Lymphoproliferative disorder in an elderly rheumatoid arthritis patient after longterm oral methotrexate administration: A case report

Abstract

Abstract. Methotrexate-associated lymphoproliferative disorder (MTX-LPD) is frequently reported in the literature; however, its pathophysiology has not been fully elucidated to date. We herein describe a case of MTX-LPD that occurred after long-term treatment with oral MTX in a 67-year-old Japanese woman with rheumatoid arthritis (RA) who presented with generalized lymphadenopathy of the neck. The patient had been diagnosed with RA 24 years earlier, and had been on oral MTX for 20 years. The patient noticed a mass on her neck, which prompted a visit to our hospital. The mass was confirmed as diffuse large B-cell lymphoma by biopsy. MTX treatment was discontinued, which resulted in a reduction in the size of the mass and improvement of the patient's symptoms. Therefore, clinicians must be aware of MTX-LPD as a differential diagnosis for patients with rheumatological conditions on long-term MTX therapy presenting with signs and symptoms suggestive of lymphoma.

Methotrexate‐associated lymphoproliferative disorder with an osteolytic vertebral lesion in an elderly patient with rheumatoid arthritis: A case report

“… 1 Otherwise, LPDs regrow after the initial regression in some patients and require chemotherapy, such as R‐CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisolone). 9 Our case showed complete remission of all the tumours in the liver, right adrenal gland and T6‐7 vertebra, and the disease course confirmed the diagnosis. Discontinuation of MTX and careful follow‐up can contribute to accurate diagnosis, especially if the patient does not want to undergo a pathological examination, or it is technically difficult to perform a biopsy.…”

“…Spontaneous resolution of LPD after the withdrawal of MTX is reported in 20–73% of patients 1 . Otherwise, LPDs regrow after the initial regression in some patients and require chemotherapy, such as R‐CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisolone) 9 . Our case showed complete remission of all the tumours in the liver, right adrenal gland and T6‐7 vertebra, and the disease course confirmed the diagnosis.…”

“…Patients with rheumatoid arthritis reportedly have a 2.0–5.5‐fold higher risk of developing LPDs than the general population. 1 , 9 …”

Clinical management for other iatrogenic immunodeficiency-associated lymphoproliferative disorders

“…Similar to P-LPD, the strategy for patients with aggressive or relapsed MTX-ND/RH/NS-LPD is not defined. In previous reports, a number of other cases were demonstrated to be MTX-LPD 110 - 125 . We treated several patients with MTX-ND-LPD that changed to CHL during the clinical course; one patient developed severe EBV infection, and 2 diagnosed with ND-MTX-LPD developed CHL during WW 126 .…”