBM antibody, C-ANCA, and PR3 were positive. The renal puncture was diagnosed as anti-glomerular basement membrane antibody disease. After treatment, her serum creatinine decreased to 104 umol/l. Discussion In the present report, we introduced the case of a rare double-positive disease in a patient with two types of tumors. Importantly, we noted that colon cancer and lung cancer, PR3, and anti-GBM disease may be related to their pathogenesis and manifestations. Further research is warranted to confirm these hypotheses.
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Tieu J, Lester S, Raymond W, Keen H, Hill CL, Nossent J. Cancer in Anti-Neutrophil Cytoplasm Antibody-Associated Vasculitis and Polyarteritis Nodosa in Australia: A Population-Based Study. ACR Open Rheumatol 2021; 4:223-230. [PMID: 34877820 PMCID: PMC8916546 DOI: 10.1002/acr2.11378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 07/22/2021] [Accepted: 06/10/2021] [Indexed: 11/11/2022] Open
Abstract
Objective The study objective was to compare incident cancer rates among patients with anti‐neutrophil cytoplasm antibody‐associated vasculitis (AAV) and polyarteritis nodosa (PAN) in Western Australia (WA) with the general population and perform time‐varying analyses to identify periods with greatest excess cancers. Methods Administrative health data from patients hospitalized with incident AAV/PAN from 1980 to 2014 were linked to the WA cancer registry, which holds compulsorily reported cancer data (excluding skin squamous cell and basal cell carcinomas). Incident cancer rates in patients with AAV/PAN were compared with age‐, sex‐, and calendar‐year‐matched WA population rates. Results Patients with AAV/PAN had higher overall rates of incident cancer compared with the matched population (standardized incidence ratio [SIR], 1.74; 95% confidence interval [CI], 1.42‐2.10). In subgroup analyses, incident cancer rates in patients with granulomatosis with polyangiitis/eosinophilic granulomatosis with polyangiitis were approximately double the general population (SIR, 2.21; 95% CI, 1.73‐2.78) but similar to the general population in patients with microscopic polyangiitis/PAN (SIR, 1.21; 95% CI, 0.85‐1.68). Patients with AAV/PAN had higher rates of genitourinary, skin, hematological, and lung cancers. Excess rates of hematological and lung cancers peaked early after diagnosis, whereas excess skin and genitourinary cancer rates peaked at 5 and 10 years, respectively. Conclusion This study highlights the importance of long‐term cancer surveillance in patients with AAV/PAN and defines time frames of excess risk for specific cancers, which may help inform guidance on cancer screening. Furthermore, it indicates the need for skin surveillance for melanoma in addition to nonmelanoma skin cancers in patients who have greater environmental ultraviolet exposure, such as in Australia.
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Affiliation(s)
- Joanna Tieu
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia.,Rheumatology Research Group, Basil Hetzel Institute, Adelaide, Australia.,Rheumatology Unit, The Queen Elizabeth Hospital, Adelaide, Australia.,Rheumatology Unit, Lyell McEwin Hospital, Adelaide, Australia
| | - Susan Lester
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia.,Rheumatology Research Group, Basil Hetzel Institute, Adelaide, Australia.,Rheumatology Unit, The Queen Elizabeth Hospital, Adelaide, Australia
| | - Warren Raymond
- Rheumatology Section, School of Medicine, University of Western Australia, Perth, Australia
| | - Helen Keen
- Rheumatology Section, School of Medicine, University of Western Australia, Perth, Australia.,Rheumatology Department, Fiona Stanley Hospital, Perth, Australia
| | - Catherine L Hill
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia.,Rheumatology Research Group, Basil Hetzel Institute, Adelaide, Australia.,Rheumatology Unit, The Queen Elizabeth Hospital, Adelaide, Australia.,Rheumatology Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Johannes Nossent
- Rheumatology Section, School of Medicine, University of Western Australia, Perth, Australia.,Rheumatology Department, Sir Charles Gairdner Hospital, Perth, Australia
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Moroni G, Frontini G, Ponticelli C. When and How Is It Possible to Stop Therapy in Patients with Lupus Nephritis: A Narrative Review. Clin J Am Soc Nephrol 2021; 16:1909-1917. [PMID: 34162696 PMCID: PMC8729481 DOI: 10.2215/cjn.04830421] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Glucocorticoids and other immunosuppressants still represent the cornerstone drugs for the management of SLE and lupus nephritis. The refined use of these drugs over the years has allowed us to obtain stable disease remission and improvement of long-term kidney and patient survival. Nevertheless, a prolonged use of immunosuppressive agents may be accompanied by severe and even life-threatening side effects. Theoretically, a transient or even definitive withdrawal of immunosuppression could be useful to prevent iatrogenic morbidities. For many years, however, the risk of SLE reactivation has held clinicians back from trying to interrupt therapy. In this review, we report the results of the attempts to interrupt glucocorticoids and other immunosuppressive agents in lupus nephritis and in SLE. The available data suggest that therapy withdrawal is feasible at least in patients enjoying a complete clinical remission after a prolonged therapy. A slow and gradual reduction of treatment under medical surveillance is needed to prevent flares of activity. After therapy withdrawal, around one-quarter of patients may have kidney or systemic flares. However, most flares may respond to therapy if rapidly diagnosed. The other patients can enter stable remission for even 20 years or more. The use of antimalarials can help in maintaining the remission after the withdrawal of the immunosuppressive therapy. A repeated kidney biopsy could be of help in deciding to stop therapy, but given the few available data, it cannot be considered essential.
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Affiliation(s)
- Gabriella Moroni
- Nephrology and Dialysis Unit, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico Milano, Milan, Italy
| | - Giulia Frontini
- Nephrology and Dialysis Unit, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico Milano, Milan, Italy
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Sun G, Yafasova A, Baslund B, Faurschou M, Schou M, Shams-Eldin A, Kristensen SL, Weeke PE, Torp-Pedersen C, Fosbøl EL, Køber L, Butt JH. Long-term Risk of Heart Failure and Other Adverse Cardiovascular Outcomes in Granulomatosis With Polyangiitis: a Nationwide Cohort Study. J Rheumatol 2021; 49:291-298. [PMID: 34782450 DOI: 10.3899/jrheum.210677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To examine the long-term rates of heart failure and other adverse cardiovascular outcomes in a nationwide cohort of patients diagnosed with granulomatosis with polyangiitis (GPA) compared with the background population. METHODS Using Danish nationwide registries, patients with first-time diagnosed GPA were identified and matched 1:4 by age, sex, and comorbidities with subjects from background population. Outcomes were compared using Cox regression. Due to violation of the proportional hazard assumption, landmark analyses for the first year and from one year were performed. RESULTS Of the 1,923 patients with GPA, 1,781 patients (median age 59 years, 47.9% men) were matched with 7,124 subjects from the background population. The median follow-up was 6.4 years. The absolute 10-year risk of HF was 6.8% (95%CI, 5.5-8.2%) for GPA patients and 5.9% (5.3-6.6%) for the background population. During the first year after diagnosis, GPA was associated with a significantly higher rate of HF (HR 3.60 [95%CI, 2.28-5.67]) and other adverse outcomes, including atrial fibrillation/flutter (HR 6.50 [4.43-9.55]) and ischemic stroke (HR 3.24 [1.92-5.48]), compared with the background population. After the first year, GPA was not associated with higher rates of HF or other cardiovascular outcomes than the background population, except atrial fibrillation/flutter (HR 1.38 [1.12-1.70]). CONCLUSION During the first year after diagnosis, the rates of HF and other cardiovascular outcomes were higher in patients with GPA compared with the background population. However, after the first year, the rates of HF and other cardiovascular outcomes, except atrial fibrillation/flutter, were similar to those in the background population.
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Affiliation(s)
- Guoli Sun
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Rheumatology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Cardiology, Herlev-Gentofte Hospital, Copenhagen University Hospital, Copenhagen, Denmark; Department of Cardiology, Nordsjællands Hospital, Hillerød, Denmark. The Capital Region of Denmark approved this study (approval number: P-2019-348) in accordance with the General Data Protection Regulation. In Denmark, registry-based studies in which individuals cannot be identified do not require ethical approval or informed consent. Address for Correspondence: Jawad Haider Butt, MD, Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark. E-mail:
| | - Adelina Yafasova
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Rheumatology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Cardiology, Herlev-Gentofte Hospital, Copenhagen University Hospital, Copenhagen, Denmark; Department of Cardiology, Nordsjællands Hospital, Hillerød, Denmark. The Capital Region of Denmark approved this study (approval number: P-2019-348) in accordance with the General Data Protection Regulation. In Denmark, registry-based studies in which individuals cannot be identified do not require ethical approval or informed consent. Address for Correspondence: Jawad Haider Butt, MD, Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark. E-mail:
| | - Bo Baslund
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Rheumatology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Cardiology, Herlev-Gentofte Hospital, Copenhagen University Hospital, Copenhagen, Denmark; Department of Cardiology, Nordsjællands Hospital, Hillerød, Denmark. The Capital Region of Denmark approved this study (approval number: P-2019-348) in accordance with the General Data Protection Regulation. In Denmark, registry-based studies in which individuals cannot be identified do not require ethical approval or informed consent. Address for Correspondence: Jawad Haider Butt, MD, Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark. E-mail:
| | - Mikkel Faurschou
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Rheumatology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Cardiology, Herlev-Gentofte Hospital, Copenhagen University Hospital, Copenhagen, Denmark; Department of Cardiology, Nordsjællands Hospital, Hillerød, Denmark. The Capital Region of Denmark approved this study (approval number: P-2019-348) in accordance with the General Data Protection Regulation. In Denmark, registry-based studies in which individuals cannot be identified do not require ethical approval or informed consent. Address for Correspondence: Jawad Haider Butt, MD, Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark. E-mail:
| | - Morten Schou
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Rheumatology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Cardiology, Herlev-Gentofte Hospital, Copenhagen University Hospital, Copenhagen, Denmark; Department of Cardiology, Nordsjællands Hospital, Hillerød, Denmark. The Capital Region of Denmark approved this study (approval number: P-2019-348) in accordance with the General Data Protection Regulation. In Denmark, registry-based studies in which individuals cannot be identified do not require ethical approval or informed consent. Address for Correspondence: Jawad Haider Butt, MD, Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark. E-mail:
| | - Abdulrahman Shams-Eldin
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Rheumatology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Cardiology, Herlev-Gentofte Hospital, Copenhagen University Hospital, Copenhagen, Denmark; Department of Cardiology, Nordsjællands Hospital, Hillerød, Denmark. The Capital Region of Denmark approved this study (approval number: P-2019-348) in accordance with the General Data Protection Regulation. In Denmark, registry-based studies in which individuals cannot be identified do not require ethical approval or informed consent. Address for Correspondence: Jawad Haider Butt, MD, Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark. E-mail:
| | - Søren Lund Kristensen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Rheumatology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Cardiology, Herlev-Gentofte Hospital, Copenhagen University Hospital, Copenhagen, Denmark; Department of Cardiology, Nordsjællands Hospital, Hillerød, Denmark. The Capital Region of Denmark approved this study (approval number: P-2019-348) in accordance with the General Data Protection Regulation. In Denmark, registry-based studies in which individuals cannot be identified do not require ethical approval or informed consent. Address for Correspondence: Jawad Haider Butt, MD, Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark. E-mail:
| | - Peter E Weeke
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Rheumatology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Cardiology, Herlev-Gentofte Hospital, Copenhagen University Hospital, Copenhagen, Denmark; Department of Cardiology, Nordsjællands Hospital, Hillerød, Denmark. The Capital Region of Denmark approved this study (approval number: P-2019-348) in accordance with the General Data Protection Regulation. In Denmark, registry-based studies in which individuals cannot be identified do not require ethical approval or informed consent. Address for Correspondence: Jawad Haider Butt, MD, Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark. E-mail:
| | - Christian Torp-Pedersen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Rheumatology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Cardiology, Herlev-Gentofte Hospital, Copenhagen University Hospital, Copenhagen, Denmark; Department of Cardiology, Nordsjællands Hospital, Hillerød, Denmark. The Capital Region of Denmark approved this study (approval number: P-2019-348) in accordance with the General Data Protection Regulation. In Denmark, registry-based studies in which individuals cannot be identified do not require ethical approval or informed consent. Address for Correspondence: Jawad Haider Butt, MD, Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark. E-mail:
| | - Emil L Fosbøl
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Rheumatology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Cardiology, Herlev-Gentofte Hospital, Copenhagen University Hospital, Copenhagen, Denmark; Department of Cardiology, Nordsjællands Hospital, Hillerød, Denmark. The Capital Region of Denmark approved this study (approval number: P-2019-348) in accordance with the General Data Protection Regulation. In Denmark, registry-based studies in which individuals cannot be identified do not require ethical approval or informed consent. Address for Correspondence: Jawad Haider Butt, MD, Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark. E-mail:
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Rheumatology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Cardiology, Herlev-Gentofte Hospital, Copenhagen University Hospital, Copenhagen, Denmark; Department of Cardiology, Nordsjællands Hospital, Hillerød, Denmark. The Capital Region of Denmark approved this study (approval number: P-2019-348) in accordance with the General Data Protection Regulation. In Denmark, registry-based studies in which individuals cannot be identified do not require ethical approval or informed consent. Address for Correspondence: Jawad Haider Butt, MD, Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark. E-mail:
| | - Jawad H Butt
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Rheumatology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Cardiology, Herlev-Gentofte Hospital, Copenhagen University Hospital, Copenhagen, Denmark; Department of Cardiology, Nordsjællands Hospital, Hillerød, Denmark. The Capital Region of Denmark approved this study (approval number: P-2019-348) in accordance with the General Data Protection Regulation. In Denmark, registry-based studies in which individuals cannot be identified do not require ethical approval or informed consent. Address for Correspondence: Jawad Haider Butt, MD, Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark. E-mail:
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Urbanska EM, Elversang J, Colville-Ebeling B, Löfgren JO, Nelveg-Kristensen KE, Szpirt WM. Uncommon Presentation of Granulomatosis with Polyangiitis Mimicking Metastatic Lung Cancer. Clin Pract 2021; 11:293-302. [PMID: 34068864 PMCID: PMC8161553 DOI: 10.3390/clinpract11020042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 05/03/2021] [Accepted: 05/11/2021] [Indexed: 11/23/2022] Open
Abstract
Diagnosis of anomalous intrathoracic lesions may be challenging and require a multidisciplinary approach. We present a case of granulomatosis with polyangiitis (GPA) clinically and radiologically mimicking metastatic lung cancer with a bilateral pulmonary mass, mediastinal and cervical lymph node involvement, and pleural effusion. Surgical biopsy of the thoracic lesion revealed necrotic granulomatous inflammation, and the final diagnosis was subsequently confirmed by kidney biopsy and biochemical parameters. This case illustrates how comprehensive diagnosis secures timely and relevant treatment. Systemic vasculitis may be one of the key differential diagnoses in patients with multiorgan involvement, especially with pattern-mimicking lung cancer.
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Affiliation(s)
- Edyta Maria Urbanska
- Department of Oncology, Rigshospitalet, University of Copenhagen, 2100 Copenhagen, Denmark
- Correspondence: (E.M.U.); (W.M.S.); Tel.: +45-3545-0604 (E.M.U.); +45-3545-1767 (W.M.S.)
| | - Johanna Elversang
- Department of Pathology, Rigshospitalet, University of Copenhagen, 2100 Copenhagen, Denmark; (J.E.); (B.C.-E.)
| | - Bonnie Colville-Ebeling
- Department of Pathology, Rigshospitalet, University of Copenhagen, 2100 Copenhagen, Denmark; (J.E.); (B.C.-E.)
| | - Johan Olof Löfgren
- Department of Clinical Physiology, Nuclear Medicine & PET, Rigshospitalet, University of Copenhagen, 2100 Copenhagen, Denmark;
| | | | - Wladimir M. Szpirt
- Department of Nephrology, Rigshospitalet, University of Copenhagen, 2100 Copenhagen, Denmark;
- Correspondence: (E.M.U.); (W.M.S.); Tel.: +45-3545-0604 (E.M.U.); +45-3545-1767 (W.M.S.)
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The cancer risk according to three subtypes of ANCA-associated vasculitis: A propensity score-matched analysis of a nationwide study. Semin Arthritis Rheum 2021; 51:692-699. [PMID: 34139522 DOI: 10.1016/j.semarthrit.2021.03.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 03/26/2021] [Accepted: 03/30/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE It remains unknown whether cancer risk differs among the three subtypes of anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) and what the cancer risk factors are. We conducted a nationwide study in Korea to evaluate the risk of cancer in patients with AAV and to identify the risk factors for cancer. METHODS We analyzed the Health Insurance Review and Assessment database of Korea and identified 1982 patients diagnosed with AAV between January 1, 2007 and December 31, 2017. The patients and controls with no history of AAV or cancer were matched 1:4 by propensity scores. The study outcome measure was incidence of cancer during 11 years of follow-up. RESULTS Patients with granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA) numbered 684, 606, and 692, respectively. The overall incidence of cancer was higher among patients with AAV than in controls (HR 1.32, 95% CI 1.08-1.61). The risk of hematological malignancy, lung cancer, and bladder cancer in the GPA group, lung cancer in the MPA group, and hematological malignancy in the EGPA group were significantly higher than in controls (HR 7.39, 3.20, 4.20, 2.86, and 4.65, respectively). Age, male sex, GPA subtype, and cyclophosphamide use were significantly associated with cancer risk in patients with AAV. CONCLUSION Overall cancer incidence was increased in patients with AAV. Cancer risk was higher in patients with GPA than in those with MPA or EGPA. The use of cyclophosphamide was associated with an increased risk of cancer, while rituximab was not.
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Hayashi Y, Katayama Y, Sakuragi M, Hayashi A, Kakita H, Uyama M, Marumo S, Fukui M. Sequential occurrence of microscopic polyangiitis and anti-glomerular basement membrane disease in a patient with small cell lung cancer: a case report. J Med Case Rep 2021; 15:30. [PMID: 33517889 PMCID: PMC7849101 DOI: 10.1186/s13256-020-02614-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 11/30/2020] [Indexed: 11/10/2022] Open
Abstract
Background The association between a preceding malignancy and the onset of anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) has been reported in several studies. While the co-existence of ANCA and anti-glomerular basement membrane (GBM) antibodies in an individual patient is not a common occurrence, this double-positive disease currently has no optimal treatment method. Herein, we report a case of a double-positive disease involving the sequential development of acute kidney injury (AKI) and diffuse alveolar hemorrhage (DAH) in a patient with small cell lung cancer (SCLC). Case presentation A 75-year-old Japanese woman was diagnosed with small cell lung cancer (cT3N2M1b cStage IV) and received chemotherapy. After one cycle of chemotherapy, she experienced fever and malaise. Her serum creatinine level rapidly increased, and she tested positive for myeloperoxidase (MPO)-ANCA and anti-GBM antibody. She was diagnosed with AKI due to microscopic polyangiitis (MPA) based on renal biopsy. Corticosteroid therapy was initiated, which improved her renal dysfunction. Eight days after she was discharged from the hospital, she complained of dyspnea and bloody sputum, and her condition rapidly progressed to respiratory failure. Upon chest imaging, ground-glass opacities were seen in her bilateral lower lungs. Laboratory examinations after admission revealed a lower MPO-ANCA titer and an elevated anti-GBM antibody titer compared to her previous admission. We diagnosed her with DAH due to an anti-GBM disease. After corticosteroid pulse therapy, plasma exchange was performed five times; her oxygen saturation and chest radiologic findings improved gradually. Following five cycles of plasma exchange, her oxygen saturation recovered to 95% in room air. Conclusions To our knowledge, this is the first reported case of vasculitis caused by MPA and anti-GBM disease leading to the development of AKI and DAH during treatment of SCLC. SCLC, MPA, and anti-GBM disease may occur sequentially. A double-positive disease might have a worse prognosis; therefore, intensive therapy is more likely to achieve a better outcome.
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Affiliation(s)
- Yusuke Hayashi
- Department of Respirology, Kitano Hospital, The Tazuke Kofukai Medical Research Institute, 2-4-20 Ohgimachi, Kita-ku, Osaka, 530-8480, Japan.
| | - Yuko Katayama
- Department of Respirology, Kitano Hospital, The Tazuke Kofukai Medical Research Institute, 2-4-20 Ohgimachi, Kita-ku, Osaka, 530-8480, Japan
| | - Minoru Sakuragi
- Department of Nephrology and Dialysis, Kitano Hospital, The Tazuke Kofukai Medical Research Institute, Osaka, Japan
| | - Ayano Hayashi
- Department of Nephrology and Dialysis, Kitano Hospital, The Tazuke Kofukai Medical Research Institute, Osaka, Japan
| | - Hiroko Kakita
- Department of Nephrology and Dialysis, Kitano Hospital, The Tazuke Kofukai Medical Research Institute, Osaka, Japan
| | - Michihiro Uyama
- Department of Respirology, Kitano Hospital, The Tazuke Kofukai Medical Research Institute, 2-4-20 Ohgimachi, Kita-ku, Osaka, 530-8480, Japan
| | - Satoshi Marumo
- Department of Respirology, Kitano Hospital, The Tazuke Kofukai Medical Research Institute, 2-4-20 Ohgimachi, Kita-ku, Osaka, 530-8480, Japan
| | - Motonari Fukui
- Department of Respirology, Kitano Hospital, The Tazuke Kofukai Medical Research Institute, 2-4-20 Ohgimachi, Kita-ku, Osaka, 530-8480, Japan
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Thet Z, Lam AK, Ng SK, Aung SY, Han T, Ranganathan D, Borg J, Pepito C, Khoo TK. Comparison of skin cancer awareness and sun protection behaviours between renal transplant recipients and patients with glomerular disease treated with immunosuppressants. Nephrology (Carlton) 2020; 26:294-302. [PMID: 34308553 DOI: 10.1111/nep.13840] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 12/01/2020] [Accepted: 12/02/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND There is no previous study that compare skin cancer awareness and photoprotective behaviours between renal transplant recipients (RTR) and patients with glomerular disease (GD). OBJECTIVES/METHODS Sixty-one RTR and 51 patients with GD were given a self-reported questionnaire to evaluate skin cancer awareness and photoprotective behaviours in this cross-sectional study. The former group received a formal education on skin cancer and the latter an informal session prior to immunosuppressant use. RESULTS Ninety-three percent (n = 57) of RTRs and 88% (n = 45) of patients with GD responded to the survey. Majority of participants from both groups were aware that ultraviolet radiation could play a role in the occurrence of skin cancers and the awareness increased in participants with higher education (odds ratio [OR] = 1.50, 95% confidence interval [CI] = 1.15-1.95, P = .003). Ninety-eight percent vs 71% were aware that immunosuppressants can increase the risk of developing cancer (P < .001) and higher awareness was noted in younger participants (OR = 0.92, 95% CI = 0.87-0.97, P = .003). Suboptimal photoprotective behaviours (sun avoidance, sunscreen usage and sun-protective clothing) were noted in both cohorts and slightly lower sun protection rates were reported in RTR when compared with patients having GD. The level of sun protective measures in RTR based on high, moderate and minimal use of photoprotective measures were 21%, 46% and 33%, respectively. In terms of patients with GD, the latter practices were 13%, 50% and 37%, respectively (P = .560). Higher educational status was significantly associated with better sunscreen usage in RTR (P = .017) whereas this finding was not observed in patients with GD. CONCLUSION Patients with GD and RTR should have formal education on the risks of skin cancers before starting immunosuppressants. Follow-up education and surveillance is required to improve skin protective practices in these patients.
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Affiliation(s)
- Zaw Thet
- School of Medicine, Griffith University, Brisbane, Queensland, Australia.,Department of Nephrology, Central Queensland Hospital and Health Service, Brisbane, Queensland, Australia
| | - Alfred K Lam
- School of Medicine, Griffith University, Brisbane, Queensland, Australia
| | - Shu-Kay Ng
- School of Medicine, Griffith University, Brisbane, Queensland, Australia
| | - Soe Yu Aung
- Department of Oncology, Central Queensland Hospital and Health Service, Brisbane, Queensland, Australia.,Rural Clinical School, University of Queensland, Rockhampton, Queensland, Australia
| | - Thin Han
- Department of Nephrology, Central Queensland Hospital and Health Service, Brisbane, Queensland, Australia.,Rural Clinical School, University of Queensland, Rockhampton, Queensland, Australia
| | - Dwarakanathan Ranganathan
- School of Medicine, Griffith University, Brisbane, Queensland, Australia.,Department of Nephrology, Metro North Hospital and Health Service, Herston, Queensland, Australia
| | - Jennifer Borg
- Department of Nephrology, Central Queensland Hospital and Health Service, Brisbane, Queensland, Australia
| | - Christine Pepito
- Department of Nephrology, Central Queensland Hospital and Health Service, Brisbane, Queensland, Australia
| | - Tien K Khoo
- School of Medicine, Griffith University, Brisbane, Queensland, Australia.,School of Medicine, University of Wollongong, New South Wales, Australia
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24
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Boyer H, Mortimore G. Anti-neutrophil cytoplasmic antibodies-associated vasculitis: a guide and case study. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2020; 29:1333-1340. [PMID: 33325285 DOI: 10.12968/bjon.2020.29.22.1333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Vasculitis is a relatively rare and poorly understood condition causing inflammation of the blood vessels, which in turn can affect a patient's respiratory and renal systems. In some cases, ocular involvement can cause loss of sight and hearing loss may also be a red flag for vasculitis, which, if not treated early, can cause complete hearing loss. Anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV) is a group comprising granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA) and eosinophilic granulomatosis (EGP). AAV is fatal if untreated and as increased risk escalates with age, coupled with a decline in renal function, these are the principal predictors of poor outcome. Vital roles for nursing vasculitis patients lie in managing inflammation and pain, as these distressing symptoms are prevalent in the disease. Because of the multiple complications that can occur with vasculitis, treatment-related information is a high priority for these patients. As nurses are well placed to deliver information, value lies in their role in reducing the negative impacts on treatment regimens and compliance that accompany patients' poor insight into their condition.
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Affiliation(s)
- Helena Boyer
- Trainee Advanced Clinical Practitioner, Royal Derby Hospital
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25
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Xie C, Stoddart C, Bewes J, Peschl H, Luqmani R, Benamore R. A hidden lung cancer in a patient with granulomatosis with polyangiitis. BJR Case Rep 2020; 6:20190114. [PMID: 33029377 PMCID: PMC7527008 DOI: 10.1259/bjrcr.20190114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 11/15/2019] [Accepted: 11/18/2019] [Indexed: 11/05/2022] Open
Abstract
Granulomatosis with polyangiitis is a systemic necrotizing vasculitis that affects the small- and medium-sized blood vessels. The diagnosis can be challenging since the clinical and imaging findings have similarities with infection, and malignancy. Serologic and histopathological investigations often help confirm the diagnosis. However, this can be falsely reassuring. We present a unique case of the coexistence of vasculitis and squamous cell carcinoma in the same cavitating lung mass. The case highlights the importance of recognizing changes in disease behaviour early to allow for timely management.
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Affiliation(s)
- Cheng Xie
- Department of Radiology, Churchill Hospital, Oxford University Hospital Trust, Old Road, Headington, Oxford, OX3 7LE, United Kingdom
| | - Catriona Stoddart
- Department of Radiology, Churchill Hospital, Oxford University Hospital Trust, Old Road, Headington, Oxford, OX3 7LE, United Kingdom
| | - James Bewes
- Department of Radiology, Churchill Hospital, Oxford University Hospital Trust, Old Road, Headington, Oxford, OX3 7LE, United Kingdom
| | - Heiko Peschl
- Department of Radiology, Churchill Hospital, Oxford University Hospital Trust, Old Road, Headington, Oxford, OX3 7LE, United Kingdom
| | - Raashid Luqmani
- Department of Radiology, Churchill Hospital, Oxford University Hospital Trust, Old Road, Headington, Oxford, OX3 7LE, United Kingdom
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26
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Masiak A, Fijałkowska J, Nowakowski S, Smoleńska Ż, Zdrojewski Z. New lung mass in a patient with granulomatosis with polyangiitis. Rheumatol Int 2020; 41:493-499. [PMID: 32671469 PMCID: PMC7835303 DOI: 10.1007/s00296-020-04646-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 07/03/2020] [Indexed: 12/19/2022]
Abstract
Granulomatosis with polyangiitis (GPA) is a potentially lethal ANCA-associated small-vessel vasculitis characterized by a typical triad of upper respiratory tract, lung, and kidney involvement. Lung involvement in GPA occurs in 25–80% of cases. The most common radiographic and computed tomography (CT) abnormalities of pulmonary GPA are lung nodules and masses, very often multiple and with cavitation. As there are various clinical presentations, the diagnosis of GPA can be challenging, and the illness is difficult to distinguish from other diseases such as infection or malignancy. Following the improved survival rates in patients with GPA, there is accumulating evidence to suggest an increased occurrence of different types of cancer. Exposure to cyclophosphamide seems to be one of its main causes. We present the case of a patient with chronic GPA who was hospitalized owing to a new infiltrate in the lung, suggesting relapse of the disease, and finally diagnosed with small cell lung cancer. Data regarding lung cancer in GPA patients are limited. While there are some case reports and short case series in the literature, there are no detailed data regarding an association between CYC exposure and lung cancer development in vasculitis. It is necessary to consider the causes of pulmonary masses other than a GPA relapse. Bronchoscopy with biopsy and histopathological examination are crucial in proper differential diagnosis. GPA patients require long-term follow-up to monitor for the development of complications during treatment.
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Affiliation(s)
- Anna Masiak
- Department of Internal Medicine, Connective Tissue Diseases and Geriatrics, Medical University of Gdansk, ul. Dębinki 7, 80-952, Gdansk, Poland.
| | - Jadwiga Fijałkowska
- Second Department of Radiology, Medical University of Gdansk, Gdansk, Poland
| | - Szymon Nowakowski
- Department of Internal Medicine, Connective Tissue Diseases and Geriatrics, Medical University of Gdansk, ul. Dębinki 7, 80-952, Gdansk, Poland
| | - Żaneta Smoleńska
- Department of Internal Medicine, Connective Tissue Diseases and Geriatrics, Medical University of Gdansk, ul. Dębinki 7, 80-952, Gdansk, Poland
| | - Zbigniew Zdrojewski
- Department of Internal Medicine, Connective Tissue Diseases and Geriatrics, Medical University of Gdansk, ul. Dębinki 7, 80-952, Gdansk, Poland
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27
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Moiseev S, Cohen Tervaert JW, Arimura Y, Bogdanos DP, Csernok E, Damoiseaux J, Ferrante M, Flores-Suárez LF, Fritzler MJ, Invernizzi P, Jayne D, Jennette JC, Little MA, McAdoo SP, Novikov P, Pusey CD, Radice A, Salama AD, Savige JA, Segelmark M, Shoenfeld Y, Sinico RA, Sousa MJ, Specks U, Terrier B, Tzioufas AG, Vermeire S, Zhao MH, Bossuyt X. 2020 international consensus on ANCA testing beyond systemic vasculitis. Autoimmun Rev 2020; 19:102618. [PMID: 32663621 DOI: 10.1016/j.autrev.2020.102618] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 03/08/2020] [Indexed: 02/07/2023]
Abstract
This document follows up on a 2017 revised international consensus on anti-neutrophil cytoplasm antibodies (ANCA) testing in granulomatosis with polyangiitis and microscopic polyangiitis and focuses on the clinical and diagnostic value of ANCA detection in patients with connective tissue diseases, idiopathic interstitial pneumonia, autoimmune liver diseases, inflammatory bowel diseases, anti-glomerular basement membrane (GBM) disease, infections, malignancy, and during drug treatment. Current evidence suggests that in certain settings beyond systemic vasculitis, ANCA may have clinical, pathogenic and/or diagnostic relevance. Antigen-specific ANCA targeting proteinase-3 and myeloperoxidase should be tested by solid phase immunoassays in any patient with clinical features suggesting ANCA-associated vasculitis and in all patients with anti-GBM disease, idiopathic interstitial pneumonia, and infective endocarditis associated with nephritis, whereas in patients with other aforementioned disorders routine ANCA testing is not recommended. Among patients with autoimmune liver diseases or inflammatory bowel diseases, ANCA testing may be justified in patients with suspected autoimmune hepatitis type 1 who do not have conventional autoantibodies or in case of diagnostic uncertainty to discriminate ulcerative colitis from Crohn's disease. In these cases, ANCA should be tested by indirect immunofluorescence as the target antigens are not yet well characterized. Many questions concerning the optimal use of ANCA testing in patients without ANCA-associated vasculitis remain to be answered.
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Affiliation(s)
- Sergey Moiseev
- Tareev Clinic of Internal Diseases, Sechenov First Moscow State Medical University, Moscow, Russia.
| | - Jan Willem Cohen Tervaert
- Department of Medicine, Division of Rheumatology, University of Alberta, Edmonton, Canada and Maastricht University, Maastricht, The Netherlands
| | - Yoshihiro Arimura
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine, Tokyo, Japan
| | - Dimitrios P Bogdanos
- Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Biopolis, Larissa, Greece
| | - Elena Csernok
- Department of Internal Medicine, Rheumatology and Immunology, Vasculitis-Center Tübingen-Kirchheim, Medius Klinik Kirchheim, University of Tübingen, Kirchheim-Teck, Germany
| | - Jan Damoiseaux
- Central Diagnostic Laboratory, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Marc Ferrante
- University Hospitals Leuven, Department of Gastroenterology and Hepatology, KU Leuven, Leuven, Belgium
| | - Luis Felipe Flores-Suárez
- Primary Systemic Vasculitides Clinic, Instituto Nacional de Enfermedades Respiratorias, Mexico City, Mexico
| | - Marvin J Fritzler
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Pietro Invernizzi
- Division Gastroenterology and Center for Autoimmune Liver Diseases, University of Milano-Bicocca School of Medicine, Monza, Italy
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - J Charles Jennette
- Division of Nephropathology, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Mark A Little
- Trinity Health Kidney Centre, Trinity Translational Medicine Institute, Dublin, Ireland
| | - Stephen P McAdoo
- Centre for Inflammatory Disease, Department of Medicine, Imperial College London, London, UK
| | - Pavel Novikov
- Tareev Clinic of Internal Diseases, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Charles D Pusey
- Centre for Inflammatory Disease, Department of Medicine, Imperial College London, London, UK
| | - Antonella Radice
- Microbiology and Virology Institute, ASST Santi Paolo e Carlo, San Carlo Borromeo Hospital, Milan, Italy
| | - Alan D Salama
- UCL Department of Renal Medicine, Royal Free Hospital, London, UK
| | - Judith A Savige
- Department of Medicine, Melbourne Health, University of Melbourne, Melbourne, Australia
| | - Mårten Segelmark
- Department of Clinical Sciences, Lund University, Department of Nephrology and Rheumatology, Skane University Hospital, Lund, Sweden
| | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Renato A Sinico
- Department of Medicine and Surgery, Università degli Studi di Milano-Bicocca, Monza, Italy
| | - Maria-José Sousa
- Immunopathology and Autoimmunity Department, Centro de Medicina Laboratorial Germano de Sousa, Lisbon, Portugal
| | - Ulrich Specks
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Benjamin Terrier
- Department of Internal Medicine, National Referral Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, Paris, France
| | - Athanasios G Tzioufas
- Department of Pathophysiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Severine Vermeire
- University Hospitals Leuven, Department of Gastroenterology and Hepatology, KU Leuven, Leuven, Belgium
| | - Ming-Hui Zhao
- Renal Division, Peking University First Hospital, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Peking-Tsinghua Centre for Life Sciences, Beijing, China
| | - Xavier Bossuyt
- Laboratory Medicine, University Hospitals Leuven, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
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Abstract
INTRODUCTION Rituximab, an anti-B-cell biological therapy, has been investigated in several clinical trials on antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAVs). AREAS COVERED In this paper, the clinical trials and open-label studies on rituximab efficacy and safety in treating AAVs are reviewed. EXPERT OPINION Rituximab achieved high remission-induction and sustained-maintenance rates for patients with these severe diseases, thereby challenging the cornerstone treatment of corticosteroids and cyclophosphamide followed by azathioprine. Rituximab should be used as first-line therapy with corticosteroids to induce remission of severe AAVs, especially in situations in which cyclophosphamide may be problematic (relapse after cyclophosphamide, women of childbearing age, risk of malignancy). Cyclophosphamide indications are likely to be restricted in the future. Whenever possible, rituximab should be preferred to azathioprine to maintain remission. The current maintenance regimen has been extended to at least 18 months but its optimal duration remains unknown and recent data suggest the possibility to extend treatment to 4 years. Future challenges include defining the best dose regimen: at present, different schedules are used as alternatives to those recognized as standards by health authorities. In addition, it remains to identify which patients will benefit the most from long-term retreatment: potentially those with relapsing disease or anti-proteinase-3 ANCA-positivity.
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Affiliation(s)
- Loïc Raffray
- Department of Internal Medicine, Félix-Guyon University Hospital of La Réunion , Saint-Denis, France
| | - Loïc Guillevin
- Referral Center for Rare Systemic and Autoimmune Diseases, Department of Internal Medicine, Hôpital Cochin, Université Paris Descartes , Paris, France
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Thet Z, Lam AK, Ranganathan D, Aung SY, Khoo TK. Cancer risks along the disease trajectory in antineutrophil cytoplasmic antibody associated vasculitis. Clin Rheumatol 2020; 39:2501-2513. [DOI: 10.1007/s10067-020-05055-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 02/20/2020] [Accepted: 03/20/2020] [Indexed: 12/12/2022]
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Treatment and its side effects in ANCA-associated vasculitides - Study based on POLVAS registry data. Adv Med Sci 2020; 65:156-162. [PMID: 31958704 DOI: 10.1016/j.advms.2020.01.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 09/08/2019] [Accepted: 01/03/2020] [Indexed: 01/02/2023]
Abstract
PURPOSE The aim of this study is to present the treatment modalities and associated side effects in a Polish nation-wide ANCA-associated vasculitides (AAV) patients' cohort. MATERIALS AND METHODS Retrospective analysis of patients diagnosed with AAV between 1990 and 2016, included in the POLVAS registry was performed. Standard descriptive statistic methods were used with an emphasis on the treatment modalities. RESULTS There were 625 patients diagnosed with AAV included in this study: 417 cases of granulomatosis with polyangiitis (GPA; 66.7%), 106 cases of microscopic polyangiitis (MPA; 17.0%) and 102 cases of eosinophilic granulomatosis with polyangiitis (EGPA; 16.3%). The mean age at the date of diagnosis was 50.4 (±15.7) years and the median observational period amounted to 4.0 (2.0-8.0) years. Glucocorticosteroids (GCs) were the medicaments most frequently used for remission induction (593/622; 95.3%), followed by cyclophosphamide (487/622; 78.3%), rituximab (44/622; 7.1%), and methotrexate (39/622; 6.3%). GCs were also most frequently administered for maintenance therapy (499/592; 84.3%), followed by azathioprine (224/592; 37.8%), methotrexate (136/592; 23.0%) and mycophenolate mofetil (99/592; 16.7%). The median cumulative doses of cyclophosphamide and rituximab equalled 7.99 g (4.18-14.0) and 2000 mg (1500-2800), respectively. The most commonly observed adverse events included: infections - 214/551 cases (38.8%), which were associated with the time of observation (OR = 1.05; 95% CI 1.01-1.10), the use of GCs intravenous pulses (OR = 2.76; 95% CI 1.68-4.54) and need for haemodialysis (OR = 1.73; 95% CI 1.10-2.71). CONCLUSIONS Polish patients with AAV were predominantly treated according to appropriate guidelines. The most frequent adverse events were typical for usually administered immunosuppressive treatment.
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Tsuchiya K, Karayama M, Sato T, Yasui H, Hozumi H, Suzuki Y, Furuhashi K, Enomoto N, Fujisawa T, Nakamura Y, Inui N, Sugimura H, Yasuda H, Suda T. Simultaneous Occurrence of Sarcoidosis and Anti-neutrophil Cytoplasmic Antibody-associated Vasculitis in a Patient with Lung Cancer. Intern Med 2019; 58:3299-3304. [PMID: 31327832 PMCID: PMC6911755 DOI: 10.2169/internalmedicine.3004-19] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 71-year-old woman with abnormal pulmonary shadows and multiple enlarged thoracic lymph nodes was diagnosed with stage IIB lung adenocarcinoma, pulmonary sarcoidosis, and sarcoidosis-associated lymphadenopathy after biopsies from multiple organ sites. She also had rapidly progressive renal dysfunction, microhematuria, and high myeloperoxidase anti-neutrophil cytoplasmic antibody (MPO-ANCA) concentrations. A renal biopsy revealed granulomatous tubulointerstitial nephritis and necrotizing glomerulonephritis with crescent formation. She was diagnosed with nephritis caused by both sarcoidosis and ANCA-associated vasculitis. Oral prednisolone was administered to treat her nephritis, resulting in improvement in both her renal dysfunction and her sarcoidosis-associated lymphadenopathy.
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Affiliation(s)
- Kazuo Tsuchiya
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Japan
- Department of Tumor Pathology, Hamamatsu University School of Medicine, Japan
| | - Masato Karayama
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Japan
- Department of Clinical Pharmacology and Therapeutics, Hamamatsu University School of Medicine, Japan
| | - Taichi Sato
- First Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Japan
| | - Hideki Yasui
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Japan
| | - Hironao Hozumi
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Japan
| | - Yuzo Suzuki
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Japan
| | - Kazuki Furuhashi
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Japan
| | - Noriyuki Enomoto
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Japan
| | - Tomoyuki Fujisawa
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Japan
| | - Yutaro Nakamura
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Japan
| | - Naoki Inui
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Japan
| | - Haruhiko Sugimura
- Department of Tumor Pathology, Hamamatsu University School of Medicine, Japan
| | - Hideo Yasuda
- First Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Japan
| | - Takafumi Suda
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Japan
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Risk of Cancers in Antineutrophil Cytoplasmic Antibody-Associated Vasculitis: Results from the Korea National Health Insurance Claims Database 2010-2018. J Clin Med 2019; 8:jcm8111871. [PMID: 31694209 PMCID: PMC6912195 DOI: 10.3390/jcm8111871] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 10/26/2019] [Accepted: 10/30/2019] [Indexed: 12/21/2022] Open
Abstract
The association between antineutrophil cytoplasmic antibody-associated vasculitis (AAV) and cancer remains poorly understood. In this study, we searched the Korea National Health Insurance Claims Database to obtain data for 2097 AAV patients, and evaluated the risk of cancers in AAV. The standardized incidence ratios (SIRs) of overall and site-specific cancers were estimated in patients with AAV compared to the general population. The overall risk of cancer was significantly higher in patients with AAV (SIR 1.90); this remained true in both males (SIR 1.74) and females (SIR 2.06). For site-specific cancers, the risks of lung (SIR 2.23) and hematological (SIR 11.39) cancers were higher in AAV patients. For males, the risks of gallbladder and hematological cancers were increased, while the risks of bladder and hematological cancers were increased in females. Among AAV subtypes, patients with granulomatosis with polyangiitis had the highest risk of cancers, and cyclophosphamide, azathioprine/mizoribine, and methotrexate ever-users had increased risk of overall cancer. The risks of overall and hematological cancers were elevated in AAV patients younger than 60 years old. Patients with AAV have increased risks of overall, lung, and hematological cancers. Distinct patterns of cancer incidence are present according to age, sex, AAV subtypes, and immunosuppressant usage.
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Tabrez S, Jabir NR, Khan MI, Khan MS, Shakil S, Siddiqui AN, Zaidi SK, Ahmed BA, Kamal MA. Association of autoimmunity and cancer: An emphasis on proteolytic enzymes. Semin Cancer Biol 2019; 64:19-28. [PMID: 31100322 DOI: 10.1016/j.semcancer.2019.05.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 05/09/2019] [Accepted: 05/10/2019] [Indexed: 12/24/2022]
Abstract
Cancer and autoimmune diseases are the two devastating conditions that together constitute a leading health problem worldwide. The rising burden of these disorders in the developing world demands a multifaceted approach to address the challenges it poses. Understanding the root causes and specific molecular mechanisms by which the progression of the diseases takes place is need of the hour. A strong inflammatory background and common developmental pathways, such as activation of immune cells, proliferation, increased cell survival and migration which are controlled by growth factors and inflammatory cytokines have been considered as the critical culprits in the progression and complications of these disorders. Enzymes are the potential immune modulators which regulate various inflammatory events and can break the circulating immune complexes via macrophages production. In the current manuscript, we have uncovered the possible role of proteolytic enzymes in the pathogenesis and progression of cancer and autoimmune diseases. In the light of the available scientific literature, we advocate in-depth comprehensive studies which will shed light towards the role of proteolytic enzymes in the modulation of inflammatory responses in cancer and autoimmune diseases together.
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Affiliation(s)
- Shams Tabrez
- King Fahd Medical Research Center, King Abdulaziz University, Jeddah, Saudi Arabia; Department of Medical Laboratory Technology, Faculty of Applied Medical Sciences, King Abdulaziz University, Jeddah, Saudi Arabia.
| | - Nasimudeen R Jabir
- Department of Biochemistry, Centre for Research and Development, PRIST University, Vallam, Thanjavur, Tamil Nadu, India
| | - Mohammad Imran Khan
- Protein Research Chair, Department of Biochemistry, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Mohd Shahnawaz Khan
- Protein Research Chair, Department of Biochemistry, College of Science, King Saud University, Riyadh, Saudi Arabia
| | - Shazi Shakil
- King Fahd Medical Research Center, King Abdulaziz University, Jeddah, Saudi Arabia; Department of Medical Laboratory Technology, Faculty of Applied Medical Sciences, King Abdulaziz University, Jeddah, Saudi Arabia; Center of Excellence in Genomic Medicine Research (CEGMR), King Abdulaziz University, Jeddah, Saudi Arabia
| | | | - Syed Kashif Zaidi
- Center of Excellence in Genomic Medicine Research (CEGMR), King Abdulaziz University, Jeddah, Saudi Arabia
| | - Bakrudeen Ali Ahmed
- Department of Biochemistry, Centre for Research and Development, PRIST University, Vallam, Thanjavur, Tamil Nadu, India
| | - Mohammad Amjad Kamal
- King Fahd Medical Research Center, King Abdulaziz University, Jeddah, Saudi Arabia.
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ANCA-Associated Vasculitides and Hematologic Malignancies: Lessons from the Past and Future Perspectives. J Immunol Res 2019; 2019:1732175. [PMID: 31198793 PMCID: PMC6526571 DOI: 10.1155/2019/1732175] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Accepted: 04/18/2019] [Indexed: 12/19/2022] Open
Abstract
The purpose of this paper is to collect and summarize all evidences relating to an association between ANCA-associated vasculitides (AAVs) and hematologic malignancies, in the form of either a paraneoplastic vasculitis or leukemias and lymphomas developing on a preexisting vasculitis. Additionally, the role of cyclophosphamide in vasculitis treatment has been assessed and compared to rituximab. Paraneoplastic AAV seems to be an uncommon presentation of hemopathies. Hematologic malignancy risk in AAV is more likely to be increased by cyclophosphamide, although not yet definitely proven. Furthermore, the pathogenesis of ANCA-associated vasculitis has been reviewed with particular emphasis on the role of proteinase 3 (PR3) in fuelling granulomatosis with polyangiitis (GPA) inflammation. PR3 is a bactericidal protein expressed by neutrophilic granules and on their plasma membrane. Derangements in its expression and function have been linked to leukemias and GPA alike. PR3-derived PR1 peptide is being studied as an immunotherapy target in leukemia and multiple myeloma. This study is aimed at bringing together various evidences from the field of immunological and hematological research, at exposing contradictions, and at revealing novel insights on the association between ANCA-associated vasculitis and hematologic malignancies.
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Ponticelli C, Glassock RJ. Prevention of complications from use of conventional immunosuppressants: a critical review. J Nephrol 2019; 32:851-870. [PMID: 30927190 DOI: 10.1007/s40620-019-00602-5] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 03/21/2019] [Indexed: 01/08/2023]
Abstract
Synthetic immunosuppressive drugs are largely used in immune-related renal diseases and in kidney transplantation. Most of these drugs have a low therapeutic index (the ratio that compares the blood concentration at which a drug becomes toxic and the concentration at which the drug is effective), which means that the drug should be dosed carefully and the patient monitored frequently. In this review, we consider the categories of synthetic immunosuppressive agents more frequently and conventionally used in clinical nephrology: glucocorticoids, Aalkylating agents (cyclophosphamide, chlorambucil), purine synthesis inhibitors (azathioprine, mycophenolate salts) and calcineurin inhibitors (cyclosporine, tacrolimus). For each category the possible side effects will be reviewed, the general and specific measures to prevent or treat the adverse events will be suggested, and the more common mistakes that may increase the risk of toxicity will be described. However, the efficacy and safety of immunosuppressive agents depend not only on the pharmacologic characteristics of single drugs but can be influenced also by the clinical condition and genetic characteristics of the patient, by the typology and severity of the underlying disease and by the interaction with other concomitantly used drugs.
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Affiliation(s)
- Claudio Ponticelli
- Division of Nephrology, Istituto Scientifico Ospedale Maggiore, Milan, Italy.
- , Via Ampere 126, 20131, Milan, Italy.
| | - Richard J Glassock
- The David Geffen School of Medicine, University of California, Los Angeles, CA, USA
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Abbass K, Krug H. Granulomatosis with polyangiitis in a patient with biopsy-proven IgG4-related pulmonary disease and coincident small cell lung cancer. BMJ Case Rep 2019; 12:12/3/e226280. [PMID: 30872335 PMCID: PMC6424371 DOI: 10.1136/bcr-2018-226280] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Granulomatosis with polyangiitis (GPA) was diagnosed in a patient with a 16-month history of IgG4-related lung disease that spontaneously became asymptomatic. Cytoplasmic antineutrophil cytoplasmic antibody (ANCA) was positive at the time of diagnosis of IgG4-related disease (IgG4-RD), but there was no vasculitis or kidney disease. Sixteen months later he developed rapidly progressive glomerulonephritis that responded to cyclophosphamide treatment. While undergoing treatment for GPA, he was found to have a lung mass identified as small cell lung cancer. This mass was present at the time of the IgG4-RD diagnosis. GPA can be confused with IgG4-RD histologically and they rarely coexist. ANCA antibodies are primarily IgG4 subclass. IgG4-RD has been associated with cancer and may improve prognosis. We speculate that this patient may have had small cell lung cancer that incited an IgG4 predominant immune response with coexistent ANCA antibodies that eventually resulted in GPA. Immunosuppressive treatment of GPA likely accelerated the progression of the lung cancer.
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Affiliation(s)
- Khurram Abbass
- Department of Medicine, Regional Medical Center, San Jose, California, USA
| | - Hollis Krug
- Rheumatology (111R), Minneapolis VA HCS, Minneapolis, Minnesota, USA
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Luqmani RA, Águeda A, O'Neill L. Small- and Medium-Vessel Primary Vasculitis. Clin Immunol 2019. [DOI: 10.1016/b978-0-7020-6896-6.00058-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Whatmough S, Fernandez S, Sweeney N, Howell L, Dhaygude A. Comparing outcomes of biopsy-proven anti-neutrophil cytoplasmic autoantibody-associated glomerulonephritis patients treated with cyclophosphamide in the 20th and 21st centuries: a 23-year study. Clin Kidney J 2018; 12:42-48. [PMID: 30746129 PMCID: PMC6366142 DOI: 10.1093/ckj/sfy084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 07/31/2018] [Indexed: 11/17/2022] Open
Abstract
Background Anti-neutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis (AAV) is a multisystem autoimmune disorder associated with significant morbidity and mortality. Approximately 80–90% of patients have circulating ANCAs. Long-term outcomes appear to be improving. This retrospective study analyses the incidence and patient outcomes over a period of 23 years at a single tertiary centre. Methods Outcomes of patients diagnosed with AAV between 1 January 1988 and 31 December 2010 were collected retrospectively. Data including patient demographics, age of diagnosis, dates of starting renal replacement therapy, death and biochemistry results were collected. Patients were divided into two cohorts (1988–99 and 2000–10) and analysed using Stata software (StataCorp, College Station, TX, USA). Results A complete dataset was obtained for 273 patients. Of these patients, 101 were diagnosed between 1988 and 1999 while 172 were diagnosed between 2000 and 2010. The number of patients diagnosed with AAV increased from 2.2/million in 1988 to 10.3/million in 2010. A higher proportion of patients (56.4%) in the earlier cohort presented with creatinine >500 μmol/L compared with the later cohort (30.2%; P < 0.001). Overall patient survival improved significantly between the two cohorts. Cohort 1 had a median survival of 59 months compared with 125 months for Cohort 2 (P = 0.003). Conclusions This study shows that AAV is being diagnosed at an earlier stage, resulting in improved outcomes. This may be because of improvements in the management of AAV and chronic kidney disease.
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Affiliation(s)
| | | | - Niamh Sweeney
- Renal Department, Royal Preston Hospital, Preston, UK
| | - Laura Howell
- Faculty of Health and Wellbeing, University of Central Lancashire, Preston, UK
| | - Ajay Dhaygude
- Renal Department, Royal Preston Hospital, Preston, UK
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Abstract
Various systemic inflammatory diseases, such as rheumatoid arthritis (RA), Sjögren's syndrome and systemic lupus erythematosus (SLE) are associated with an increased risk for the development of lymphomas. Studies on patients with RA and Sjögren's syndrome have shown that there is a clear association of the incidence of lymphoma with the severity and activity of the disease and lymphomas in particular are diseases which preferentially occur in immunosuppressed patients; therefore, knowledge of the different lymphoma subtypes, their prognosis and treatment options are important for rheumatologists. Currently, there is no evidence for an increased risk of lymphoma with the available conventional basis therapies or biologic disease-modifying antirheumatic drugs (DMARDs). The decision on how to treat a patient with previous lymphoma who requires antirheumatic treatment is more difficult as patients with previous malignancies are not included in clinical studies and in registries a bias with respect to patient selection must be taken into consideration. Decisions on the treatment approach, therefore need to be individualized and interdisciplinary management together with the treating hematologist is warranted.
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Granulomatosis with polyangiitis presenting as a renal mass mimicking immunoglobulin G4-related disease. HUMAN PATHOLOGY: CASE REPORTS 2017. [DOI: 10.1016/j.ehpc.2017.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Mechanistic and clinical insights at the scleroderma-cancer interface. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2017; 2:153-159. [PMID: 29264402 DOI: 10.5301/jsrd.5000250] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Emerging data suggest tantalizing links between cancer and systemic inflammatory rheumatic syndromes. In scleroderma, patients may have an increased risk of cancer secondary to chronic inflammation and damage from the disease, malignant transformation promoted by immunosuppressive therapies, a shared susceptibility to both cancer and autoimmunity, or a common inciting exposure. However, it is increasingly recognized that a subset of patients develop cancer around the time that scleroderma clinically manifests, raising the question of cancer-induced autoimmunity. In this review, we discuss data suggesting a mechanistic link between cancer and the development of scleroderma, and the clinical implications of these findings.
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Giat E, Ehrenfeld M, Shoenfeld Y. Cancer and autoimmune diseases. Autoimmun Rev 2017; 16:1049-1057. [DOI: 10.1016/j.autrev.2017.07.022] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 07/12/2017] [Indexed: 02/06/2023]
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Abstract
Vasculitides comprise several diseases affecting vessels of different sizes, mainly arteries, but also capillaries and veins. Antineutrophil cytoplasm antibody-associated vasculitides (AAVs) belong to the systemic necrotizing small-vessel vasculitis group that comprises granulomatosis with polyangiitis, microscopic polyangiitis and eosinophilic granulomatosis with polyangiitis. Internists often see AAV patients, and although their outcomes are usually good, the disease can be responsible for morbidity and mortality. Herein, after reviewing the literature, we concentrate on selected aspects important for the internist, including classification, diagnostic dilemmas, treatment novelties, and follow-up.
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Affiliation(s)
- Benjamin Chaigne
- Department of Internal Medicine, Hôpital Cochin, APHP, Université Paris Descartes, 27, rue du faubourg Saint-Jacques, 75679, Paris Cedex 14, France
| | - Loïc Guillevin
- Department of Internal Medicine, Hôpital Cochin, APHP, Université Paris Descartes, 27, rue du faubourg Saint-Jacques, 75679, Paris Cedex 14, France.
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Bernal-Bello D, de Tena JG, Guillén-Del Castillo A, Selva-O'Callaghan A, Callejas-Moraga EL, Marín-Sánchez AM, Fonollosa-Pla V, Simeón-Aznar CP. Novel risk factors related to cancer in scleroderma. Autoimmun Rev 2017; 16:461-468. [PMID: 28285170 DOI: 10.1016/j.autrev.2017.03.012] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 02/09/2017] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Emerging data have shown an increased risk of malignancy among patients diagnosed with systemic sclerosis (SSc) so identification of risk factors linking both disorders might have prognostic implications. The aim of this study was to assess the clinical and treatment-related risk factors for cancer in a single-center cohort of patients with SSc. METHODS Demographic, clinical, capillaroscopic, immunological and treatment-related data from 432 consecutive SSc patients were retrospectively analyzed. Variables that reached significant association in the univariate analysis were entered into a logistic regression in order to identify independent risk factors for cancer. RESULTS Malignancy was diagnosed in 53 patients (12.2%). Fifty-eight neoplasms were identified, among which breast (n=15), lung (n=10) and hematologic (n=9) malignancies were the most prevalent. In 19 patients the diagnosis of both scleroderma and tumour was made in <3years apart. Cancer significantly decreased the probability of survival (OR=2.61; 95%CI 1.46-4.69; p=0.001). No association with age, sex, smoking, cutaneous subset or RNA polymerase-III antibodies was found. However, risk of cancer was directly associated with the presence of anti-PM/Scl antibodies (OR=3.90; 95%CI 1.31-11.61; p=0.014), and inversely related to aspirin use (OR=0.33; 95%CI 0.12-0.90; p=0.031), which remained as independent risk factors for cancer on multivariate analysis. CONCLUSIONS PM/Scl antibodies seem to be associated with a higher risk of cancer in scleroderma. In contrast, the use of aspirin is related to a lower risk of cancer in our series. More studies are needed to ascertain the role of anti PM/Scl antibodies and aspirin in the development of malignancy among patients with SSc.
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Affiliation(s)
- David Bernal-Bello
- Department of Internal Medicine, Hospital Universitario de Fuenlabrada, Universidad Rey Juan Carlos, C/Camino del Molino, 2, 28942, Fuenlabrada, Madrid, Spain.
| | - Jaime García de Tena
- Department of Internal Medicine, Hospital Universitario de Guadalajara, Universidad de Alcalá, C/Donante de Sangre, s/n, 19002 Guadalajara, Spain.
| | - Alfredo Guillén-Del Castillo
- Department of Internal Medicine, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Spain, P. Vall d'Hebron, 119-129, 08035 Barcelona, Spain.
| | - Albert Selva-O'Callaghan
- Department of Internal Medicine, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Spain, P. Vall d'Hebron, 119-129, 08035 Barcelona, Spain.
| | - Eduardo L Callejas-Moraga
- Department of Internal Medicine, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Spain, P. Vall d'Hebron, 119-129, 08035 Barcelona, Spain.
| | - Ana María Marín-Sánchez
- Department of Immunology, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Spain, P. Vall d'Hebron, 119-129, 08035 Barcelona, Spain.
| | - Vicent Fonollosa-Pla
- Department of Internal Medicine, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Spain, P. Vall d'Hebron, 119-129, 08035 Barcelona, Spain.
| | - Carmen Pilar Simeón-Aznar
- Department of Internal Medicine, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Spain, P. Vall d'Hebron, 119-129, 08035 Barcelona, Spain.
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Affiliation(s)
- G. Moroni
- Nephrological Unit, Divisione di Nefrologia e Dialisi, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - C. Ponticelli
- Nephrological Unit, Humanitas Clinical and Research Center, Rozzano (Milano), Italy
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McNicholas BA, Griffin TP, Donnellan S, Ryan L, Garrahy A, Coughlan R, Giblin L, Lappin D, Reddan D, Carey JJ, Griffin MD. ANCA-associated vasculitis: a comparison of cases presenting to nephrology and rheumatology services. QJM 2016; 109:803-809. [PMID: 27318367 DOI: 10.1093/qjmed/hcw100] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 05/19/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Anti-neutrophil cytoplasmic antibody (ANCA) -associated vasculitis (AAV) is a disease characterized by inflammation of small vessels and detectable ANCA in the circulation. Patients may develop a broad spectrum of clinical features ranging from indolent sino-nasal disease and rashes to fulminant renal failure or acute life-threatening pulmonary haemorrhage. Consequently, patients with AAV present to a variety of specialties including nephrology and rheumatology, whose training and approaches to management of such patients may differ. There is little literature comparing patients presenting to different specialties and their outcomes. METHODS We compared two cohorts of patients with ANCA-positive AAV presenting to either the rheumatology or nephrology department at Galway University Hospitals from June 2002 to July 2011. A standardized data collection form was used to collect information regarding baseline demographics, manifestations of AAV, initial management, relapses and complications. RESULTS Forty-five patients were included in this study (15 rheumatology/30 nephrology). The nephrology cohort was older, had a higher C-reactive protein, Birmingham Vascular Activity Score and ANCA titer at presentation compared to the rheumatology group. Induction treatment varied between the cohorts with rheumatology patients most commonly receiving a combination of oral corticosteroids (73%) and methotrexate (60%) and nephrology patients receiving a combination of intravenous corticosteroids (93%) and cyclophosphamide (90%). Fifty-three percent of the rheumatology patients who completed induction therapy relapsed compared to 30% of the nephrology patients. CONCLUSION This study presents two different cohorts of patients with the same disease that were managed by two different disciplines. It highlights the heterogeneity of AAV and the importance of interdisciplinary communication and cooperation when managing these patients.
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Affiliation(s)
- B A McNicholas
- From the Nephrology Department , Galway University Hospitals, Saolta University Health Group, Galway, Ireland
- School of Medicine, College of Medicine, Nursing and Health Sciences, National University of Ireland, Galway, Ireland
| | - T P Griffin
- From the Nephrology Department , Galway University Hospitals, Saolta University Health Group, Galway, Ireland
- School of Medicine, College of Medicine, Nursing and Health Sciences, National University of Ireland, Galway, Ireland
- Rheumatology Department, Galway University Hospitals, Saolta University Health Group, Galway, Ireland
| | - S Donnellan
- From the Nephrology Department , Galway University Hospitals, Saolta University Health Group, Galway, Ireland
| | - L Ryan
- From the Nephrology Department , Galway University Hospitals, Saolta University Health Group, Galway, Ireland
| | - A Garrahy
- From the Nephrology Department , Galway University Hospitals, Saolta University Health Group, Galway, Ireland
| | - R Coughlan
- School of Medicine, College of Medicine, Nursing and Health Sciences, National University of Ireland, Galway, Ireland
- Rheumatology Department, Galway University Hospitals, Saolta University Health Group, Galway, Ireland
| | - L Giblin
- From the Nephrology Department , Galway University Hospitals, Saolta University Health Group, Galway, Ireland
- School of Medicine, College of Medicine, Nursing and Health Sciences, National University of Ireland, Galway, Ireland
| | - D Lappin
- From the Nephrology Department , Galway University Hospitals, Saolta University Health Group, Galway, Ireland
- School of Medicine, College of Medicine, Nursing and Health Sciences, National University of Ireland, Galway, Ireland
| | - D Reddan
- From the Nephrology Department , Galway University Hospitals, Saolta University Health Group, Galway, Ireland
- School of Medicine, College of Medicine, Nursing and Health Sciences, National University of Ireland, Galway, Ireland
| | - J J Carey
- School of Medicine, College of Medicine, Nursing and Health Sciences, National University of Ireland, Galway, Ireland
- Rheumatology Department, Galway University Hospitals, Saolta University Health Group, Galway, Ireland
| | - M D Griffin
- From the Nephrology Department , Galway University Hospitals, Saolta University Health Group, Galway, Ireland
- School of Medicine, College of Medicine, Nursing and Health Sciences, National University of Ireland, Galway, Ireland
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Haris Á, Dolgos S, Polner K. Therapy and prognosis of ANCA-associated vasculitis from the clinical nephrologist's perspective. Int Urol Nephrol 2016; 49:91-102. [PMID: 27671907 DOI: 10.1007/s11255-016-1419-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Accepted: 09/12/2016] [Indexed: 10/20/2022]
Abstract
This paper reviews the recently published scientific information regarding ANCA-associated vasculitis (AAV), aiming to highlight the most important data from the clinical nephrologists' perspective. The classification, pathomechanism, recent achievements of the treatment, short-term and long-term outcomes of the disease, and the difficulties nephrologists face when taking care for patients with AAV are summarized. There has been significant progress in the understanding of the genetic and pathologic background of the disease in the last years, and results of histological studies guide us to predict long-term renal function. Findings of several multicentered trials with reasonable number of participants provide comparison of the efficacy and safety of different remission induction and maintenance therapies, and evaluate recently introduced immunosuppressive agents. Although the clinical outcome of patients with AAV has improved significantly since modern immunosuppressive drugs are available, the treatment-related complications still contribute to the morbidity and mortality. To improve the survival and quality of life of patients with AAV further, knowledge of the predictors of relapse, end-stage kidney disease, and mortality, also prevention of infections and other treatment-related adverse events are important. The eligibility for renal transplantation and the option for successful pregnancies for young women are also important factors which influence the patients' quality of life. In order to provide favorable outcome, the clinicians need to establish personalized treatment strategies to optimize the intensity and minimize the toxicity of the immunosuppressive therapy.
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Affiliation(s)
- Ágnes Haris
- Nephrology Department, Szent Margit Hospital, 132 Bécsi Street, Budapest, 1032, Hungary.
| | - Szilveszter Dolgos
- Nephrology Department, Szent Margit Hospital, 132 Bécsi Street, Budapest, 1032, Hungary
| | - Kálmán Polner
- Nephrology Department, Szent Margit Hospital, 132 Bécsi Street, Budapest, 1032, Hungary
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Egiziano G, Bernatsky S, Shah AA. Cancer and autoimmunity: Harnessing longitudinal cohorts to probe the link. Best Pract Res Clin Rheumatol 2016; 30:53-62. [PMID: 27421216 DOI: 10.1016/j.berh.2016.03.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
In many autoimmune rheumatic diseases, there is an increased risk of cancer compared to the general population. While reasons for this increased risk have not been elucidated, it has been hypothesized that the link between cancer and autoimmunity may be bidirectional. For instance, chronic inflammation and damage from the rheumatic disease or its therapies may trigger malignant transformation; conversely, antitumor immune responses targeting cancers may become cross-reactive resulting in autoimmunity. In rare rheumatic diseases, longitudinal observational studies can play a critical role in studying these complex relationships, thereby enabling investigators to quantify the extent of cancer risk, identify unique clinical phenotypes associated with cancer, investigate the biological link between these conditions, and define optimal strategies for screening and treatment of the underlying cancer. In this review, we discuss recent data on cancer in the rheumatic diseases and suggest a research agenda to address several gaps in our current knowledge base.
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Affiliation(s)
- Giordano Egiziano
- Resident Internal Medicine, McGill University, Royal Victoria Hospital, Glen Site, Rm D05.5840, 1001 Decarie Boulevard, Montreal, QC H4A 3J1, Canada.
| | - Sasha Bernatsky
- Division of Clinical Epidemiology, McGill University Health Center, 687 Pine Avenue, V Building, Montreal, QC H3A 1A1, Canada.
| | - Ami A Shah
- Johns Hopkins Scleroderma Center, 5501 Hopkins Bayview Circle, Room 1B.15, Baltimore, MD 21224, USA.
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