Arthritis as a presenting feature of non-Hodgkin's lymphoma

Presentation of B-cell lymphoma in childhood and adolescence: a systematic review and meta-analysis

BACKGROUND

The diagnosis of B-cell lymphoma, one of the commonest cancers seen in childhood and adolescence, is challenging. There is a crucial need to identify and delineate the prevalence of associated symptoms in order to improve early diagnosis.

AIMS

To identify clinical presentations associated with childhood and adolescent B-cell lymphomas and estimate symptom prevalence.

METHODS

A systematic review of observational studies and meta-analysis of proportions was carried out. Medline and EMBASE were systematically searched, with no language restrictions, from inception to 1st August 2022. Observational studies with at least 10 participants, exploring clinical presentations of any childhood and adolescent lymphoma, were selected. Proportions from each study were inputted to determine the weighted average (pooled) proportion, through random-effects meta-analysis.

RESULTS

Studies reported on symptoms, signs and presentation sites at diagnosis of 12,207 children and adolescents up to the age of 20. Hodgkin's lymphoma most frequently presented with adenopathy in the head-and-neck region (79% [95% CI 58%-91%]), whilst non-Hodgkin's lymphoma presented abdominally (55% [95% CI 43%-68%]). Symptoms associated with lymphoma included cervical lymphadenopathy (48% [95% CI 20%-77%]), peripheral lymphadenopathy (51% [95% CI 37%-66%]), B-symptoms (40% [95% CI 34%-44%]), fever (43% [95% CI 34%-54%]), abdominal mass (46% [95% CI 29%-64%]), weight loss (53% [95% CI 39%-66%]), head-and-neck mass (21% [95% CI 6%-47%]), organomegaly (29% [95% CI 23%-37%]), night sweats (19% [95% CI 10%-32%]), abdominal pain (28% [95% CI 15%-47%]), bone pain (17% [95% CI 10%-28%]) and abnormal neurology (11% [95% CI 3%-28%]).

CONCLUSION

This systematic review and meta-analysis of proportions provides insight into the heterogeneous clinical presentations of B-cell lymphoma in childhood and adolescence and provides estimates of symptom prevalence. This information is likely to increase public and clinical awareness of lymphoma presentations and aid earlier diagnosis. This review further highlights the lack of studies exploring childhood and adolescent lymphoma presentations in primary care, where patients are likely to present at the earliest stages of their disease.

A Rare Case of Anaplastic Large Cell Lymphoma of the Knee Joint

Introduction

Anaplastic large cell lymphoma (ALCL), which makes up only 2-5% of instances of NHL, is a rare and aggressive form of the disease. Anaplastic Lymphoma Kinase (ALK)-positive ALCL is a variant of the illness that is identified by the presence of an ALK gene fusion. The disease is most commonly confined to the nodes, but extranodal spread has been reported. Skin and soft tissue are the most frequently identified locations for extranodal involvement, while joints are extremely rare. We describe a rare case of ALCL affecting the knee joint that is ALK -positive.

Case Report

A 51-year-old female presented with pain in her right knee. It was diagnosed as synovitis and treated accordingly. The symptoms did not relieve and a magnetic resonance imaging (MRI) scan was performed that indicated a meniscus tear. She was treated for it; however, the symptoms worsened. She underwent two more scans (1 MRI and 1 PET) that indicated an enhancing polypoidal mass in the knee joint, and two arthroscopic procedures. The histopathology report indicated an ALK-positive ALCL. She was treated with Brentuximab vedotin + CHP followed by involved-site radiotherapy to the postoperative region with margins. The patient has had a complete clinical and pathological response which was assessed after 1 year from the start of the treatment.

Conclusion

This is the first instance of primary ALK-positive ALCL affecting the knee joint that has been documented, to the best of our knowledge. The case emphasizes the significance of taking ALCL into account when determining the differential diagnosis of knee joint tumors as well as the requirement for a thorough assessment of extranodal involvement.

Musculoskeletal Diagnoses before Cancer in Children: A Danish Registry-Based Cohort Study

OBJECTIVE

To identify the prevalence of musculoskeletal diagnoses recorded 6 months before the diagnosis of cancer and to evaluate whether preceding musculoskeletal diagnoses affected survival.

STUDY DESIGN

We performed a nationwide registry-based cohort study including all children under 15 years of age diagnosed with cancer in Denmark over a 23-year period (1996-2018). The Danish National Patient Registry was used to identify musculoskeletal diagnoses and associated dates recorded within 6 months preceding the diagnosis of cancer. We compared the characteristics of children with and without a prior musculoskeletal diagnoses using prevalence ratios and 95% CI and diagnostic interval as median with IQR. We compared survival using Kaplan-Meier and Cox proportional hazards regression analysis adjusting for age, sex, and presence of metastasis at diagnosis.

RESULTS

Of 3895 children with all types of cancer, 264 (7%) had a total of 451 hospital visits with musculoskeletal diagnosis within 6 months preceding the diagnosis of cancer; however, survival was not affected. The overall median diagnostic interval from first musculoskeletal diagnosis (within 6 months before cancer diagnosis) to cancer diagnosis was 15 days (IQR, 7-47 days). A diagnosis of juvenile idiopathic arthritis, unspecified arthritis, and arthropathy each accounted for 5% of the contacts, primarily in children with acute lymphoblastic leukemia, bone sarcomas, or neuroblastomas.

CONCLUSIONS

A preliminary musculoskeletal diagnosis occurred in 7% of children with cancer, but did not affect the overall survival.

Rheumatologic manifestations of benign and malignant haematological disorders

Diseases of blood and lymphoreticular system can have multisystem manifestations. Rheumatologic involvement has been reported in association with many benign and malignant haematological disorders; these patients are equally likely to present to both clinical rheumatologists and haematologists. This review focuses on the well-described rheumatologic features, other occasionally reported rheumatologic manifestations and unusual musculoskeletal complications related to the treatment in patients with underlying haematological conditions. The aim of this review is to help increase the awareness of rheumatologic manifestations seen in the blood disorders and to highlight the potential diagnostic pitfalls.

Anaplastic large cell lymphoma presenting with symmetric polyarthritis in pregnancy

Anaplastic large-cell lymphoma (ALCL) is a rare T-cell lymphoma and typically is seen in children and young adults. Primary bone infiltration of ALCL is exceedingly rare. Herein we report ALCL of bone in a pregnant admitted with symmetric polyarthritis. Magnetic resonance imaging of the pelvis revealed soft tissue component of that destructive mass lesion on the right iliac crest after delivery. Excisional biopsy from the destructive mass showed anaplastic large cell lymphoma (CD 30 was positive and ALK negative). The patient was treated with combination chemotherapy consisting of cyclophosphamide, doxorubicin, vincristine and prednisolone (CHOP) every 4 weeks. After the third cycle of chemotherapy, a marked improvement of her arthritis and right iliac pain was noted.

Associations between rheumatoid arthritis and malignancy

There are many complex associations between rheumatoid arthritis(RA) and malignancy. Patients with rheumatic diseases on the whole appear to be at increased risk for the development of certain malignancies. The data from several studies are persuasive that the presence of RA conveys an increased risk for the development of lymphoproliferative disorders and may convey a decreased risk for the development of malignancies of the digestive tract. Understanding the complex interrelationships between RA and malignancy will lead to more accurate diagnosis of underlying pathology, more effective treatment of symptoms and underlying disease, and appropriate surveillance for the development of later complications.

Incidence of occult cancer in children presenting with musculoskeletal symptoms: a 10-year survey in a pediatric rheumatology unit

OBJECTIVES

To assess the frequency and types of cancer found in children presenting to our Unit with musculoskeletal symptoms over a 10-year period.

METHODS

The medical records of patients with musculoskeletal symptoms and a final diagnosis of cancer were reviewed. In each case age, gender, presenting symptoms, laboratory data, diagnostic procedures, provisional and final diagnoses, and time between clinical onset and correct diagnosis were reviewed.

RESULTS

An underlying neoplasia was found in 10 of 1,254 patients (<1%) complaining of musculoskeletal symptoms. The types of malignancies found included acute lymphocytic leukemia (ALL) (6 cases), lymphoma (2 cases), neuroblastoma (1 case), and Ewing's sarcoma (1 case). The mean time between disease onset and final diagnosis was 3.2 months. The most common presenting feature was monoarthritis, involving the larger joints such as the elbows, knees or ankles. Juvenile idiopathic arthritis (JIA) was the most frequent provisional diagnosis. In the preliminary hematologic evaluation, eight patients had an increased erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) value. White blood cell (WBC) count was normal in almost all children, with a normal differential count. Lactic dehydrogenase (LDH) was raised in all children. Bone marrow aspirates and lymph node or bone biopsies were necessary to reach the final diagnosis.

CONCLUSIONS

A malignancy should always be excluded in children with musculoskeletal symptoms, especially when the clinical pattern is not characteristic of a specific rheumatic disease. Routine laboratory tests may be misleading. The simultaneous presence of high LDH or alpha-hydroxybutyric dehydrogenase (alpha-HBDH) levels and raised ESR or CRP, even with normal blood cell counts, should lead to additional investigations.

RELEVANCE

All patients presenting with arthritis or other musculoskeletal symptoms should have a thorough clinical examination. Disproportionate pain levels and an atypical pattern of "arthritis," especially in the presence of systemic manifestations, suggest a possible underlying malignancy.

Rheumatologic features of hematologic disorders

This review focuses on the various rheumatologic manifestations of hematologic diseases and is based on the English literature published over the past year. Interrelationships between leukemia, lymphoma, POEMS syndrome, multiple myeloma, hemophilia, and rheumatic manifestations are discussed. Other less common associated conditions dealt with include the RS3PE syndrome, large granular lymphocyte syndrome, and interferon-related arthritis. Finally, therapeutic measures, such as bone marrow transplantation and the use of granulocyte colony-stimulating factor, are reviewed.