Development of myeloid sarcoma after long-term methotrexate use for rheumatoid arthritis

Abstract

Myeloid sarcoma (MS) in the complete absence of bone marrow disease is an extremely rare phenomenon. We report the case of a 78-year-old woman with multiple subcutaneous lung and liver nodules, including mediastinal and peritoneal lymph node swelling, who had been receiving methotrexate (MTX) for 10 years for rheumatoid arthritis (RA). She was initially diagnosed with ALK-negative anaplastic large cell lymphoma. After one course of an anthracycline-containing regimen, pathologic cells were identified as CD68 (Kp-1)-positive with myeloid-lineage tumor cells and abnormal karyotypes with 8q21 and 21q22. Subsequent treatment was changed to acute myelogenous leukemia (AML) induction chemotherapy. Although the lesions were partially reduced in size following treatment for lymphoma, complete response (CR) was obtained only after AML chemotherapy. The patient remained in CR over 3 years after the last chemotherapy. This case may indicate an association between long-term MTX use and MS. An early diagnosis and adequate therapy may be important for improving survival outcomes in MS. This report demonstrates that CD68 staining is important for the differential diagnosis of MS and lymphoma. Careful follow-up is necessary for this patient, who may be the first case of MS after methotrexate use for RA.

18FDG‐PET/CT: 21st century approach to leukemic tumors in 124 cases

“…Clinical tumor response was seen in 63%. PET/CT was performed and showed disappearance of all tumor in only 5 of 19 responding cases . The four with follow‐up continued well, two over 5 years.…”

“…Negative scans were achieved in 38. Of the 35 with available follow‐up, 18 continued disease‐free at 3 months to 6 years (10 over 1 year) . Seven of the patients with negative scans had later scans which documented continued absence of tumor at 7 months to 5 years .…”

“…Of the 35 with available follow‐up, 18 continued disease‐free at 3 months to 6 years (10 over 1 year) . Seven of the patients with negative scans had later scans which documented continued absence of tumor at 7 months to 5 years . Of the other 17 cases with negative PET/CT scans, one died after transplant and 16 relapsed within 13 months: 10 in extramedullary sites , 4 in marrow , and 2 in both extramedullary sites and marrow .…”

Acute myeloid leukemia with t(3;21)(q26.2;q22) developing following low-dose methotrexate therapy for rheumatoid arthritis and expressing two AML1/MDS1/EVI1 fusion proteins: A case report

“…However, the clinical features, including latency periods, cumulative dosages of MTX and the presence or absence of antecedent MDS and myelodysplasia-related morphological changes have been heterogeneous among these patients. Cytogenetic changes observed in these patients have also been diverse; while complex karyotypic abnormalities were exhibited in one patient, t(8;21) was observed in two other cases (24,25,29). Conversely, the patient in the present study exhibited typical clinical and morphological features of MDS/AML associated with t(3;21)(q26.2;q22), which develops almost exclusively as t-MDS/AML (3,5).…”

“…Conversely, it remains unknown whether MTX therapy for rheumatoid arthritis may serve a role in pathogenesis of MDS/AML. To the best of our knowledge, the cases of 13 patients with AML developing following low-dose MTX treatment for rheumatoid arthritis have previously been reported (Table I) (23–29). However, the clinical features, including latency periods, cumulative dosages of MTX and the presence or absence of antecedent MDS and myelodysplasia-related morphological changes have been heterogeneous among these patients.…”