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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] [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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Krüger K. [DMARD (disease-modifying antirheumatic drug) treatment in patients with former or current cancer]. Z Rheumatol 2023; 82:206-211. [PMID: 36757415 DOI: 10.1007/s00393-023-01316-7] [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] [Accepted: 12/19/2022] [Indexed: 02/10/2023]
Abstract
In contrast to the original fear that treatment with disease-modifying antirheumatic drugs (DMARDs) and especially with biologic DMARDs (bDMARDs), was associated with an increased risk of the induction of malignancies, this has meanwhile fortunately not been confirmed over the long-term administration. Evaluations from register-based investigations as well as from other long-term cohort studies confirm that neither conventional DMARDs, such as methotrexate, nor tumor necrosis factor (TNF) inhibitors or biologics with a different mode of action show such a risk for induction of cancer or hematological malignancies (for skin tumors see the other article). Regarding the question whether recurrences of former malignancies can be induced by DMARDs, the database is considerably smaller; however, published investigations dealing with this topic so far signal that also in this respect no increased risk can be found. When comparing the individual substances with each other no substantial differences can be found. Although used in the treatment of hematological cancers, rituximab does not offer any advantages in comparison to other biologics. For the group of Janus kinase (JAK) inhibitors, which have been in use only for a few years, data outside the randomized controlled studies (which are limited in time and are conducted with a selected patient population) are limited so that a clear statement regarding the malignancy risk is not yet possible for these substances. In a solitary study comparing tofacitinib with TNF inhibitors in high-risk patients, the malignancy risk of the JAK inhibitor was increased compared to that under TNF inhibitor treatment; however, these results have not yet been confirmed by a second investigation.
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Affiliation(s)
- Klaus Krüger
- Rheumatologisches Praxiszentrum, St. Bonifatius Str. 5, 81541, München, Deutschland.
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3
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Methotrexate-associated lymphoproliferative disorder of the thoracic spine in a patient with rheumatoid arthritis receiving methotrexate: a case report. Skeletal Radiol 2021; 50:2117-2123. [PMID: 33772624 PMCID: PMC8364545 DOI: 10.1007/s00256-021-03764-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 03/18/2021] [Accepted: 03/18/2021] [Indexed: 02/02/2023]
Abstract
Methotrexate-associated lymphoproliferative disorder is recognized as a lymphoma that occurs following methotrexate administration. The lesion of the spine is extremely rare, and only one case of lesion in the lumbar spine has been reported so far. Here, we present a case of methotrexate-associated lymphoproliferative disorder of the thoracic spine in a 54-year-old woman with rheumatoid arthritis. The lesion formed an extra-skeletal tumor mass from lateral to the vertebral body to the paravertebral muscle extending posterior to the epidural space without bone destruction. Magnetic resonance imaging showed low signal intensities on both T1- and T2-weighted images and high signal intensity with short-tau inversion recovery. These radiological findings were similar to those for primary spinal lymphoma. The lesion rapidly paralyzed the patient, forcing her to be treated with posterior spinal decompression. The lesion could not be resected because it adhered to the dura. Following the histopathological diagnosis as methotrexate-associated lymphoproliferative disorder, methotrexate administration was terminated. The remaining mass lesion showed complete regression within 6 months. Methotrexate-associated lymphoproliferative disorder, which could be cured by the discontinuation of methotrexate, should be considered a differential diagnosis in spinal lesion cases showing lymphoma-like appearance with methotrexate treatment to avoid unnecessary treatments.
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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] [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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5
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Momose S, Tamaru JI. Iatrogenic immunodeficiency-associated lymphoproliferative disorders of B-cell type that develop in patients receiving immunosuppressive drugs other than in the post-transplant setting. J Clin Exp Hematop 2019; 59:48-55. [PMID: 31257345 PMCID: PMC6661961 DOI: 10.3960/jslrt.19014] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
In the current revised 4th edition of the World Health Organization (WHO) classification,
‘other iatrogenic immunodeficiency-associated lymphoproliferative disorders (Oii-LPDs)’ is
listed in the last section in the chapter on immunodeficiency-associated
lymphoproliferative disorders. Oii-LPDs cover a broad spectrum from benign lesions to
lymphoma, and correspond to one of the subtypes in the WHO classification for
immunocompetent patients. The WHO classification does not clearly indicate the histological subtype of this disease
category; however, the framework of subtype classification is similar to the
classification of post-transplant lymphoproliferative disorders, and recent studies have
attempted to subcategorize Oii-LPDs that fit this unique disease type. In this review, we
provide an overview of B-cell-type Oii-LPDs regarding their histopathology and
immunophenotype, genetics and clinical behaviors.
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6
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Hellbacher E, Hjorton K, Backlin C, Enblad G, Sundström C, Baecklund E, Knight A. Malignant lymphoma in granulomatosis with polyangiitis: subtypes, clinical characteristics and prognosis. Acta Oncol 2019; 58:1655-1659. [PMID: 31407922 DOI: 10.1080/0284186x.2019.1634833] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Erik Hellbacher
- Department of Medical Sciences, Section of Rheumatology, Uppsala University, Uppsala, Sweden
| | - Karin Hjorton
- Department of Medical Sciences, Section of Rheumatology, Uppsala University, Uppsala, Sweden
| | - Carin Backlin
- Department of Medical Sciences, Section of Rheumatology, Uppsala University, Uppsala, Sweden
| | - Gunilla Enblad
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Christer Sundström
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Eva Baecklund
- Department of Medical Sciences, Section of Rheumatology, Uppsala University, Uppsala, Sweden
| | - Ann Knight
- Department of Medical Sciences, Section of Rheumatology, Uppsala University, Uppsala, Sweden
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Bedoui Y, Guillot X, Sélambarom J, Guiraud P, Giry C, Jaffar-Bandjee MC, Ralandison S, Gasque P. Methotrexate an Old Drug with New Tricks. Int J Mol Sci 2019; 20:ijms20205023. [PMID: 31658782 PMCID: PMC6834162 DOI: 10.3390/ijms20205023] [Citation(s) in RCA: 197] [Impact Index Per Article: 39.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 09/16/2019] [Accepted: 09/30/2019] [Indexed: 12/16/2022] Open
Abstract
Methotrexate (MTX) is the first line drug for the treatment of a number of rheumatic and non-rheumatic disorders. It is currently used as an anchor disease, modifying anti-rheumatic drug in the treatment of rheumatoid arthritis (RA). Despite the development of numerous new targeted therapies, MTX remains the backbone of RA therapy due to its potent efficacy and tolerability. There has been also a growing interest in the use of MTX in the treatment of chronic viral mediated arthritis. Many viruses—including old world alphaviruses, Parvovirus B19, hepatitis B/C virus, and human immunodeficiency virus—have been associated with arthritogenic diseases and reminiscent of RA. MTX may provide benefits although with the potential risk of attenuating patients’ immune surveillance capacities. In this review, we describe the emerging mechanisms of action of MTX as an anti-inflammatory drug and complementing its well-established immunomodulatory activity. The mechanisms involve adenosine signaling modulation, alteration of cytokine networks, generation of reactive oxygen species and HMGB1 alarmin suppression. We also provide a comprehensive understanding of the mechanisms of MTX toxic effects. Lastly, we discussed the efficacy, as well as the safety, of MTX used in the management of viral-related rheumatic syndromes.
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Affiliation(s)
- Yosra Bedoui
- Unité Mixte de Recherche Processus Infectieux en Milieu Insulaire Tropical (PIMIT), INSERM U1187, CNRS 9192, IRD 249, Université de La Réunion-Plateforme Technologique CYROI-2, rue Maxime Rivière, 97490 Sainte-Clotilde, France.
| | - Xavier Guillot
- Service de Rhumatologie, CHU La Réunion site Félix Guyon, Allée des Topazes, CS11021, 97400 Saint Denis de La Réunion, France.
| | - Jimmy Sélambarom
- Unité Mixte de Recherche Processus Infectieux en Milieu Insulaire Tropical (PIMIT), INSERM U1187, CNRS 9192, IRD 249, Université de La Réunion-Plateforme Technologique CYROI-2, rue Maxime Rivière, 97490 Sainte-Clotilde, France.
| | - Pascale Guiraud
- Unité Mixte de Recherche Processus Infectieux en Milieu Insulaire Tropical (PIMIT), INSERM U1187, CNRS 9192, IRD 249, Université de La Réunion-Plateforme Technologique CYROI-2, rue Maxime Rivière, 97490 Sainte-Clotilde, France.
| | - Claude Giry
- Laboratoire de biologie, CNR associé des arbovirus, CHU La Réunion site Félix Guyon, Allée des Topazes, CS11021, 97400 Saint Denis de La Réunion, France.
| | - Marie Christine Jaffar-Bandjee
- Laboratoire de biologie, CNR associé des arbovirus, CHU La Réunion site Félix Guyon, Allée des Topazes, CS11021, 97400 Saint Denis de La Réunion, France.
| | - Stéphane Ralandison
- Service de Rhumatologie-Médecine Interne, CHU Morafeno, Route d'Ivoloina 501, Toamasina, Madagascar.
| | - Philippe Gasque
- Unité Mixte de Recherche Processus Infectieux en Milieu Insulaire Tropical (PIMIT), INSERM U1187, CNRS 9192, IRD 249, Université de La Réunion-Plateforme Technologique CYROI-2, rue Maxime Rivière, 97490 Sainte-Clotilde, France.
- Pôle de Biologie, secteur Laboratoire d'Immunologie Clinique et Expérimentale de la zone de l'Océan Indien (LICE-OI), CHU La Réunion site Félix Guyon, Allée des Topazes, CS11021, 97400 Saint Denis de La Réunion, France.
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8
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Matsubayashi RN, Iwasaki H, Iwakuma N, Momosaki S. Methotrexate (MTX)-associated malignant lymphoma of the bilateral breast: imaging features in comparison to other nipple-areolar tumors. Clin Imaging 2019; 53:120-125. [DOI: 10.1016/j.clinimag.2018.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 09/06/2018] [Accepted: 10/02/2018] [Indexed: 11/28/2022]
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9
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Genomic Profile and Pathologic Features of Diffuse Large B-Cell Lymphoma Subtype of Methotrexate-associated Lymphoproliferative Disorder in Rheumatoid Arthritis Patients. Am J Surg Pathol 2018; 42:936-950. [DOI: 10.1097/pas.0000000000001071] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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10
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The prognostic value of positron emission tomography/computed tomography in rheumatoid arthritis patients with methotrexate-associated lymphoproliferative disorders. Ann Hematol 2018; 97:1611-1618. [DOI: 10.1007/s00277-018-3327-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 04/03/2018] [Indexed: 12/15/2022]
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11
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Furukawa S, Oobu K, Moriyama M, Kawano S, Sako S, Hayashida JN, Matsubara R, Ogata KI, Kiyoshima T, Nakamura S. Oral Methotrexate-related Lymphoproliferative Disease Presenting with Severe Osteonecrosis of the Jaw: A Case Report and Literature Review. Intern Med 2018; 57:575-581. [PMID: 29225245 PMCID: PMC5849556 DOI: 10.2169/internalmedicine.8946-17] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Long-term methotrexate (MTX) treatment can cause MTX-related lymphoproliferative disorder (MTX-LPD). We experienced a case of MTX-LPD that was associated with severe osteonecrosis of the jaw mimicking medication-related osteonecrosis of the jaw. The patient was an 81-year-old woman with rheumatoid arthritis (RA) who was treated with MTX and bisphosphonate. After 7 years, she was referred to our department for the assessment of giant ulcer and exposure of the alveolar bone of the left maxilla. Histopathological and immunological analyses confirmed a diagnosis of MTX-LPD. At seven months after the cessation of MTX treatment, the ulcerative and necrotic lesions had markedly decreased in size. A 1-year follow-up examination showed no evidence of recurrence and good RA control.
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Affiliation(s)
- Sachiko Furukawa
- Section of Oral and Maxillofacial Oncology, Division of Maxillofacial Diagnostic and Surgical Sciences, Faculty of Dental Science, Kyushu University, Japan
| | - Kazunari Oobu
- Section of Oral and Maxillofacial Oncology, Division of Maxillofacial Diagnostic and Surgical Sciences, Faculty of Dental Science, Kyushu University, Japan
| | - Masafumi Moriyama
- Section of Oral and Maxillofacial Oncology, Division of Maxillofacial Diagnostic and Surgical Sciences, Faculty of Dental Science, Kyushu University, Japan
- OBT Research Center, Faculty of Dental Science, Kyushu University, Japan
| | - Shintaro Kawano
- Section of Oral and Maxillofacial Oncology, Division of Maxillofacial Diagnostic and Surgical Sciences, Faculty of Dental Science, Kyushu University, Japan
| | - Saori Sako
- Section of Oral and Maxillofacial Oncology, Division of Maxillofacial Diagnostic and Surgical Sciences, Faculty of Dental Science, Kyushu University, Japan
| | - Jun-Nosuke Hayashida
- Section of Oral and Maxillofacial Oncology, Division of Maxillofacial Diagnostic and Surgical Sciences, Faculty of Dental Science, Kyushu University, Japan
| | - Ryota Matsubara
- Section of Oral and Maxillofacial Oncology, Division of Maxillofacial Diagnostic and Surgical Sciences, Faculty of Dental Science, Kyushu University, Japan
| | - Ken-Ichi Ogata
- Section of Oral and Maxillofacial Oncology, Division of Maxillofacial Diagnostic and Surgical Sciences, Faculty of Dental Science, Kyushu University, Japan
| | - Tamotsu Kiyoshima
- Laboratory of Oral Pathology, Division of Maxillofacial Diagnostic and Surgical Sciences, Faculty of Dental Science, Kyushu University, Japan
| | - Seiji Nakamura
- Section of Oral and Maxillofacial Oncology, Division of Maxillofacial Diagnostic and Surgical Sciences, Faculty of Dental Science, Kyushu University, Japan
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12
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CT assessment of axillary lymphadenopathy in patients with rheumatoid arthritis: association with disease activity and severity. Rheumatol Int 2018; 38:1017-1022. [DOI: 10.1007/s00296-018-3992-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 02/04/2018] [Indexed: 11/26/2022]
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13
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Sparks JA, Barbhaiya M, Karlson EW, Ritter SY, Raychaudhuri S, Corrigan CC, Lu F, Selhub J, Chasman DI, Paynter NP, Ridker PM, Solomon DH. Investigating methotrexate toxicity within a randomized double-blinded, placebo-controlled trial: Rationale and design of the Cardiovascular Inflammation Reduction Trial-Adverse Events (CIRT-AE) Study. Semin Arthritis Rheum 2017; 47:133-142. [PMID: 28284844 PMCID: PMC5765986 DOI: 10.1016/j.semarthrit.2017.02.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 02/01/2017] [Accepted: 02/04/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND The role of low dose methotrexate (LDM) in potential serious toxicities remains unclear despite its common use. Prior observational studies investigating LDM toxicity compared LDM to other active drugs. Prior placebo-controlled clinical trials of LDM in inflammatory conditions were not large enough to investigate toxicity. The Cardiovascular Inflammation Reduction Trial (CIRT) is an ongoing NIH-funded, randomized, double-blind, placebo-controlled trial of LDM in the secondary prevention of cardiovascular disease. We describe here the rationale and design of the CIRT-Adverse Events (CIRT-AE) ancillary study which aims to investigate adverse events within CIRT. DESIGN CIRT will randomize up to 7000 participants with cardiovascular disease and no systemic rheumatic disease to either LDM (target dose: 15-20mg/week) or placebo for an average follow-up period of 3-5 years; subjects in both treatment arms receive folic acid 1mg daily for 6 days each week. The primary endpoints of CIRT include recurrent cardio vascular events, incident diabetes, and all-cause mortality, and the ancillary CIRT-AE study has been designed to adjudicate other clinically important adverse events including hepatic, gastrointestinal, respiratory, hematologic, infectious, mucocutaneous, oncologic, renal, neurologic, and musculoskeletal outcomes. Methotrexate polyglutamate levels and genome-wide single nucleotide polymorphisms will be examined for association with adverse events. SUMMARY CIRT-AE will comprehensively evaluate potential LDM toxicities among subjects with cardiovascular disease within the context of a large, ongoing, double-blind, placebo-controlled trial. This information may lead to a personalized approach to monitoring LDM in clinical practice.
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Affiliation(s)
- Jeffrey A Sparks
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women׳s Hospital, Boston, MA; Harvard Medical School, Boston, MA.
| | - Medha Barbhaiya
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women׳s Hospital, Boston, MA; Harvard Medical School, Boston, MA.
| | - Elizabeth W Karlson
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women׳s Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Susan Y Ritter
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women׳s Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Soumya Raychaudhuri
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women׳s Hospital, Boston, MA; Harvard Medical School, Boston, MA; Program in Medical and Population Genetics, Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge, MA
| | - Cassandra C Corrigan
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women׳s Hospital, Boston, MA
| | - Fengxin Lu
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women׳s Hospital, Boston, MA
| | - Jacob Selhub
- Jean Mayer USDA, Human Nutrition Center on Aging, Tufts University, Boston, MA
| | - Daniel I Chasman
- Harvard Medical School, Boston, MA; Department of Medicine, Center for Cardiovascular Disease Prevention, Brigham and Women׳s Hospital, Boston, MA
| | - Nina P Paynter
- Harvard Medical School, Boston, MA; Department of Medicine, Center for Cardiovascular Disease Prevention, Brigham and Women׳s Hospital, Boston, MA
| | - Paul M Ridker
- Harvard Medical School, Boston, MA; Department of Medicine, Center for Cardiovascular Disease Prevention, Brigham and Women׳s Hospital, Boston, MA
| | - Daniel H Solomon
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women׳s Hospital, Boston, MA; Harvard Medical School, Boston, MA
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14
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Harigai M. Lymphoproliferative disorders in patients with rheumatoid arthritis in the era of widespread use of methotrexate: A review of the literature and current perspective. Mod Rheumatol 2017; 28:1-8. [PMID: 28758827 DOI: 10.1080/14397595.2017.1352477] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Lymphoproliferative disorders (LPD) in patients receiving methotrexate (MTX) have gained strong attention. In this article, I reviewed the basic and clinical findings of this issue. Patients with RA possess a high risk of lymphoma, but epidemiological evidence showing an association between the use of MTX and lymphoma is still limited. Rapid regression of LPD after stopping MTX in patients with RA strongly suggests that there is a causative relationship. Genetic predisposition, accumulated inflammation, impaired generation of Epstein-Barr virus (EBV)-specific cytotoxic T lymphocytes, effects of MTX on the regulation of EBV genes, and low hypermethylation of apoptosis-related genes are relevant to the development of LPD and rapid regression after cessation of MTX. The clinical and histological characteristics of LPD in RA patients who are treated with MTX have been established, and recent data indicate that initial cessation of MTX and watchful waiting to observe an increase in peripheral lymphocyte counts have a therapeutic value. In advanced cases, various chemotherapy regimens are used, and consultation with hematologists is recommended to select the optimal treatment. There is no consensus on the treatment of RA after development of LPD, and long-term observation is necessary to investigate the safety of disease-modifying antirheumatic drugs in these patients.
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Affiliation(s)
- Masayoshi Harigai
- a Division of Epidemiology and Pharmacoepidemiology, Institute of Rheumatology , Tokyo Women's Medical University , Tokyo , Japan
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15
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Stübgen JP. Juvenile dermatomyositis/polymyositis and lymphoma. J Neurol Sci 2017; 377:19-24. [PMID: 28477693 DOI: 10.1016/j.jns.2017.03.033] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Revised: 03/18/2017] [Accepted: 03/21/2017] [Indexed: 12/12/2022]
Abstract
In patients with juvenile dermatomyositis/polymyositis (JDM/PM), malignancy is a rare phenomenon. An extensive workup for neoplastic disease is not routinely indicated, but should be considered if unusual physical findings are noted at JDM/PM diagnosis or during follow-up period. The objective of this literature review was to assess for any association between, and disease profile of, JDM/PM and lymphoma in childhood. Risk determinants of the possible development of lymphoma in the pediatric population with JDM/PM appear to be the degree and duration of inflammatory activity with chronic B-cell activation and/or antigen stimulation; a paraneoplastic relationship is unlikely.
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Affiliation(s)
- Joerg-Patrick Stübgen
- Department of Neurology, Weill Cornell Medicine/New York Presbyterian Hospital, 525 East 68th Street, New York, NY 10065-4885, USA.
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Inflammatory myopathies and lymphoma. J Neurol Sci 2016; 369:377-389. [PMID: 27653927 DOI: 10.1016/j.jns.2016.08.060] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 08/28/2016] [Accepted: 08/29/2016] [Indexed: 12/18/2022]
Abstract
The inflammatory myopathies comprise a group of immune-mediated muscle diseases. Lymphoma is a term for a variety of lymphatic system malignancies. Autoimmune diseases and lymphoproliferative malignancies share a complex bidirectional relationship. A causal relationship between inflammatory mypathies and lymphoma has not been established. The diagnosis/treatment of inflammatory myopathy usually precedes the detection/diagnosis of lymphoma. Immune system dysregulation presumably underlies the evolution of lymphoma in patients with inflammatory myopathies. Inflammatory activity with chronic B-cell activation and/or antigen stimulation is deemed the major risk factor for lymphoma in patients with autoimmunity. A "paraneoplastic" phenomenon or the effects of immunosuppressive therapy may be alternative immune-based mechanisms. In chronic lymphocytic leukemia immune system disturbance rarely results in non-hematological autoimmune disease, including inflammatory myopathies.
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Kojima M, Itoh H, Shimizu K, Saruki N, Murayama K, Higuchi K, Tamaki Y, Matsumoto M, Hirabayashi K, Igarishi S, Masawa N, Nakamura S. Malignant Lymphoma in Patients with Systemic Rheumatic Disease (Rheumatoid Arthritis, Systemic Lupus Erythematosus, Systemic Sclerosis, and Dermatomyositis): A Clinicopathologic Study of 24 Japanese Cases. Int J Surg Pathol 2016; 14:43-8. [PMID: 16501834 DOI: 10.1177/106689690601400108] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We conducted clinicopathologic and immunohistochemical analyses of the prevalence of Epstein-Barr virus (EBV) among 24 patients with malignant lymphoma complicating systemic rheumatic diseases. (SRD) These 24 patients included 17 with rheumatoid arthritis (RA), 3 with systemic lupus erythematosus (SLE), 2 with systemic sclerosis (SS), and 2 with dermatomyositis (DM). There were 2 men and 22 women ranging in age from 30 to 86 years (mean: 64 years). The interval between the onset of rheumatic disease and that of malignant lymphomas ranged from 3 months to 35 years (mean: 142 months). The use of immunosuppressive drugs before the onset of malignant lymphoma was recorded in 15 patients. Among them, 5 patients received methotrexate (MTX) therapy. Malignant lymphomas were found at extranodal sites in 9 patients, and the disease was in the advanced stage in 17 patients. Histologic and immunohistochemical studies demonstrated that 18 cases (75%) were B-cell lymphoma (RA=12, SLE=2, SS=2, DM=2), 3 (12.5%) were peripheral T-cell lymphoma (RA=3), and 3 (12.5%) were classical Hodgkin lymphoma (RA=2, SLE=1). As in previous reports, there was an increased frequency of diffuse large B-cell lymphoma (50%) in the present series. Moreover, a majority of the diffuse large B-cell lymphomas exhibited activated B-cell phenotype. EBV-encoded small RNAs (Epstein-Barr early region [EBER]-) and/or LMP-1+tumor cells were identified in only 3 cases of classical Hodgkin lymphomas. Our findings suggested EBV-associated lymphoma comprised only a small fraction of all non-Hodgkin's lymphomas in the general SRD patient population.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Antigens, CD20/analysis
- Arthritis, Rheumatoid/complications
- Arthritis, Rheumatoid/pathology
- Dermatomyositis/complications
- Dermatomyositis/pathology
- Epstein-Barr Virus Infections/complications
- Epstein-Barr Virus Infections/diagnosis
- Epstein-Barr Virus Infections/epidemiology
- Epstein-Barr Virus Infections/pathology
- Female
- Herpesvirus 4, Human/genetics
- Hodgkin Disease/complications
- Hodgkin Disease/pathology
- Hodgkin Disease/virology
- Humans
- Immunohistochemistry
- Japan
- Lupus Erythematosus, Systemic/complications
- Lupus Erythematosus, Systemic/pathology
- Lymphoma/complications
- Lymphoma/pathology
- Lymphoma/virology
- Lymphoma, B-Cell/complications
- Lymphoma, B-Cell/pathology
- Lymphoma, B-Cell/virology
- Lymphoma, T-Cell/complications
- Lymphoma, T-Cell/pathology
- Lymphoma, T-Cell/virology
- Male
- Middle Aged
- RNA, Viral/analysis
- Rheumatic Diseases/complications
- Rheumatic Diseases/pathology
- Scleroderma, Systemic/complications
- Scleroderma, Systemic/pathology
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Affiliation(s)
- Masaru Kojima
- Department of Pathology and Clinical Laboratories, Gunma Cancer Center Hospital, Ohta, Dokkyo University School of Medicine, Mibu, Japan
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18
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Kojima M, Motoori T, Itoh H, Shimizu K, Iijima M, Tamaki Y, Murayama K, Ohno Y, Yoshida K, Masawa N, Nakamura S. Distribution of Epstein-Barr Virus in Systemic Rheumatic Disease (Rheumatoid Arthritis, Systemic Lupus Erythematosus, Dermatomyositis) With Associated Lymphadenopathy: A Study of 49 Cases. Int J Surg Pathol 2016; 13:273-8. [PMID: 16086083 DOI: 10.1177/106689690501300307] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Among systemic rheumatic diseases (SRDs), lymphadenopathy is frequently found in patients with rheumatoid arthritis (RA) and systemic lupus erythematous (SLE). Epstein-Barr virus (EBV)-associated lymphoproliferative disorders (LPDs) may occur in patients following methotrexate therapy for RA and dermatomyositis (DM). However, little is known about the distribution of EBV in reactive LPDs in patients with SRDs who had no history of methotrexate therapy. We analyzed 49 such patients (SLE=25, RA=23, DM=1) for the presence and distribution of EBV+ cells using Epstein-Barr virus (EBV)-encoded small RNA (EBER) specific in situ hybridization. A positive signal for EBERs was identified in 9 (SLE=5, RA=4) (18%) of 49 cases, and 3 main distribution patterns of EBER+ cells could be delineated: pattern A, more than 500 EBER-positive cells were located in the germinal centers as well as interfollicular area (SLE=2); pattern B, EBER + cells were located in a few germinal centers (RA=2); and pattern C, up to 100 EBER+ cells were located in the interfollicular area (SLE=3, RA=2). Recent EBV infection may be a cause of lymph node lesion in only 2 cases of patients with pattern A. However, the pathognomonic significance of pattern B and pattern C EBER+ cell distribution patterns still remains unclear. Our study indicates that the underlying immune deficits of patients with SRDs may also play an important role in the development of EBV-associated LPDs in SRDs, as previously suggested by several authors.
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Affiliation(s)
- Masaru Kojima
- Department of Pathology and Clinical Laboratories, Gunma Cancer Center Hospital, 617-1 Takabayashinishi-cho, Ohta, Japan
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Dasgupta N, Gelber AC, Racke F, Fine DM. Central nervous system lymphoma associated with mycophenolate mofetil in lupus nephritis. Lupus 2016; 14:910-3. [PMID: 16335585 DOI: 10.1191/0961203303lu2179cr] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Lymphomas, both within and outside the central nervous system, are uncommon among patients with systemic lupus erythematosus (SLE). We describe a 58-year old Korean woman with SLE who presented with acute headache and confusion in the setting of prednisone and mycophenolate mofetil (MMF) therapy used to treat focal proliferative and membranous lupus nephritis. Three-dimensional brain magnetic resonance imaging (MRI) showed two peripherally (‘ring’) enhancing lesions within the basal ganglia, bilaterally, with associated mass effect and subfalcine herniation. A brain biopsy revealed an Epstein-Barr virus (EBV)-positive diffuse large B cell lymphoma. This is the first description of CNS lymphoma in a patient treated with MMF for lupus nephritis. While intracerebral lymphoma in the immunocompromised patient with lupus is rare, this disorder should be considered in the differential diagnosis of new-onset neurological symptoms among such patients.
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Affiliation(s)
- N Dasgupta
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
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20
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Romão VC, Lima A, Bernardes M, Canhão H, Fonseca JE. Three decades of low-dose methotrexate in rheumatoid arthritis: can we predict toxicity? Immunol Res 2015; 60:289-310. [PMID: 25391609 DOI: 10.1007/s12026-014-8564-6] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Methotrexate (MTX) is the anchor disease-modifying antirheumatic drug (DMARD) in rheumatoid arthritis (RA) treatment. It is used in monotherapy and/or in combination with other synthetic or biological DMARDs, and is known to have the best cost-effectiveness and efficacy/toxicity ratios. However, toxicity is still a concern, with a significant proportion of patients interrupting long-term treatment due to the occurrence of MTX-related adverse drug reactions (ADRs), which are the main cause of drug withdrawal. Despite the extensive accumulated experience in the last three decades, it is still impossible in routine clinical practice to identify patients prone to develop MTX toxicity. While clinical and biological variables, including folate supplementation, partially help to minimize MTX-related ADRs, the advent of pharmacogenomics could provide further insight into risk stratification and help to optimize drug monitoring and long-term retention. In this paper, we aimed to review and summarize current data on low-dose MTX-associated toxicity, its prevention and predictors, keeping in mind practical RA clinical care.
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Affiliation(s)
- Vasco C Romão
- Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina da Universidade de Lisboa, Lisbon Academic Medical Centre, Edifício Egas Moniz, Av. Prof. Egas Moniz, 1649-028, Lisbon, Portugal
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21
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Naidu A, Kessler HP, Pavelka MA. Epstein-Barr Virus–Positive Oral Ulceration Simulating Hodgkin Lymphoma in a Patient Treated With Methotrexate: Case Report and Review of the Literature. J Oral Maxillofac Surg 2014; 72:724-9. [DOI: 10.1016/j.joms.2013.09.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Revised: 09/06/2013] [Accepted: 09/09/2013] [Indexed: 11/30/2022]
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Complete Remission of Methotrexate-Related Epstein-Barr-Virus-Associated Hodgkin-Like Lymphoma following Withdrawal of MTX Coupled with Clarithromycin Administration. Case Rep Hematol 2012; 2012:658745. [PMID: 23316401 PMCID: PMC3535817 DOI: 10.1155/2012/658745] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Accepted: 11/27/2012] [Indexed: 01/28/2023] Open
Abstract
Patients with rheumatoid arthritis (RA) are known to develop lymphoproliferative disorders (LPDs) during the course of illness, particularly in cases treated with methotrexate (MTX) for long periods. We describe a case of MTX-related Epstein-Barr-virus-(EBV-) associated LPD resembling Hodgkin's lymphoma (HL), in which a dramatic complete remission was achieved after withdrawal of MTX coupled with clarithromycin (CAM) administration. Withdrawal of MTX coupled with CAM administration seemed to be effective for treating MTX-related EBV-associated LPDs. In particular, an immunomodulative effect of CAM might have been involved in achieving complete remission.
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Tsukamoto N, Handa H, Yokohama A, Mitsui T, Saitoh T, Koiso H, Uchiumi H, Hoshino T, Karasawa M, Murakami H, Kojima M, Nojima Y. Long-term follow-up of EBV-positive lymphoproliferative disorders in a patient with systemic lupus erythematosus. Med Mol Morphol 2011; 44:237-41. [PMID: 22179188 DOI: 10.1007/s00795-011-0551-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Accepted: 05/13/2011] [Indexed: 12/19/2022]
Abstract
We report a woman in her early thirties with a long-term history of systemic lupus erythematosus (SLE) and prednisolone administration, who progressed to Epstein-Barr virus (EBV)-positive lymphoproliferative disorder (LPD). Treatment for SLE consisted of 1 mg/kg/ day prednisolone followed by 5 mg/day of maintenance therapy. Lymph node biopsies were performed when the patient was in her early thirties, mid-forties, and late fifties. Histologically, the initial lymph node lesion was characterized by numerous enlarged, coalescing lymphoid follicles. The second biopsy showed effacement of the follicles and expansion of the paracortical area. A polymorphous population of small- to medium-sized lymphocytes, plasma cells, and immunoblasts had diffusely infiltrated the paracortical area. In the third lymph node biopsy, fibrous collagen bands divided the epithelioid cell granulomas into nodules. There were numerous Hodgkin and Reed-Sternberg cells in the epithelioid cell granuloma. In situ hybridization demonstrated there were no EBV-infected lymphocytes in the first biopsy; however, EBER(+) cells were detected in the second and third biopsy specimens. The current findings illustrate the natural progression in a patient with a long-term history of EBV(+) B-cell LPD in which the immunodeficiency was caused by SLE and probably her aging, which together resulted in histological change.
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Affiliation(s)
- Norifumi Tsukamoto
- Department of Medicine and Clinical Science, Gunma University Graduate School of Medicine, Showa-machi, Maebashi, Gunma, Japan.
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Sawada A, Koyama-Sato M, Yasui M, Kondo O, Ishihara T, Takeshita Y, Okamura T, Nishikawa M, Inoue M, Kawa K. Multiplex polymerase chain reaction for six herpesviruses after hematopoietic stem cell transplantation. Pediatr Int 2011; 53:1010-7. [PMID: 21810148 DOI: 10.1111/j.1442-200x.2011.03437.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Herpesviruses cause life-threatening diseases after hematopoietic stem cell transplantation (HSCT). It is necessary that viral diseases are identified early and safely diagnosed. The purpose of this study was to evaluate the efficacy of multiplex polymerase chain reaction (PCR) for qualitative detection of the six herpesviruses simultaneously: herpes simplex virus type 1 and type 2, varicella-zoster virus, cytomegalovirus, Epstein-Barr virus (EBV) and human herpesvirus 6B. METHODS Multiplex PCR was applied to patients with various clinical manifestations including central nervous system, cutaneous and mucosal complications after allogeneic HSCT, and the data were retrospectively analyzed. RESULTS Patients positive for cytomegalovirus in peripheral blood by multiplex PCR might need pre-emptive treatment, but a positive result for EBV had no specific correlation with EBV-associated post-transplant lymphoproliferative disease, and positive result for human herpesvirus 6B failed to show any clinical significance. The multiplex PCR was safe and helpful to diagnose viral diseases of local regions, for example, the central nervous system, skin and mucosa. CONCLUSIONS It may be worthwhile to survey the six herpesviruses with multiplex PCR after HSCT.
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Affiliation(s)
- Akihisa Sawada
- Department of Hematology/Oncology, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan.
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FDG PET/CT in a patient with spontaneous remission of methotrexate-associated lymphoproliferative disorders after interruption of methotrexate. Clin Nucl Med 2011; 36:582-3. [PMID: 21637066 DOI: 10.1097/rlu.0b013e3182177284] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We report a case that fluorodeoxyglucose positron emission tomography (FDG PET)/computed tomography (CT) depicted systemically multiple lesions of methotrexate (MTX)-associated lymphoproliferative disorders. A 70-year-old man receiving MTX for rheumatoid arthritis complained of neck swelling. FDG PET/CT revealed multiple FDG-avid lesions in lymph nodes, lungs, bones, and muscles. Lesions in bones and muscles were not detected on X-CT. Final diagnosis of cervical node was confirmed as MTX-associated lymphoproliferative disorders. FDG PET/CT performed 148 days after discontinuing MTX demonstrated complete remission.
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Adams B, Lazarchick J, Medina AM, Willner IR, Neville B, Murphy E, Stuart R, Costa LJ. Iatrogenic immunodeficiency-associated lymphoproliferative disease of the Hodgkin lymphoma-like variant in a patient treated with mycophenolate mofetil for autoimmune hepatitis. Am J Hematol 2010; 85:627-9. [PMID: 20658594 DOI: 10.1002/ajh.21753] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Niitsu N, Okamoto M, Nakamine H, Hirano M. Clinicopathologic correlations of diffuse large B-cell lymphoma in rheumatoid arthritis patients treated with methotrexate. Cancer Sci 2010; 101:1309-13. [PMID: 20210795 PMCID: PMC11159245 DOI: 10.1111/j.1349-7006.2010.01517.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Among methotrexate (MTX)-related lymphoproliferative disorders (MTX-LPD), diffuse large B-cell lymphoma (DLBCL) accounts for about half. We studied the clinicopathological characteristics and prognosis of patients with DLBCL in MTX-LPD. This study included 29 patients who developed DLBCL after receiving MTX for rheumatoid arthritis. MTX was discontinued in all patients. Their median age was 62 years. Elevated lactate dehydrogenase (LDH) level was observed in 97% of the patients, bone marrow involvement in 17%, and involvement of extranodal sites in 41%. As for the cellular immunophenotype, CD20 was positive in 93%, CD5 in 3%, CD10 in 31%, BCL2 in 21%, BCL6 in 69%, and Epstein-Barr virus (EBV)-encoded small non-polyadenylated RNA (EBER) in 24%. Chemotherapy was started within 2 months after MTX withdrawal in 23 patients, of whom 12 patients received combination with rituximab. Spontaneous remission occurred in the remaining six patients. The EEBV-positive rate was 67% (4/6), and the four EBV-positive patients achieved complete response. Among the 23 DLBCL patients treated with chemotherapy, 20 patients achieved complete response. The 5-year overall survival was 74% and the 5-year progression-free survival was 65%. After the development of DLBCL, withdrawal of MTX was the first choice of treatment. Germinal center B-cell type and EBER-positive patients tended to show spontaneous remission. The utility of rituximab should be examined in future studies.
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MESH Headings
- Adult
- Aged
- Antirheumatic Agents/adverse effects
- Arthritis, Rheumatoid/drug therapy
- Arthritis, Rheumatoid/genetics
- Arthritis, Rheumatoid/immunology
- Female
- Humans
- Lymphoma, Large B-Cell, Diffuse/chemically induced
- Lymphoma, Large B-Cell, Diffuse/mortality
- Lymphoma, Large B-Cell, Diffuse/pathology
- Lymphoma, Large B-Cell, Diffuse/virology
- Male
- Methotrexate/adverse effects
- Middle Aged
- RNA, Viral/analysis
- Translocation, Genetic
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Affiliation(s)
- Nozomi Niitsu
- Department of Hematology, Comprehensive Cancer Center, International Medical Center, Saitama Medical University, Saitama, Japan.
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Abstract
Approximately 33% of adult patients with dermatomyositis develop malignancy with up to 42% presenting after the diagnosis has been made; careful evaluation for malignancy is often undertaken at the time of dermatomyositis diagnosis. This phenomenon has rarely been noted in pediatric patients and extensive workup for malignancy is not indicated in pediatric patients. In 1993, 6 cases were reported in which juvenile dermatomyositis/polymyositis (JDM/PM) appeared to be part of a paraneoplastic phenomenon. Our objective was to update the literature for reported cases of malignancy associated with JDM/PM; we reviewed the literature over the last 15 years and located 6 additional cases. In 9 of 12 reported patients an unusual physical finding such as splenomegaly or lymphadenopathy was noted at the time of diagnosis, and in the entire group, the malignancy occurred within a mean of 12 months. It is less likely that JDM/PM in pediatric patients is a paraneoplastic phenomenon as it is in adult patients. However, if the physical examination at the time of diagnosis of JDM/PM is atypical the presence of malignancy must be considered and a more in-depth evaluation to rule out malignancy should be performed prior to the initiation of treatment.
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EBV positive mucocutaneous ulcer--a study of 26 cases associated with various sources of immunosuppression. Am J Surg Pathol 2010; 34:405-17. [PMID: 20154586 DOI: 10.1097/pas.0b013e3181cf8622] [Citation(s) in RCA: 380] [Impact Index Per Article: 27.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
We describe a series of Epstein Barr virus (EBV)-positive circumscribed, ulcerative lesions associated with various types of immunosuppression (IS). The study group (26 patients) comprised 10 males and 16 females, median age 77 years (range 42 to 101). IS in 9 cases included azathioprine (AZA), methotrexate (MTX) or cyclosporin-A (CyA). Seventeen patients had age-related immunosenescence. Patients presented with isolated sharply circumscribed ulcers involving oropharyngeal mucosa (16), skin (6), and gastrointestinal tract (4). Lesions were histologically characterized by a polymorphous infiltrate and atypical large B-cell blasts often with Hodgkin/Reed-Sternberg (HRS) cell-like morphology. The B cells showed strong CD30 and EBER positivity, some with reduced CD20 expression, in a background of abundant T cells. CD15 was positive in 43% of cases (10/23). The pathologic features were identical regardless of the anatomic site or cause of IS. Polymerase chain reaction revealed 39% (7/18) clonal Ig gene rearrangements with 38% (6/16) and 31% (5/16) clonal and restricted T-cell patterns, respectively. Twenty-five percent of patients (5/20) received standard chemotherapy and/or radiotherapy. Forty-five percent (9/20) regressed spontaneously with no treatment and 15% (3/20) were characterized by a relapsing and remitting course. All of the iatrogenic lesions (6/6) with available follow-up responded to reduction of IS. All patients achieved complete remission with no disease-associated deaths over a median follow-up period of 22 months (range 3 to 72). We propose EBV-positive mucocutaneous ulcer as a newly recognized clinicopathologic entity with Hodgkin-like features and a self-limited, indolent course, generally responding well to conservative management. Association with various forms of IS implies a common pathogenetic mechanism. The localized nature of the disease may be owing to a minimal and localized lapse in immunosurveillance over EBV.
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Yager EJ, Kim IJ, Freeman ML, Lanzer KG, Burkum CE, Cookenham T, Woodland DL, Blackman MA. Differential impact of ageing on cellular and humoral immunity to a persistent murine gamma-herpesvirus. IMMUNITY & AGEING 2010; 7:3. [PMID: 20181071 PMCID: PMC2843645 DOI: 10.1186/1742-4933-7-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/20/2009] [Accepted: 02/02/2010] [Indexed: 12/03/2022]
Abstract
Background Oncogenic γ-herpesviruses establish life-long infections in their hosts and control of these latent infections is dependent on continual immune surveillance. Immune function declines with age, raising the possibility that immune control of γ-herpesvirus infection becomes compromised with increasing age, allowing viral reactivation and/or increased latent load, both of which are associated with the development of malignancies. Results In this study, we use the experimental mouse γ-herpesvirus model, γHV68, to investigate viral immunity in aged mice. We found no evidence of viral recrudescence or increased latent load in aged latently-infected mice, suggesting that effective immune control of γ-herpesvirus infection remains intact with ageing. As both cellular and humoral immunity have been implicated in host control of γHV68 latency, we independently examined the impact of ageing on γHV68-specific CD8 T cell function and antibody responses. Virus-specific CD8 T cell numbers and cytolytic function were not profoundly diminished with age. In contrast, whereas ELISA titers of virus-specific IgG were maintained over time, there was a progressive decline in neutralizing activity. In addition, although aged mice were able to control de novo acute infection with only slightly delayed viral clearance, serum titers of neutralizing antibody were reduced in aged mice as compared to young mice. Conclusion Although there is no obvious loss of immune control of latent virus, these data indicate that ageing has differential impacts on anti-viral cellular and humoral immune protection during persistent γHV68 infection. This observation has potential relevance for understanding γ-herpesvirus immune control during disease-associated or therapeutic immunosuppression.
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Affiliation(s)
- Eric J Yager
- Trudeau Institute, 154 Algonquin Ave, Saranac Lake, NY 12983, USA
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Composite Cutaneous Lymphoma in a Patient With Rheumatoid Arthritis Treated With Methotrexate. Am J Dermatopathol 2010; 32:65-70. [DOI: 10.1097/dad.0b013e3181af7dee] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Kojima M, Nakamura N, Tsukamoto N, Itoh H, Matsuda H, Kobayashi S, Ueki K, Irisawa H, Murayama K, Igarashi T, Masawa N, Nakamura S. Atypical Lymphoplasmacytic and Immunoblastic Proliferation of Autoimmune Disease : Clinicopathologic and Immunohistochemical Study of 9 Cases. J Clin Exp Hematop 2010; 50:113-9. [DOI: 10.3960/jslrt.50.113] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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35
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A Putative Case of Methotrexate-Related Lymphoma: Clinical Course and PET/CT Findings. Case Rep Med 2009; 2009:469343. [PMID: 20069057 PMCID: PMC2801466 DOI: 10.1155/2009/469343] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2009] [Accepted: 10/07/2009] [Indexed: 01/07/2023] Open
Abstract
Patients with autoimmune conditions develop lymphoproliferative disorders (LPDs) at a higher frequency than normal both in association with and independent of Methotrexate (MTX). We describe a case of MTX-associated lymphoma in a patient with psoriasis on long-standing MTX. The case is notable for the initial tumor burden, the dramatic disappearance of the PET-CT findings on discontinuation of MTX, and the subsequent early regrowth of disease. Our case report is illustrative of an MTX-related NHL in an autoimmune patient. Conclusion. Withdrawal of MTX in a patient with lymphoma is reasonable before initiating chemotherapy, but observation for early regrowth of disease is necessary.
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Steff M, Le Corre Y, Penisson-Besnier I, Michalak S, Drossard G, Lebrun-Vignes B, Le Clec’h C. Syndrome lymphoprolifératif cutané lié à l’EBV au cours d’une dermatomyosite traitée par immunosuppresseurs. Rev Med Interne 2009; 30:720-3. [DOI: 10.1016/j.revmed.2008.10.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2008] [Revised: 09/24/2008] [Accepted: 10/12/2008] [Indexed: 10/21/2022]
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Salliot C, van der Heijde D. Long-term safety of methotrexate monotherapy in patients with rheumatoid arthritis: a systematic literature research. Ann Rheum Dis 2009; 68:1100-4. [PMID: 19060002 PMCID: PMC2689525 DOI: 10.1136/ard.2008.093690] [Citation(s) in RCA: 418] [Impact Index Per Article: 27.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2008] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To perform a systematic literature review of the long-term safety of methotrexate (MTX) monotherapy in rheumatoid arthritis (RA). METHODS A search was performed in Medline, Cochrane and EMBASE. Adults with RA who had received MTX monotherapy for more than 2 years were studied. RESULTS 88 published studies were included. Over 12 years of treatment, the termination rate of MTX due to toxicity was less than for sulfasalazine, gold, d-penicillamine and higher than for hydroxychloroquine (level of evidence 2a-2b). Long-term use of MTX does not appear to be a risk factor for serious infections, including herpes zoster (2b-4), and could provide a survival benefit by reducing cardiovascular mortality (2b). The prevalence of raised liver enzymes (more than twice the upper limit of normal) is close to 13% of patients; 3.7% of patients stopped MTX permanently owing to liver toxicity (2b). Data on the risk for liver fibrosis/cirrhosis are conflicting: a meta-analysis showed an incidence of fibrosis of 2.7% after 4 years of MTX (2a). However, two other studies on sequential liver biopsies did not show evidence for developing severe damage (2b). Insufficient data are available to fully assess the risk of lymphoma and malignancies, although there is no strong evidence of increased risk (2b-4). CONCLUSION This systematic literature search on MTX monotherapy with relatively low-dose use during at least 2 years shows favourable long-term safety.
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Affiliation(s)
- C Salliot
- Paris Descartes University, Medicine Faculty, Rheumatology B Department, Cochin Hospital, Paris, France.
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Shimura C, Satoh T, Takayama K, Yokozeki H. Methotrexate-related lymphoproliferative disorder with extensive vascular involvement in a patient with rheumatoid arthritis. J Am Acad Dermatol 2009; 61:126-9. [DOI: 10.1016/j.jaad.2008.10.051] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2008] [Revised: 10/24/2008] [Accepted: 10/29/2008] [Indexed: 11/24/2022]
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Morris P, Herrera-Guerra A, Parham D. Lymphoma arising from a calcinotic lesion in a patient with juvenile dermatomyositis. Pediatr Dermatol 2009; 26:159-61. [PMID: 19419462 DOI: 10.1111/j.1525-1470.2009.00875.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Approximately one-third of adult patients with dermatomyositis develop malignancy, usually within 1 year of diagnosis of dermatomyositis. This phenomenon is not seen in patients with juvenile dermatomyositis. We are reporting a case of B-cell lymphoma arising from a calcinotic lesion in a 14-year-old girl who had been diagnosed with juvenile dermatomyositis 3 years prior. Our review of the literature revealed only one other case of malignancy arising from an area of calcinosis.
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Affiliation(s)
- Paula Morris
- University of Arkansas for Medical Sciences, College of Medicine, Department of Pediatrics, Rheumatology and Arkansas Children's Hospital, Little Rock, Arkansas 72202, USA.
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Visser K, Katchamart W, Loza E, Martinez-Lopez JA, Salliot C, Trudeau J, Bombardier C, Carmona L, van der Heijde D, Bijlsma JWJ, Boumpas DT, Canhao H, Edwards CJ, Hamuryudan V, Kvien TK, Leeb BF, Martín-Mola EM, Mielants H, Müller-Ladner U, Murphy G, Østergaard M, Pereira IA, Ramos-Remus C, Valentini G, Zochling J, Dougados M. Multinational evidence-based recommendations for the use of methotrexate in rheumatic disorders with a focus on rheumatoid arthritis: integrating systematic literature research and expert opinion of a broad international panel of rheumatologists in the 3E Initiative. Ann Rheum Dis 2008; 68:1086-93. [PMID: 19033291 PMCID: PMC2689523 DOI: 10.1136/ard.2008.094474] [Citation(s) in RCA: 307] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Objectives: To develop evidence-based recommendations for the use of methotrexate in daily clinical practice in rheumatic disorders. Methods: 751 rheumatologists from 17 countries participated in the 3E (Evidence, Expertise, Exchange) Initiative of 2007–8 consisting of three separate rounds of discussions and Delphi votes. Ten clinical questions concerning the use of methotrexate in rheumatic disorders were formulated. A systematic literature search in Medline, Embase, Cochrane Library and 2005–7 American College of Rheumatology/European League Against Rheumatism meeting abstracts was conducted. Selected articles were systematically reviewed and the evidence was appraised according to the Oxford levels of evidence. Each country elaborated a set of national recommendations. Finally, multinational recommendations were formulated and agreement among the participants and the potential impact on their clinical practice was assessed. Results: A total of 16 979 references was identified, of which 304 articles were included in the systematic reviews. Ten multinational key recommendations on the use of methotrexate were formulated. Nine recommendations were specific for rheumatoid arthritis (RA), including the work-up before initiating methotrexate, optimal dosage and route, use of folic acid, monitoring, management of hepatotoxicity, long-term safety, mono versus combination therapy and management in the perioperative period and before/during pregnancy. One recommendation concerned methotrexate as a steroid-sparing agent in other rheumatic diseases. Conclusions: Ten recommendations for the use of methotrexate in daily clinical practice focussed on RA were developed, which are evidence based and supported by a large panel of rheumatologists, enhancing their validity and practical use.
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Affiliation(s)
- K Visser
- Leiden University Medical Center, Department of Rheumatology, Leiden, The Netherlands.
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Tanaka A, Shigematsu H, Kojima M, Sakashita H, Kusama K. Methotrexate-associated lymphoproliferative disorder arising in a patient with adult Still's disease. J Oral Maxillofac Surg 2008; 66:1492-5. [PMID: 18571037 DOI: 10.1016/j.joms.2007.05.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2007] [Revised: 03/26/2007] [Accepted: 05/01/2007] [Indexed: 12/28/2022]
Affiliation(s)
- Akio Tanaka
- Division of Pathology, Department of Diagnostic and Therapeutic Sciences, Meikai University School of Dentistry, Sakado, Saitama, Japan.
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VIRABEN R, BROUSSE P, LAMANT L. Reversible cutaneous lymphoma occurring during methotrexate therapy. Br J Dermatol 2008. [DOI: 10.1046/j.1365-2133.1996.d01-946.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Primary central nervous system lymphoma in rheumatoid arthritis. J Clin Rheumatol 2008; 14:54-5. [PMID: 18431104 DOI: 10.1097/rhu.0b013e318163cd02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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López San Román A, Van Domselaar M, Rivero M, Redondo C, Arribas R, Rey A. Complete remission of a primary rectal lymphoma on ulcerative colitis, after withdrawal of azathioprine and infliximab. J Crohns Colitis 2008; 2:93-6. [PMID: 21172197 DOI: 10.1016/j.crohns.2007.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2007] [Accepted: 10/17/2007] [Indexed: 02/08/2023]
Abstract
A 45-year-old woman was diagnosed with ulcerative colitis and treated with mesalazine, prednisone and, finally, azathioprine and infliximab. Colonoscopy revealed a rectal ulcer, identified by biopsy as a large cell B-lymphoma, positive for leukocyte common antigen (LCA), CD 20 and LMP-1 and negative for CD 3. Three months after withdrawal of all immunosuppressors, a proctocolectomy was performed. The resection specimen contained an area of B-cell polymorphic hyperplasia, but no residual tumour. The patient remains well after 2 years of follow-up, without any further antineoplastic therapy.
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Risks of immunosuppressive therapies including biologic agents in patients with rheumatic diseases and co-existing chronic viral infections. Curr Opin Rheumatol 2008; 19:619-25. [PMID: 17917544 DOI: 10.1097/bor.0b013e3282f05b63] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW A number of chronic viral infections could be reactivated by immunosuppressive agents used in rheumatic diseases. In this review, we will focus on the complex effect of immunosuppressive agents, including biologic agents, on the natural course of chronic viral infections as well as an approach to the prevention and management of therapy-induced viral reactivation. RECENT FINDINGS Chronic viral infections that are affected by immunosuppression in the setting of an underlying rheumatic disease include those due to hepatitis B virus, hepatitis C virus, or human immunodeficiency virus, and latent infections from Epstein-Barr virus, JC virus, or varicella zoster virus. The most recent data of the effects of immunosuppressive agents are reviewed, with special emphasis on the effects of biologic therapies (anti-tumor necrosis factor, anti-B cell), on these viral agents. SUMMARY Clinicians should be aware of the risk for viral reactivation of an underlying chronic viral infection during immunosuppressive therapy. Despite the existence of such risk, the presence of chronic viral infection is not a contraindication to immunosuppressive therapy, given that appropriate pretherapy screening and close monitoring is applied.
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Kojima M, Morita Y, Nakamura N, Shimizu K, Murayama K, Nakamura S. Plasmacytic hyperplasia in age-related Epstein-Barr virus-associated lymphoproliferative disorders: a report of two cases. Pathol Res Pract 2008; 204:267-72. [PMID: 18187262 DOI: 10.1016/j.prp.2007.11.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2007] [Accepted: 11/18/2007] [Indexed: 10/22/2022]
Abstract
Age-related Epstein-Barr virus (EBV)+B-cell lymphoproliferative disorder (LPD) is a recently recognized entity that occurs in patients over 40 years of age without any known immunodeficiency. However, this entity is thought to be related to the immunological deterioration that is part of the aging process. Histologically, age-related EBV+B-cell LPDs are classified into the polymorphous subtype and large B-cell lymphoma subtypes. However, plasmacytic hyperplasia, which is thought to be the earliest recognizable EBV+PT-LPD, has not been reported among EBV+B-cell LPDs. We report here two cases of age-related EBV-associated LPD and demonstrate the histological evolution. Pathologically, the initial lymph node biopsy specimens from both cases showed the classical Hodgkin lymphoma-like polymorphous subtype. Hodgkin (H) and Reed-Sternberg (RS) cells were CD3-, CD20+, CD15-. CD30+, CD45RB+, and latent membrane antigen-1+. In-situ hybridization (ISH) study demonstrated that numerous H and RS cells contained EBV-encoded small RNA (EBER)+. Repeated lymph node biopsy specimens from each case contained a mixture of lymphoid cells with prominent plasma cell differentiation, including immunoblasts without atypia. A portion of B-immunoblasts were CD30+ and EBER+. As assessed by polymerase chain reaction (PCR) assay, only the initial biopsy specimen in Case 1 displayed a solitary faint immunoglobulin heavy chain (IgH) gene rearrangement, consistent with the presence of a small clonal B-cell population. However, PCR analyses for EBV-genomes demonstrated the same single clonal infection of EBV in the initial and recurrent lymph node lesions in the present two cases. These two cases demonstrated the presence of plasmacytic hyperplasia in age-related EBV+B-cell LPDs, and plasmacytic hyperplasia also appears to be the earliest lesion of age-related EBV+B-cell LPDs.
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Affiliation(s)
- Masaru Kojima
- Department of Pathology and Clinical Laboratories, Gunma Cancer Center Hospital, 617-1, Takabayashinishi-cho, Ohta 373-8550, Japan.
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Miyazaki T, Fujimaki K, Shirasugi Y, Yoshiba F, Ohsaka M, Miyazaki K, Yamazaki E, Sakai R, Tamaru JI, Kishi K, Kanamori H, Higashihara M, Hotta T, Ishigatsubo Y. Remission of lymphoma after withdrawal of methotrexate in rheumatoid arthritis: relationship with type of latent Epstein-Barr virus infection. Am J Hematol 2007; 82:1106-9. [PMID: 17654684 DOI: 10.1002/ajh.21003] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Rheumatoid arthritis (RA) is associated with an increased risk of developing lymphoma. Although the pathogenesis is still unclear, the increased risk appears to be related to the high inflammatory activity of RA, immunosuppressive agents, or Epstein-Barr virus (EBV) infection. We investigated the relationship between EBV latent infection and methotrexate (MTX)-associated lymphoma in RA patients. Nine patients were diagnosed with non-Hodgkin's lymphoma (NHL) during MTX treatment for RA in a multicenter study. The pathologic findings were consistent with diffuse large B-cell lymphoma in 8 patients and peripheral T-cell lymphoma, unspecified in 1. EBV infection was detected in 3 patients by in situ hybridization. Among all 9 patients who were initially treated by MTX withdrawal alone, 2 obtained spontaneous complete response (CR), 1 had partial response, 2 had stable disease (SD), and 4 had progressive disease. Both patients who had a CR and 1 who had SD were positive for EBV. Further examination of the latent EBV infection patterns revealed that 2 patients who obtained a CR had latency Type III, and the other with SD had latency Type II. These results demonstrate that immunodeficiency caused by MTX treatment is associated with the development of EBV-related NHL in RA patients. In patients who were treated by MTX for RA and developed NHL, remission can be observed following MTX withdrawal especially in NHL with latency Type III EBV infection. The analysis of EBV infection, including the latency types, is useful to decide the optimum therapeutic strategy.
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Affiliation(s)
- Takuya Miyazaki
- Department of Internal Medicine and Clinical Immunology, Yokohama City University Graduate School of Medicine, Kanagawa, Japan.
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Maruani A, Wierzbicka E, Machet MC, Abdallah-Lotf M, de Muret A, Machet L. Reversal of multifocal cutaneous lymphoproliferative disease associated with Epstein-Barr virus after withdrawal of methotrexate therapy for rheumatoid arthritis. J Am Acad Dermatol 2007; 57:S69-71. [DOI: 10.1016/j.jaad.2005.09.015] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2005] [Revised: 08/23/2005] [Accepted: 09/25/2005] [Indexed: 11/27/2022]
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Jois RN, Gaffney K, Cane P, Nicholson AG, Wotherspoon AC. Methotrexate-associated lymphoproliferative disorder masquerading as interstitial lung disease. Histopathology 2007; 51:709-12. [PMID: 17927594 DOI: 10.1111/j.1365-2559.2007.02830.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Clarke LE, Junkins-Hopkins J, Seykora JT, Adler DJ, Elenitsas R. Methotrexate-associated lymphoproliferative disorder in a patient with rheumatoid arthritis presenting in the skin. J Am Acad Dermatol 2007; 56:686-90. [PMID: 17141365 DOI: 10.1016/j.jaad.2006.09.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2006] [Revised: 08/18/2006] [Accepted: 09/14/2006] [Indexed: 11/29/2022]
Abstract
A 91-year-old woman who had been taking methotrexate for approximately 5 years for rheumatoid arthritis developed papules and nodules on her face that enlarged during 6 months. A series of biopsy specimens demonstrated a lymphoplasmacytic infiltrate with increasingly atypical histopathologic features that resembled diffuse large B-cell lymphoma. Epstein-Barr virus was not identified. Withdrawal of methotrexate resulted in complete resolution of all lesions within 8 weeks. This case illustrates the rare occurrence of methotrexate-associated lymphoproliferative disorder with primary presentation in the skin and documents clinical and histopathologic progression from early changes to fully developed lesions.
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Affiliation(s)
- Loren E Clarke
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, USA.
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