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Tanaka K, Ichikawa A, Umezawa N, Yamamoto K, Yoshifuji K, Okada K, Nogami A, Umezawa Y, Nagao T, Sakashita C, Mori T, Tohda S, Koike R, Yasuda S, Yamamoto M. Lymphoproliferative disorder risk after methotrexate treatment for rheumatoid arthritis. Cancer Sci 2023; 114:3719-3727. [PMID: 37365854 PMCID: PMC10475769 DOI: 10.1111/cas.15894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 06/06/2023] [Accepted: 06/12/2023] [Indexed: 06/28/2023] Open
Abstract
Methotrexate (MTX)-associated lymphoproliferative disorder (MTX-LPD) is a troublesome problem in patients receiving MTX for rheumatoid arthritis (RA). However, its incidence, prognosis, and risk factors remain unclear. In this retrospective study, we evaluated the actual incidence, prognostic impact, and risk factors of MTX-LPD. Of the 986 patients with RA treated with MTX, 90 patients experienced 95 new malignancies (NMs), with LPD as the most frequent in 26 patients. The cumulative LPD incidences were 1.3% and 4.7% at 5 and 10 years after MTX initiation, respectively. Among the 24 patients who discontinued MTX after developing LPD, 15 showed sustained regression, without difference in overall survival between patients with LPD and without NM. Inflammatory markers and absolute lymphocyte counts were not useful for early LPD development detection, but most of the patients with LPD had persistently elevated erythrocyte sedimentation ratios. Regarding concomitant drugs, tacrolimus increased the risk only if patients were not receiving biological disease-modifying antirheumatic drugs (bDMARDs). bDMARDs did not increase the risk for any of the drugs or the number of classes used. The number of LPD cases was lower in patients with IL-6A even after a long period after MTX, although with no statistically significant difference. Thus, approximately 1 in 20 patients with RA developed MTX-LPD over the 10 years of MTX treatment, but it did not affect the survival of patients with RA. Tacrolimus increased the risk of developing LPD for certain patients and should be used with caution.
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Affiliation(s)
- Keisuke Tanaka
- Department of HematologyTokyo Medical and Dental UniversityTokyoJapan
| | - Ayako Ichikawa
- Department of HematologyTokyo Medical and Dental UniversityTokyoJapan
| | - Natsuka Umezawa
- Department of RheumatologyTokyo Medical and Dental UniversityTokyoJapan
| | - Kouhei Yamamoto
- Department of PathologyTokyo Medical and Dental UniversityTokyoJapan
| | - Kota Yoshifuji
- Department of HematologyTokyo Medical and Dental UniversityTokyoJapan
| | - Keigo Okada
- Department of HematologyTokyo Medical and Dental UniversityTokyoJapan
| | - Ayako Nogami
- Department of HematologyTokyo Medical and Dental UniversityTokyoJapan
- Department of Laboratory MedicineTokyo Medical and Dental UniversityTokyoJapan
| | - Yoshihiro Umezawa
- Department of HematologyTokyo Medical and Dental UniversityTokyoJapan
| | - Toshikage Nagao
- Department of HematologyTokyo Medical and Dental UniversityTokyoJapan
| | - Chizuko Sakashita
- Department of HematologyTokyo Medical and Dental UniversityTokyoJapan
| | - Takehiko Mori
- Department of HematologyTokyo Medical and Dental UniversityTokyoJapan
| | - Shuji Tohda
- Department of HematologyTokyo Medical and Dental UniversityTokyoJapan
- Department of Laboratory MedicineTokyo Medical and Dental UniversityTokyoJapan
| | - Ryuji Koike
- Department of RheumatologyTokyo Medical and Dental UniversityTokyoJapan
| | - Shinsuke Yasuda
- Department of RheumatologyTokyo Medical and Dental UniversityTokyoJapan
| | - Masahide Yamamoto
- Department of HematologyTokyo Medical and Dental UniversityTokyoJapan
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Kuribayashi A, Kawashima S, Kayamori K, Sakamoto J, Tomisato H, Watanabe H, Kurabayashi T. Magnetic resonance imaging of methotrexate-related lymphoproliferative disorder with a chief complaint of oral symptoms. Oral Radiol 2023; 39:235-241. [PMID: 35689759 DOI: 10.1007/s11282-022-00626-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 05/10/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To determine the magnetic resonance imaging (MRI) features of methotrexate-related lymphoproliferative disorder (MTX-LPD) in the oral cavity of a patient with a chief complaint of oral symptoms. METHODS We included six patients who visited our hospital between November 2014 and November 2019, histopathologically diagnosed with MTX-LPD. All images were examined using 3 T MRI and reviewed by two radiologists. RESULTS Masses were detected in five cases; all masses demonstrated signal hypointensity and homogeneous signal hyperintensity on T1- and T2-weighted images with fat suppression. Homogeneous enhancement with fat suppression was evident on post-contrast T1-weighted imaging. We performed dynamic contrast-enhanced MRI in three cases and observed early enhancement with a low washout ratio pattern in all cases. Four patients underwent diffusion-weighted MRI and revealed low mean apparent diffusion coefficient (ADC) of 0.57 (range 0.5-0.65) × 10-3 mm2/s. CONCLUSIONS We reported on the imaging characteristics of six rare cases of MTX-LPD in the oral cavity. Homogeneous hyperintensity on fat-suppressed T2-weighted images and low ADC values are possible features of MTX-LPD. Moreover, MTX-LPD can be differentiated from other carcinomas in the oral cavity.
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Affiliation(s)
- Ami Kuribayashi
- Oral and Maxillofacial Radiology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan.
| | - Sakurako Kawashima
- Oral and Maxillofacial Radiology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Kou Kayamori
- Department of Oral Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Junichiro Sakamoto
- Oral and Maxillofacial Radiology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Hiroshi Tomisato
- Department of Oral Radiology, Dental Hospital, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hiroshi Watanabe
- Oral and Maxillofacial Radiology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Tohru Kurabayashi
- Oral and Maxillofacial Radiology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
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Shirakabe K, Mizokami K. Methotrexate-associated lymphoproliferative disease detected as a colorectal mass lesions: a case report. J Surg Case Rep 2023; 2023:rjad098. [PMID: 36896165 PMCID: PMC9991593 DOI: 10.1093/jscr/rjad098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 02/10/2023] [Indexed: 03/09/2023] Open
Abstract
Methotrexate-related lymphoproliferative disorder (MTX-LPD) is a rare but serious complication that occurs in patients treated with methotrexate (MTX); although MTX-LPD has been reported recently, the incidence in the colon is very low. A 79-year-old woman who had been receiving MTX for 15 years came to our hospital complaining of postprandial abdominal pain and nausea. Computed tomography scan showed the dilation of the small bowel and a tumor in the cecum. In addition, numerous nodular lesions were seen in the peritoneum. Ileal-transverse colon bypass surgery was performed for small bowel obstruction. Histopathological findings of both the cecum and the peritoneal nodules revealed the diagnosis of MTX-LPD. We report MTX-LPD occurring in the colon; it is important to consider MTX-LPD when intestinal symptoms occur during MTX therapy.
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Affiliation(s)
- Katsudai Shirakabe
- Department of General Surgery, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, Chiba, Japan
| | - Ken Mizokami
- Department of General Surgery, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, Chiba, Japan
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Tsuruoka M, Inoue J, Kakazu E, Ninomiya M, Iwata T, Sano A, Masamune A. Methotrexate-associated Lymphoproliferative Disorder in the Liver Resembling Hepatocellular Carcinoma Treated with Transarterial Chemoembolization. Intern Med 2020; 59:2255-2260. [PMID: 32522926 PMCID: PMC7578598 DOI: 10.2169/internalmedicine.4787-20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Methotrexate-related lymphoproliferative disorder (MTX-LPD) is known to be a side effect of MTX, but its involvement in the liver has been rarely reported. We herein report a 70-year-old woman with autoimmune hepatitis and rheumatoid arthritis who developed multiple liver tumors. We initially considered that she had developed rapid-growing hepatocellular carcinoma (HCC) in the cirrhotic liver based on imaging tests. A tumor biopsy and transcatheter arterial chemoembolization were thus performed. The tumors were then diagnosed as diffuse large B-cell lymphoma pathologically and considered to be MTX-LPD. This case indicates that MTX-LPD should be considered even in cirrhotic patients with liver tumors resembling HCC.
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Affiliation(s)
- Mio Tsuruoka
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Jun Inoue
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Eiji Kakazu
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Masashi Ninomiya
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Tomoaki Iwata
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Akitoshi Sano
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Atsushi Masamune
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
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Tomita M, Oura S, Nishiguchi H, Makimoto S. A case of bilateral methotrexate-associated diffuse large B-cell lymphomas of the breasts with unique clinical presentation and outcome. Breast Cancer 2020; 27:1038-1043. [PMID: 32361905 DOI: 10.1007/s12282-020-01102-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 04/22/2020] [Indexed: 11/29/2022]
Abstract
A 54-year-old woman on methotrexate (MTX) treatment developed reddish skin change in her right breast. Mammography and ultrasound showed no masses in the breasts but bilateral mammary glands presented diffuse lower-level echoes. Only 19 days later, the patient developed bilateral breast masses. Histological examination showed that diffuse large B-cell lymphoma cells spread widely and sparsely in the bilateral breasts in addition to the tumor cell conglomerate, leading to the diagnosis of MTX-associated lympho-proliferative disorders (MTX-LPDs). Withdrawal of MTX resulted in complete disappearance of the left MTX-LPD in 2 months but no regression of the right MTX-LPD. Chemotherapy led to a partial response followed by re-growth of the right MTX-LPD. Re-biopsy of the right MTX-LPD revealed double/triple hit lymphoma. Second-line and later-line chemotherapies caused no regression of the right MTX-LPD. The patient died in a year after the diagnosis of MTX-LPDs. Breast oncologists should note the presence, biology, and diagnostic images of MTX-LPD.
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Affiliation(s)
- Masafumi Tomita
- Department of Surgery, Kishiwada Tokushukai Hospital, 4-27-1, Kamori-cho, Kishiwada, Osaka, 596-8522, Japan
| | - Shoji Oura
- Division of Breast Surgery, Kishiwada Tokushukai Hospital, 4-27-1, Kamori-cho, Kishiwada, Osaka, 596-8522, Japan.
| | - Haruka Nishiguchi
- Breast Surgery, Wakaura Chuo Hospital, 6-2-70, Shioya, Wakayama, Wakayama, 641-0055, Japan
| | - Shinichirou Makimoto
- Department of Surgery, Kishiwada Tokushukai Hospital, 4-27-1, Kamori-cho, Kishiwada, Osaka, 596-8522, Japan
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Kondo M, Murakawa Y, Moriyama M, Honda M, Sugiura T, Onoda K, Watanabe Y, Kakimaru H. Distinct decrease in peripheral lymphocytes in EBER-positive cases of MTX-LPD. Mod Rheumatol 2020; 31:88-93. [PMID: 32075469 DOI: 10.1080/14397595.2020.1733246] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVES To determine the clinical characteristics of methotrexate-associated lymphoproliferative disorder (MTX-LPD). METHODS In this study, 12 RA patients who developed MTX-LPD were assessed. The peripheral blood lymphocyte (PBL) count at the onset of MTX-LPD was compared to that 6 months before the onset, in Epstein-Barr virus-encoded RNA (EBER)-positive and -negative subgroups. We examined the change in the PBL count after MTX withdrawal. In patients with relapsed LPD, changes in the PBL count before relapse were also examined. RESULTS Regression of LPD after MTX withdrawal was noted in eight patients. In these patients, the PBL count was decreased at the onset of MTX-LPD compared to 6 months before the onset; the decrease was significantly more prominent in EBER-positive patients. In cases of spontaneous regression of LPD, the PBL count recovered quickly after MTX withdrawal. Four of eight patients showed a recurrence of LPD after they improved following MTX withdrawal. These patients also exhibited a decreased PBL count at recurrence compared to 6 months before recurrence. CONCLUSION A decrease in the PBL count might be involved in the pathogenesis of MTX-LPD, especially in EBER-positive cases and in patients with LPD relapse after MTX withdrawal following initial improvement.
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Affiliation(s)
- Masahiro Kondo
- Department of Rheumatology, Shimane University Faculty of Medicine, Shimane, Japan
| | - Yohko Murakawa
- Department of Rheumatology, Shimane University Faculty of Medicine, Shimane, Japan
| | - Mayuko Moriyama
- Department of Rheumatology, Shimane University Faculty of Medicine, Shimane, Japan
| | - Manabu Honda
- Department of Rheumatology, Shimane University Faculty of Medicine, Shimane, Japan
| | | | - Keiichi Onoda
- Department of Neurology, Shimane University Faculty of Medicine, Shimane, Japan
| | - Yohei Watanabe
- Department of Orthopedics, National Hospital Organization Hamada Medical Center, Shimane, Japan
| | - Hiroyuki Kakimaru
- Department of Orthopedics, National Hospital Organization Hamada Medical Center, Shimane, Japan
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Ono R, Kumagae T, Uojima H, Teshima S, Kudo M, Kitagawa I, Yoshizawa M. Hepatic methotrexate-associated lymphoproliferative disorders identified by multiple liver tumors: a case report and review of the literature. J Med Case Rep 2019; 13:196. [PMID: 31242930 PMCID: PMC6595583 DOI: 10.1186/s13256-019-2135-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 05/29/2019] [Indexed: 12/12/2022] Open
Abstract
Background Methotrexate, an immunosuppressant, is widely used as the standard therapeutic drug for rheumatoid arthritis. With the increasing frequency of use of methotrexate, adverse effects of methotrexate have been reported, one of which is known as methotrexate-associated lymphoproliferative disorders. The etiology of hepatic methotrexate-associated lymphoproliferative disorders remains largely unknown. To date, there have only been ten cases of hepatic methotrexate-associated lymphoproliferative disorders reported in the English literature and a case report is very rare. Case presentation An 82-year-old Japanese man with rheumatoid arthritis treated with methotrexate presented with fever. Contrast-enhanced computed tomography showed multiple hypovascular nodules in his liver, spleen, and lung, and para-aortic lesions. Endoscopic ultrasound-guided fine-needle aspiration biopsy for liver tumors was performed, and pathological results identified cluster of differentiation 20-positive lymphocytes. Discontinuance of methotrexate led to regression of the nodules and a final definitive diagnosis of methotrexate-associated lymphoproliferative disorders was made. Conclusions We review 11 reported cases of hepatic methotrexate-associated lymphoproliferative disorders including the present case. Physicians should discontinue methotrexate in patients with rheumatoid arthritis treated with methotrexate when elevated soluble interleukin-2 receptor and hypovascular lesions in contrast-enhanced computed tomography are confirmed considering the possibility of methotrexate-associated lymphoproliferative disorders.
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Affiliation(s)
- Ryohei Ono
- Department of General Internal Medicine, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura city, Kanagawa, 247-8533, Japan.
| | - Tomohiro Kumagae
- Department of General Internal Medicine, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura city, Kanagawa, 247-8533, Japan
| | - Haruki Uojima
- Department of Gastroenterology, Internal Medicine, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0375, Japan
| | - Shinichi Teshima
- Department of Diagnostic Pathology, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura city, Kanagawa, 247-8533, Japan
| | - Madoka Kudo
- Department of Diagnostic Pathology, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura city, Kanagawa, 247-8533, Japan
| | - Izumi Kitagawa
- Department of General Internal Medicine, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura city, Kanagawa, 247-8533, Japan
| | - Masaki Yoshizawa
- Department of Rheumatology, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura city, Kanagawa, 247-8533, Japan
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Aota Y, Nonaka T, Kimura S, Honda T, Okuda Y, Watanabe T, Fujiwara K, Yokoyama T, Wakabayashi Y, Sakurai M, Gotoh A. [A methotrexate-associated lympholiferative disorder patient with gastrointestinal perforation]. Nihon Ronen Igakkai Zasshi 2017; 54:567-572. [PMID: 29213000 DOI: 10.3143/geriatrics.54.567] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
A 70-year-old woman was diagnosed with chronic rheumatoid arthritis and treated with methotrexate and prednisolone. She visited our hospital to determine the cause of her continuous fatigue and fever for the past three weeks. She consumed no food orally and was provided antibiotics because free air was found on computed tomography (CT). Intraperitoneal small lymphadenopathy and swelling of both adrenal glands was also found on CT, and MTX-associated lymphoproliferative disorder (MTX-LPD) was suspected. Am adrenal gland biopsy showed diffuse large B-cell lymphoma (DLBCL) associated with MTX-LPD. The causes of gastrointestinal perforation with collagen diseases have been reported to be functional gastrointestinal disorders with collagen diseases like amyloidosis, gastrointestinal infections in immunocompromised patients, and side effects of medication, such as steroids or NSAIDs and MTX. MTX-LPD is an uncommon side effect of methotrexate. To ensure its appropriate diagnosis and treatment, it is important to improve the degree of recognition of MTX-LPD, and a prompt response is needed.
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Affiliation(s)
- Yasuo Aota
- Department of Internal Medicine, Kohsei Chuo General Hospital.,Department of Hematology, Juntendo University School of Medicine
| | - Tadahito Nonaka
- Department of Gastroenterology & Hepatology, Kohsei Chuo General Hospital
| | - Sei Kimura
- Department of Gastroenterology & Hepatology, Kohsei Chuo General Hospital
| | - Tadahiro Honda
- Department of Internal Medicine, Kohsei Chuo General Hospital.,Department of Hematology, Juntendo University School of Medicine
| | - Yuko Okuda
- Department of Internal Medicine, Kohsei Chuo General Hospital
| | | | | | | | | | - Michio Sakurai
- Department of Internal Medicine, Kohsei Chuo General Hospital
| | - Akihiko Gotoh
- Department of Internal Medicine, Kohsei Chuo General Hospital.,Department of Hematology, Juntendo University School of Medicine
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Inui Y, Matsuoka H, Yakushijin K, Okamura A, Shimada T, Yano S, Takeuchi M, Ito M, Murayama T, Yamamoto K, Itoh T, Aiba K, Minami H. Methotrexate-associated lymphoproliferative disorders: management by watchful waiting and observation of early lymphocyte recovery after methotrexate withdrawal. Leuk Lymphoma 2015; 56:3045-51. [PMID: 25721751 DOI: 10.3109/10428194.2015.1022769] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
No optimum treatment of iatrogenic immunodeficiency-associated lymphoproliferative disorders due to methotrexate in patients with rheumatoid arthritis (MTX-LPD) has yet been established, although MTX withdrawal is known to have a substantial effect on tumor regression. Here, we retrospectively analyzed 20 cases of MTX-LPD. Tumor shrinkage occurred in 18 of 20 cases, but only following MTX withdrawal. This tumor regression ratio was considerably better than in previous reports, and appeared due to longer "watchful waiting." Lymphocyte recovery at 2 weeks after MTX withdrawal was significantly higher in cases with tumor regression in 1 month than in those without tumor regression (p = 0.001). Median time to maximal efficacy after MTX cessation in cases without chemotherapy was 12 weeks (range 2-76). In conclusion, watchful waiting for a longer period after MTX cessation with observation of early lymphocyte recovery and uninterrupted continuation of other anti-rheumatoid drugs may be an acceptable management plan for MTX-LPD.
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Affiliation(s)
- Yumiko Inui
- a Division of Medical Oncology/Hematology, Department of Medicine , Kobe University Graduate School of Medicine , Kobe , Japan
| | - Hiroshi Matsuoka
- a Division of Medical Oncology/Hematology, Department of Medicine , Kobe University Graduate School of Medicine , Kobe , Japan
| | - Kimikazu Yakushijin
- a Division of Medical Oncology/Hematology, Department of Medicine , Kobe University Graduate School of Medicine , Kobe , Japan
| | - Atsuo Okamura
- a Division of Medical Oncology/Hematology, Department of Medicine , Kobe University Graduate School of Medicine , Kobe , Japan
| | - Takaki Shimada
- b Division of Clinical Oncology and Hematology, Jikei University School of Medicine , Tokyo , Japan
| | - Shingo Yano
- b Division of Clinical Oncology and Hematology, Jikei University School of Medicine , Tokyo , Japan
| | - Mai Takeuchi
- c Department of Pathology , Kobe University Graduate School of Medicine , Kobe , Japan
| | - Mitsuhiro Ito
- d Laboratory of Hematology, Division of Medical Biophysics, Kobe University Graduate School of Health Sciences , Kobe , Japan
| | - Tohru Murayama
- a Division of Medical Oncology/Hematology, Department of Medicine , Kobe University Graduate School of Medicine , Kobe , Japan.,e Hematology Division, Department of Medicine , Hyogo Cancer Center , Hyogo , Japan
| | - Katsuya Yamamoto
- a Division of Medical Oncology/Hematology, Department of Medicine , Kobe University Graduate School of Medicine , Kobe , Japan
| | - Tomoo Itoh
- c Department of Pathology , Kobe University Graduate School of Medicine , Kobe , Japan
| | - Keisuke Aiba
- b Division of Clinical Oncology and Hematology, Jikei University School of Medicine , Tokyo , Japan
| | - Hironobu Minami
- a Division of Medical Oncology/Hematology, Department of Medicine , Kobe University Graduate School of Medicine , Kobe , Japan
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