RA & lymphoma

A short presentation on two cases highlighting the association between rheumatoid arthritis and lymphoma.

Transcript

1. RA & LYMPHOMA 2 case presentations Andrew Ho (F2) July 2013
2. CF: 72˂ Presentation SSZ started early 1990’s Jan 2003 Jan 2013 Feb Mar Apr May MTX added CXR CT CAP Biopsy #1 RCHOP USS
3. Chest radiograph removed for confidentiality (raised left hemidiaphragm)
4. CF: 72˂ Presentation SSZ started early 1990’s Jan 2003 Jan 2013 Feb Mar Apr May MTX added CXR CT CAP Biopsy #1 RCHOP USS CXR done for vague chest discomfort Retrospectively noted 10kg weight loss since December 2012
5. Excision biopsy HRCT HCQ started HK: 41˂ Initial presentation Dec 2012 Jan 2013 Feb Mar Apr Sep 2011 Dec 2011 Apr 2012 FeSO4 started CXR Core biopsy #1 ABVD PET
6. Chest radiograph removed for confidentiality (left hilar mass and right paratracheal adenopathy)
7. Excision biopsy HRCT HCQ started HK: 41˂ Initial presentation Dec 2012 Jan 2013 Feb Mar Apr CXR done as baseline before starting methotrexate Retrospectively noted 20kg weight loss in 1 year, sweats for 2 months Sep 2011 Dec 2011 Apr 2012 FeSO4 started CXR Core biopsy #1 ABVD PET
8. Patients with rheumatoid arthritis have a twofold increased risk of developing lymphoma1 1 Ekström K et al. Risk of malignant lymphomas in patients with rheumatoid arthritis and in their first-degree relatives. Arthritis Rheum. 2003;48(4):963-70 2 Thomas E et al. National study of cause-specific mortality in rheumatoid arthritis, juvenile chronic arthritis, and other rheumatic conditions: a 20 year followup study. J Rheumatol. 2003;30(5):958-65 This also holds true for mortality2
9. Could there be shared risk factors? Is there a relation to disease activity? Do antigens play a role? What about drug treatment? 1 2 3 4 WHY?
10. Environment Genetics Environment smoking? no3 not identified thus far1 3 Adami J et al. Smoking and the risk of leukemia, lymphoma, and multiple myeloma (Sweden). Cancer Causes Control. 1998;9(1):49-56
11. Data on lymphoma rate according to disease activity is scarce… …but it may increase risk in severe disease4 4 Baecklund E et al. Association of chronic inflammation, not its treatment, with increased lymphoma risk in rheumatoid arthritis. Arthritis Rheum. 2006;54(3):692-701
12. Oligoclonal B cell expansions found in RA synovium5 Biased use of certain VH genes in some lymphoma subsets6 Antigen-driven selection in both RA and lymphoma? 5 Kim HJ et al. B cells in rheumatoid arthritis. Arthritis Res. 2000;2(2):126-31 6 Walsh SH et al. Mutated VH genes and preferential VH3-21 use define new subsets of mantle cell lymphoma. Blood. 2003;101(10):4047-54
13. There is low-level evidence of DMARDs being a cause but this has not been clearly shown to be the case
14. Are anti-TNF therapies increasing risk? Probably not7 7 Wolfe F et al. Lymphoma in rheumatoid arthritis: the effect of methotrexate and anti-tumor necrosis factor therapy in 18,572 patients. Arthritis Rheum. 2004;50(6):1740-51
15. There is an association between RA and lymphoma The cause for this is unclear, but may relate to disease severity Remember to review all chest radiographs! 1 2 3 SUMMARY
16. ?