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SALEEM KAINAT, NASRAZADANI AZADEH, KUANG CHAOYUAN, JAITLY VANYA, HO JONHAN, RAPTIS ANASTASIOS, SMITH ROY, SEAMAN CRAIG. Intravascular Lymphoma - The Creepy Crawler: A Case Series and Brief Literature Review. CANCER DIAGNOSIS & PROGNOSIS 2023; 3:31-37. [PMID: 36632582 PMCID: PMC9801442 DOI: 10.21873/cdp.10176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 11/14/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Intravascular large B-cell lymphoma (IVLBCL) is a rare subtype of extranodal B-cell lymphoma, which has traditionally been associated with poor outcomes. Despite increasing recognition, IVLBCL requires a high degree of clinical suspicion on the part of the clinician for its diagnosis. CASE SERIES We present four patient cases: A 69-year-old female with constitutional symptoms and cognitive decline; a 78-year-old female with kidney injury and constitutional symptoms whose disease rapidly progressed to multiorgan failure and death; a 70-year-old asymptomatic female with an incidentally found, enlarged thyroid; and a 63-year-old male with cytopenia and constitutional symptoms. Retrospective chart analysis was performed on these four patients diagnosed with IVLBCL at our Institute to identify the pathognomonic features of the disease and compare these to the published evidence. IVLBCL has a heterogeneous presentation, as seen in our four patients. The disease is characterized by the exclusive presence of malignant cells inside the blood vessels and lack of organ infiltration. Traditional preliminary diagnostic modalities such as imaging are usually inconclusive, given the paucity of lymphomatous aggregates. A bone marrow biopsy, random skin biopsies, or a focal organ biopsy in appropriate cases is required for diagnosis. Immunosuppression might play a role in the pathogenesis. Timely initiation of aggressive cancer-directed therapy was associated with improved outcomes. Monitoring for disease response and relapse continues to be a challenge. CONCLUSION Our mini-series highlights the significance of timely diagnosis and intervention in IVLBCL and emphasizes the importance of further research to determine its association with immunosuppression.
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Affiliation(s)
- KAINAT SALEEM
- Division of Hematology-Oncology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, U.S.A
| | - AZADEH NASRAZADANI
- Division of Hematology-Oncology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, U.S.A
| | - CHAOYUAN KUANG
- Division of Hematology-Oncology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, U.S.A
| | - VANYA JAITLY
- Division of Hematopathology, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, U.S.A
| | - JONHAN HO
- Division of Dermatopathology, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, U.S.A
| | - ANASTASIOS RAPTIS
- Division of Hematology-Oncology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, U.S.A
| | - ROY SMITH
- Division of Hematology-Oncology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, U.S.A
| | - CRAIG SEAMAN
- Division of Hematology-Oncology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, U.S.A
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Abstract
A 56-year-old woman with rheumatoid arthritis who had been taking methotrexate (MTX) for six years visited our hospital with dyspnea and dizziness. Abdominal ultrasonography revealed mild splenomegaly. Laboratory examinations showed a marked elevation in soluble interleukin-2 receptor and lactate dehydrogenase levels. These abnormalities revealed a spontaneous regression after MTX discontinuation, however, they worsened again four months later. Skin biopsies revealed a diagnosis of intravascular large B-cell lymphoma (IVLBCL), and we diagnosed MTX-associated IVLBCL (MTX-IVLBCL) based on its characteristic course. Despite the recurrence of IVLBCL, it showed a good response to chemotherapy. MTX-IVLBCL should therefore be treated with consideration since it has different characteristics from that of de novo IVLBCL.
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Affiliation(s)
| | - Hirosaka Inoue
- Department of Hematology, Imakiire General Hospital, Japan
| | - Kosuke Obama
- Department of Hematology, Imakiire General Hospital, Japan
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Nagata H, Kuriyama K, Nishikawa R, Ohshiro M, Yamamoto-Sugitani M, Fujimoto-Hirakawa Y, Matsumoto Y, Iwai T, Tsukamoto T, Mizutani S, Shimura Y, Kobayashi T, Fukuda W, Uchiyama H, Kuroda J. Iguratimod triggers the relapse of methotrexate-associated lymphoproliferative disorder. Ann Hematol 2021; 100:2849-2850. [PMID: 34420071 DOI: 10.1007/s00277-021-04645-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 08/16/2021] [Indexed: 01/14/2023]
Affiliation(s)
- Hiroaki Nagata
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 602-8566, Japan.,Department of Hematology, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Kodai Kuriyama
- Department of Hematology, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Rina Nishikawa
- Department of Hematology, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Muneo Ohshiro
- Department of Hematology, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | | | | | - Yosuke Matsumoto
- Department of Hematology, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Toshiki Iwai
- Department of Hematology, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Taku Tsukamoto
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Shinsuke Mizutani
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Yuji Shimura
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Tsutomu Kobayashi
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Wataru Fukuda
- Center for Rheumatic Disease, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Hitoji Uchiyama
- Department of Hematology, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Junya Kuroda
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 602-8566, Japan.
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Wen L, Jiang W, Zhou M, Wu Z. Effect of combined application of iguratimod in the treatment of active rheumatoid arthritis on bone metabolism, Th17 cells and Treg cells. Am J Transl Res 2021; 13:1676-1684. [PMID: 33841689 PMCID: PMC8014432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 11/22/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVE This study was designed to analyse the effect of combined application of iguratimod with methotrexate in the treatment of active rheumatoid arthritis (RA). METHODS A total of 115 patients with active RA admitted to our hospital were enrolled and divided into group A (n=58) and group B (n=57) according to the method of random number table. Patients in group B were treated with methotrexate alone, while patients in group A were treated with methotrexate combined with iguratimod. The curative efficacy was compared between the two groups. RESULTS At 6 months after treatment, the levels of CTX-1 and RANKL in group A were higher than those in group B, and the levels of OPG, IL-17 and TGF-α in group A were lower than those in group B (P<0.05). The level of Th17 cells in group A was higher than that in group B, and the level of Treg cells in group A was lower than that in group B at 6 months after treatment (P<0.05). Tender joints count, swollen joints count and DAS28 score in group A were less than those in group B at 6 months after treatment (P<0.05). The duration of morning stiffness of the joints and the score of joint pain degree in group A were less than those in group B at 1, 2, 3, 4, 5, and 6 months after treatment (P<0.05). CONCLUSION The combined application of methotrexate and iguratimod in the treatment of active RA can effectively improve bone metabolism, regulate the levels of Th17 and Treg cells, play a prominent role in anti-inflammatory effect, and relieve symptoms, and thus achieve a more satisfactory curative effect.
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Affiliation(s)
- Li Wen
- Department of Rheumatology and Immunology, First People's Hospital Fuyang District, Hangzhou 311400, Zhejiang Province, China
| | - Wei Jiang
- Department of Rheumatology and Immunology, First People's Hospital Fuyang District, Hangzhou 311400, Zhejiang Province, China
| | - Meiqun Zhou
- Department of Rheumatology and Immunology, First People's Hospital Fuyang District, Hangzhou 311400, Zhejiang Province, China
| | - Zhenxia Wu
- Department of Rheumatology and Immunology, First People's Hospital Fuyang District, Hangzhou 311400, Zhejiang Province, China
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Koźmiński P, Halik PK, Chesori R, Gniazdowska E. Overview of Dual-Acting Drug Methotrexate in Different Neurological Diseases, Autoimmune Pathologies and Cancers. Int J Mol Sci 2020; 21:ijms21103483. [PMID: 32423175 PMCID: PMC7279024 DOI: 10.3390/ijms21103483] [Citation(s) in RCA: 131] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 05/08/2020] [Accepted: 05/12/2020] [Indexed: 02/07/2023] Open
Abstract
Methotrexate, a structural analogue of folic acid, is one of the most effective and extensively used drugs for treating many kinds of cancer or severe and resistant forms of autoimmune diseases. In this paper, we take an overview of the present state of knowledge with regards to complex mechanisms of methotrexate action and its applications as immunosuppressive drug or chemotherapeutic agent in oncological combination therapy. In addition, the issue of the potential benefits of methotrexate in the development of neurological disorders in Alzheimer’s disease or myasthenia gravis will be discussed.
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Iwami E, Ito F, Sasahara K, Kuroda A, Matsuzaki T, Nakajima T, Abe D, Matsumoto K, Sasaki A, Eguchi K, Terashima T. Pulmonary Intravascular Large B-cell Lymphoma in a Patient Administered Methotrexate for Rheumatoid Arthritis. Intern Med 2020; 59:429-433. [PMID: 31619597 PMCID: PMC7028407 DOI: 10.2169/internalmedicine.3216-19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
A 70-year-old woman with rheumatoid arthritis undergoing methotrexate (MTX) treatment presented with dyspnea and a subfever. Computed tomography (CT) revealed a diffuse minimal ground-glass appearance in both lungs and splenomegaly. The gallium scintigram showed a diffuse, mild uptake in both lungs and the spleen. The lung biopsy specimen revealed the presence of CD20-positive atypical lymphocytes in the small pulmonary vessels. The patient was diagnosed with pulmonary intravascular diffuse large B-cell lymphoma (IVLBCL) and exhibited spontaneous regression after MTX was discontinued. This report describes a rare case of MTX-associated lymphoproliferative disorder expressing pulmonary IVLBCL.
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Affiliation(s)
- Eri Iwami
- Department of Respiratory Medicine, Tokyo Dental College Ichikawa General Hospital, Japan
| | - Fumimaro Ito
- Department of Respiratory Medicine, Tokyo Dental College Ichikawa General Hospital, Japan
| | - Kotaro Sasahara
- Department of Respiratory Medicine, Tokyo Dental College Ichikawa General Hospital, Japan
| | - Aoi Kuroda
- Department of Respiratory Medicine, Tokyo Dental College Ichikawa General Hospital, Japan
| | - Tatsu Matsuzaki
- Department of Respiratory Medicine, Tokyo Dental College Ichikawa General Hospital, Japan
| | - Takahiro Nakajima
- Department of Respiratory Medicine, Tokyo Dental College Ichikawa General Hospital, Japan
| | - Daichi Abe
- Department of Internal Medicine, Tokyo Dental College Ichikawa General Hospital, Japan
| | - Kimihiro Matsumoto
- Department of Internal Medicine, Tokyo Dental College Ichikawa General Hospital, Japan
| | - Aya Sasaki
- Department of Pathology and Laboratory Medicine, Tokyo Dental College Ichikawa General Hospital, Japan
| | - Keisuke Eguchi
- Department of Surgery, Tokyo Dental College Ichikawa General Hospital, Japan
| | - Takeshi Terashima
- Department of Respiratory Medicine, Tokyo Dental College Ichikawa General Hospital, Japan
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Tokuhira M, Tamaru JI, Kizaki M. Clinical management for other iatrogenic immunodeficiency-associated lymphoproliferative disorders. J Clin Exp Hematop 2019; 59:72-92. [PMID: 31257348 PMCID: PMC6661962 DOI: 10.3960/jslrt.19007] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Other iatrogenic immunodeficiency-associated lymphoproliferative disorders (OIIA-LPD), a category of immunodeficiency-associated LPD according to the World Health Organization classification, is associated with immunosuppressive drugs (ISDs). Several factors, including autoimmune disease (AID) activity, Epstein-Barr virus (EBV) infection, ISD usage, and aging, influence the development of OIIA-LPD, resulting in complicated clinical courses and outcomes. Most OIIA-LPD develops in patients with rheumatoid arthritis using methotrexate (MTX-LPD). The management of MTX-LPD is based on the clinical course, i.e., with/without regression, with/without relapse/regrowth event (RRE), LPD subtype, and ISDs for AIDs after LPD development. There are three clinical courses after ISD withdrawal: regressive LPD without relapse/regrowth (R-G), regressive LPD with RRE (R/R-G), and persistent LPD (P-G). The majority of EBV+ diffuse large B-cell lymphomas are classified in R-G, whereas classic Hodgkin lymphoma is generally classified in R/R-G. Polymorphic LPD (P-LPD) in MTX-LPD develops with heterogeneous pathological features similar to monomorphic LPD. Chemotherapy for MTX-LPD is selected according to that for de novo LPD, although the strategy for aggressive P-LPD and non-specific LPD is not well established. The absolute lymphocyte count in the peripheral blood has been suggested as a candidate marker for MTX-LPD development and RRE. Several clinical issues, including correct diagnosis among overlapping clinicopathological features in MTX-LPD and clinical management of LPD by ISDs other than MTX, require further investigation.
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Hemophagocytic Syndrome-Associated Variant of Methotrexate-Associated Intravascular Large B-Cell Lymphoma in a Rheumatoid Arthritis Patient. Case Rep Hematol 2019; 2019:8947616. [PMID: 31612088 PMCID: PMC6755279 DOI: 10.1155/2019/8947616] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 07/13/2019] [Accepted: 08/14/2019] [Indexed: 01/23/2023] Open
Abstract
A 59-year-old man was treated for rheumatoid arthritis (RA) for 12 years with methotrexate (MTX) and prednisolone. After MTX-associated interstitial pneumonia developed, he was treated with cyclophosphamide and prednisolone for 7 months. Arthritis worsened, and tacrolimus was added to the treatment regimen. One month later, he had fever, loss of appetite, and dyspnea on exertion. Blood tests showed pancytopenia with large, atypical lymphocytes. Computed tomography showed mild splenomegaly. Bone marrow examination demonstrated CD20-positive, EBER-positive atypical lymphocytes, and hemophagocytosis. Random skin biopsy led to the diagnosis of intravascular large B-cell lymphoma (IVLBCL). The final diagnosis was a hemophagocytic syndrome-associated variant of IVLBCL. Complete remission was achieved after seven courses of R-CHOP. However, within a month, he complained of dizziness. Magnetic resonance imaging revealed focal infarctions in the cerebellum and around the left lateral ventricle. Central nervous system relapse was suspected. Although salvage chemotherapy (CHASER), whole brain irradiation, and intrathecal injection of cytarabine and prednisolone were temporarily effective, he died. Autopsy revealed infiltration of lymphoma cells in the brain and adrenal glands. To the best of our knowledge, this is the sixth case of IVLBCL and the first case of the hemophagocytic syndrome-associated variant of IVLBCL in RA patients in the literature.
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