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Nagata Y, Akiba S, Horiuchi H, Okumoto K, Hachinohe S, Ohe R. A case of methotrexate-related lymphoproliferative disease showing multiple liver lesions in a patient with rheumatoid arthritis. Clin J Gastroenterol 2024:10.1007/s12328-024-01963-6. [PMID: 38642276 DOI: 10.1007/s12328-024-01963-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 03/19/2024] [Indexed: 04/22/2024]
Abstract
A 66-year-old woman with rheumatoid arthritis (RA) who had been receiving methotrexate (MTX) for 2 years presented with tarry stools. Contrast-enhanced computed tomography (CT) of the abdomen revealed irregular wall thickening in the ileocecal region and multiple low-contrast masses in both lobes of the liver. Lower gastrointestinal endoscopy revealed a type 2 tumor in the ileocecal region with a semi-peripheral ulcer. Histological examination of liver and colon biopsies showed other iatrogenic immunodeficiency-associated lymphoproliferative disorder (Oi-LPD), diffuse large B-cell lymphoma type, with positivity for Epstein-Barr virus DNA. After withdrawal of MTX, the LPD lesions disappeared and the patient achieved remission. We considered this to be a sporadic case of Oi-LPD, diffuse large B-cell lymphoma type, in the liver and colon due to treatment with MTX. There has been no previous report of this condition with simultaneous hepatic and colonic lesions, and the present case is thought to be highly informative in relation to the pathogenesis.
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Affiliation(s)
- Yamato Nagata
- Department of Gastroenterology, Yamagata Prefectural Shinjo Hospital, 720-1 Kanazawa, Shinjo, Yamagata, 996-8585, Japan.
| | - Shotaro Akiba
- Department of Gastroenterology, Yamagata Prefectural Shinjo Hospital, 720-1 Kanazawa, Shinjo, Yamagata, 996-8585, Japan
| | - Hidekazu Horiuchi
- Department of Gastroenterology, Yamagata Prefectural Shinjo Hospital, 720-1 Kanazawa, Shinjo, Yamagata, 996-8585, Japan
| | - Kazuo Okumoto
- Department of Gastroenterology, Yamagata Prefectural Shinjo Hospital, 720-1 Kanazawa, Shinjo, Yamagata, 996-8585, Japan
| | - Shigemi Hachinohe
- Department of Gastroenterology, Yamagata Prefectural Shinjo Hospital, 720-1 Kanazawa, Shinjo, Yamagata, 996-8585, Japan
| | - Rintaro Ohe
- Department of Pathology, Faculty of Medicine, Yamagata University, Yamagata, Japan
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Miyamoto Y, Kawasoe C, Ito K, Oguri N, Murashima T, Kamibeppu T, Nagai T, Takamori H, Kamimura T, Mukai S, Sato Y, Kamoto T. Hepatic and lung methotrexate-associated polymorphic lymphoproliferative disorders arising during postoperative follow-up of renal cell carcinoma: a case report. J Med Case Rep 2023; 17:524. [PMID: 38129899 PMCID: PMC10740260 DOI: 10.1186/s13256-023-04288-z] [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: 09/21/2023] [Accepted: 11/28/2023] [Indexed: 12/23/2023] Open
Abstract
INTRODUCTION Methotrexate induces lymphoproliferative disorders on rare occasions; however, its pathogenesis remains unknown. A clinical diagnosis based on imaging studies alone is often difficult. CASE PRESENTATION A 57-year-old Japanese woman was referred to our department for the evaluation of multiple lung and hepatic nodules that developed during methotrexate treatment for rheumatoid arthritis. Since she had a history of nephrectomy for localized renal cell carcinoma, multiple lung and hepatic metastases were initially considered. However, pathological diagnosis of the lung nodules (needle biopsy) revealed methotrexate-associated polymorphic-type lymphoproliferative disorders. After methotrexate discontinuation, continuous smooth shrinkage of the lung and liver lymphoproliferative disorders was observed. CONCLUSION Methotrexate-associated lymphoproliferative disorders should be considered in the event of newly appearing neoplastic lesions, even during follow-up for renal cell carcinoma, if methotrexate is being administered.
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Affiliation(s)
- Yoshi Miyamoto
- Department of Urology, Faculty of Medicine, Miyazaki University Hospital, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Chihiro Kawasoe
- Department of Urology, Faculty of Medicine, Miyazaki University Hospital, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Kaoru Ito
- Department of Urology, Faculty of Medicine, Miyazaki University Hospital, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Nobuyuki Oguri
- Department of Diagnostic Pathology, Faculty of Medicine, Miyazaki University Hospital, Miyazaki, Japan
| | - Takaya Murashima
- Department of Urology, Faculty of Medicine, Miyazaki University Hospital, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | | | - Takahiro Nagai
- Department of Urology, Faculty of Medicine, Miyazaki University Hospital, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Hiroki Takamori
- Department of Urology, Faculty of Medicine, Miyazaki University Hospital, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Toshio Kamimura
- Department of Urology, Faculty of Medicine, Miyazaki University Hospital, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Shoichiro Mukai
- Department of Urology, Faculty of Medicine, Miyazaki University Hospital, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan.
| | - Yuichiro Sato
- Department of Diagnostic Pathology, Faculty of Medicine, Miyazaki University Hospital, Miyazaki, Japan
| | - Toshiyuki Kamoto
- Department of Urology, Faculty of Medicine, Miyazaki University Hospital, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
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Hatayama Y, Sugiyama H, Murakami D, Oura H, Shima Y, Shirato M, Nishino T, Nakazawa T, Suehiro K, Arai M. Primary Hepatic Other Iatrogenic Immunodeficiency-Associated Lymphoproliferative Disorders After Methotrexate Therapy. J Med Cases 2023; 14:282-288. [PMID: 37692367 PMCID: PMC10482596 DOI: 10.14740/jmc4135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 08/07/2023] [Indexed: 09/12/2023] Open
Abstract
Prior reports described cases of lymphoproliferative diseases occurring after methotrexate (MTX) administration, which are called methotrexate-associated lymphoproliferative disorders (MTX-LPDs). It has become clear that these lymphoproliferative diseases also occur following treatment with other immunosuppressive drugs, and they have been termed as other iatrogenic immunodeficiency-associated lymphoproliferative disorders (OIIA-LPDs). In most of these cases, the duration of immunosuppressive drugs is very long, on the order of years. In the present study, we evaluated the development of lymphoproliferative disease despite the short duration of immunosuppressive treatment and determined the tumor doubling time. A 71-year-old woman was diagnosed with adult-onset Still's disease. The patient was administered prednisone 30 mg per day starting on February 25, 2022 and MTX 6 mg per week starting 2 weeks later. Because she was a hepatitis B virus (HBV) carrier, nucleic acid analog therapy was also started to prevent HBV activation. Eight weeks later, biweekly tocilizumab was started. After 5 months of MTX administration, a solitary liver tumor measuring 37 × 32 mm2 was detected. Three months later, repeat computed tomography revealed that the liver tumor had grown rapidly to 7 cm in diameter. We considered the possibility of OIIA-LPDs and stopped MTX therapy. Biopsy specimens of the liver tumor exhibited lymphocyte proliferation, which was consistent with OIIA-LPDs. The doubling time for tumor growth was 33 days. Despite withdrawing MTX for 6 weeks, the tumor continued to grow, and thus, the patient was referred to the hematology unit. In previously reported cases of MTX-LPDs of hepatic origin, the average duration of MTX administration was 7.3 (2 - 13) years. This report describes a primary hepatic OIIA-LPDs-associated tumor that rapidly increased in size after an extremely short period of MTX administration.
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Affiliation(s)
- Yasuki Hatayama
- Department of Gastroenterology, Tokyo Women’s Medical University Yachiyo Medical Center, Chiba 276-8523, Japan
| | - Harutoshi Sugiyama
- Department of Gastroenterology, Tokyo Women’s Medical University Yachiyo Medical Center, Chiba 276-8523, Japan
| | - Daisuke Murakami
- Department of Gastroenterology, Tokyo Women’s Medical University Yachiyo Medical Center, Chiba 276-8523, Japan
| | - Hirotaka Oura
- Department of Gastroenterology, Tokyo Women’s Medical University Yachiyo Medical Center, Chiba 276-8523, Japan
| | - Yukiko Shima
- Department of Gastroenterology, Tokyo Women’s Medical University Yachiyo Medical Center, Chiba 276-8523, Japan
| | - Miho Shirato
- Department of Gastroenterology, Tokyo Women’s Medical University Yachiyo Medical Center, Chiba 276-8523, Japan
| | - Takayoshi Nishino
- Department of Gastroenterology, Tokyo Women’s Medical University Yachiyo Medical Center, Chiba 276-8523, Japan
| | - Tadao Nakazawa
- Department of Pathology, Tokyo Women’s Medical University Yachiyo Medical Center, Chiba 276-8523, Japan
| | - Kenichi Suehiro
- Center for Rheumatic Diseases, Chibaken Saiseikai Narashino Hospital, Chiba 275-8580, Japan
| | - Makoto Arai
- Department of Gastroenterology, Tokyo Women’s Medical University Yachiyo Medical Center, Chiba 276-8523, Japan
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Omameuda T, Miyato H, Sata N, Lefor AK. Primary hepatic methotrexate-associated lymphoproliferative disorder associated with Epstein-Barr virus reactivation and accompanied by spontaneous necrosis: A case report. Medicine (Baltimore) 2022; 101:e31993. [PMID: 36451467 PMCID: PMC9705001 DOI: 10.1097/md.0000000000031993] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
RATIONALE Methotrexate-associated lymphoproliferative disorder (MTX-LPD) is a major complication of methotrexate (MTX) therapy that can develop in patients with rheumatoid arthritis (RA), although primary hepatic MTX-LPD is extremely rare. Discontinuation of MTX results in remission in half of the patients with MTX-LPDs and is one treatment approach. PATIENT CONCERN A 64-year-old Japanese woman suffering from rheumatoid arthritis treated with MTX presented with upper abdominal pain. DIAGNOSIS Pathological evaluation showed that the tumor contained geographic necrosis and proliferation of large atypical lymphocytes strongly positive for cluster of differentiation 20 (CD20) antigen with immunohistochemical staining and Epstein-Barr Virus-encoded RNA transcript by in situ hybridization. The tumor was finally diagnosed as a primary hepatic MTX-associated Epstein-Barr Virus positive B-cell LPD. INTERVENTIONS Left hepatic lobectomy was performed for diagnosis and therapy. OUTCOMES No sighs of recurrence were observed for 2 years. LESSONS This patient demonstrated that MTX-LPD could arise in the liver, although it is rare. If liver tumors arise in patients taking MTX, examination of sIL-2R, Epstein-Barr virus-VCA IgG and EBNA might support the diagnosis of MTX-LPD. In this case, the primary hepatic MTX-LPD became necrotic without discontinuation of MTX. It is generally believed that withdrawal of MTX restores antitumor immunity resulting in tumor necrosis. This case indicates that spontaneous regression might occur without any treatment in some patients treated for RA with MTX-LPD. The relationship between MTX-LPD and spontaneous necrosis is unclear and further data is required to characterize the types of patients that will develop spontaneous regression without intervention.
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Affiliation(s)
- Takahiko Omameuda
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
- * Correspondence: Takahiko Omameuda, Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke-shi, Tochigi-ken 329-0498, Japan (e-mail: )
| | - Hideyo Miyato
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Naohiro Sata
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Alan Kawarai Lefor
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
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Hepatotoxic potentials of methotrexate: Understanding the possible toxicological molecular mechanisms. Toxicology 2021; 458:152840. [PMID: 34175381 DOI: 10.1016/j.tox.2021.152840] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 06/10/2021] [Accepted: 06/22/2021] [Indexed: 12/12/2022]
Abstract
Methotrexate (MTX) is one of the most effective and widely used drugs in the management of autoimmune and dermatological diseases. Rheumatoid arthritis and psoriasis patients who are under long term MTX-therapy are at high risk of developing a liver injury. Accumulation of intracellular MTX-polyglutamate (MTX-PG), a metabolite of MTX triggers oxidative stress, inflammation, steatosis, fibrosis, and apoptosis in hepatocytes. MTX-PG causes oxidative stress in the liver by inducing lipid peroxidation thereby releasing reactive oxygen species and suppressing antioxidant response elements. MTX-PG induces several pro-inflammatory signaling pathways and cytokines such as tumor necrosis factor-α, nuclear factor kappa B and interleukin 6 (IL-6), IL- β1, IL-12. MTX-PG depletes hepatic folate level and decreases RNA and DNA synthesis leading to hepatocyte death. MTX-PG inhibits 5-aminoimidazole-4-carboxamide ribonucleotide transformylase enzyme and thereby causes accumulation of intracellular adenosine, which causes activation of hepatic stellate cells, extracellular matrix accumulation and hepatic fibrosis. MTX-PG induces hepatocytes apoptosis by activation of caspase 3 via the intrinsic pathway. Clinically, aggravation of underlying fatty liver to non-alcoholic steatohepatitis with fibrosis seems to be an important mechanism of liver injury in MTX-treated RA patients. Therefore, there is a need for monitoring liver injury in RA, psoriatic and cancer patients with NAFLD and fibrosis risk factors during MTX treatment. This review summarizes the possible molecular mechanism of MTX-induced hepatotoxicity. It may pave the way for early detection of liver injury and develop novel strategies for treating MTX mediated hepatotoxicity.
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Hirata C, Kenzaka T, Akita H. Methotrexate-associated lymphoproliferative disorder with an osteolytic vertebral lesion in an elderly patient with rheumatoid arthritis: A case report. J Clin Pharm Ther 2021; 46:1178-1181. [PMID: 33768586 PMCID: PMC8360114 DOI: 10.1111/jcpt.13415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 02/23/2021] [Accepted: 03/10/2021] [Indexed: 01/19/2023]
Abstract
WHAT IS KNOWN AND OBJECTIVE Methotrexate-associated lymphoproliferative disorder (MTX-LPD) is a rare complication that develops in patients treated with methotrexate (MTX). CASE SUMMARY A 76-year-old male patient had been taking MTX for his rheumatoid arthritis. Computed tomography (CT) revealed masses in the liver, right adrenal gland and T6-T7 vertebra, including an osteolytic lesion. FDG-PET scan showed increased uptake in each lesion. MTX was discontinued, and CT showed complete remission of the tumours after three months. The disease course confirmed MTX-LPD diagnosis. WHAT IS NEW AND CONCLUSION Bone lesions in LPDs mimic those of metastatic cancer. MTX-LPD should be considered in patients on MTX presenting with mass lesions.
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Affiliation(s)
- Chihiro Hirata
- Department of Internal Medicine, Hyogo Prefectural Tamba Medical Center, Tamba, Japan
| | - Tsuneaki Kenzaka
- Department of Internal Medicine, Hyogo Prefectural Tamba Medical Center, Tamba, Japan.,Division of Community Medicine and Career Development, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hozuka Akita
- Department of Internal Medicine, Hyogo Prefectural Tamba Medical Center, Tamba, Japan
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Tsuruoka M, Inoue J, Kakazu E, Ninomiya M, Iwata T, Sano A, Masamune A. Methotrexate-associated Lymphoproliferative Disorder in the Liver Resembling Hepatocellular Carcinoma Treated with Transarterial Chemoembolization. Intern Med 2020; 59:2255-2260. [PMID: 32522926 PMCID: PMC7578598 DOI: 10.2169/internalmedicine.4787-20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Methotrexate-related lymphoproliferative disorder (MTX-LPD) is known to be a side effect of MTX, but its involvement in the liver has been rarely reported. We herein report a 70-year-old woman with autoimmune hepatitis and rheumatoid arthritis who developed multiple liver tumors. We initially considered that she had developed rapid-growing hepatocellular carcinoma (HCC) in the cirrhotic liver based on imaging tests. A tumor biopsy and transcatheter arterial chemoembolization were thus performed. The tumors were then diagnosed as diffuse large B-cell lymphoma pathologically and considered to be MTX-LPD. This case indicates that MTX-LPD should be considered even in cirrhotic patients with liver tumors resembling HCC.
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Affiliation(s)
- Mio Tsuruoka
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Jun Inoue
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Eiji Kakazu
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Masashi Ninomiya
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Tomoaki Iwata
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Akitoshi Sano
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Atsushi Masamune
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
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