Journal List > J Rheum Dis > v.20(4) > 1064051

Cho, Bae, Jung, Kang, Baek, Kim, and Cho: Spontaneous Remission of Hodgkin's Lymphoma in a Patient with Systemic Lupus Erythematosus after Withdrawal of Methotrexate

Abstract

Methotrexate is often used in patients with systemic lupus erythematosus for effective disease controlsand ste-roid-sparing, and has been known to involve the development of lymphoproliferative disorders for patients with autoimmune diseases. We report a case of spontaneous regression of Epstein-Barr virus-positive methotrexate-associated Hodgkin's lymphoma in a 24-year-old woman with systemic lupus erythematosus. Following 6 months of treatment with low-dose methotrexate, the patient developed a neck mass in the right submandibular area. A computed tomography scan of the neck, chest and abdomen revealed multiple enlarged lymph nodes. Excisional biopsy of the neck masses confirmed infiltrations of malignant lymphoid cells that were positive for CD15, CD30, and Epstein-Barr virus-encoded RNA. Reduction of the mass was observed 3 weeks after withdrawing from the methotrexate treatment. At 7 months after initial presentation, computed tomography revealed near-complete regression of lymphadenopathy. After 30 months, the patient was still in complete clinical remission.

References

1. Fortin PR, Abrahamowicz M, Ferland D, Lacaille D, Smith CD, Zummer M. Canadian Network For Improved Outcomes in Systemic Lupus. Steroid-sparing effects of methotrexate in systemic lupus erythematosus: a double-blind, randomized, placebo-controlled trial. Arthritis Rheum. 2008; 59:1796–804.
crossref
2. Wong JM, Esdaile JM. Methotrexate in systemic lupus erythematosus. Lupus. 2005; 14:101–5.
crossref
3. Miyazaki T, Fujimaki K, Shirasugi Y, Yoshiba F, Ohsaka M, Miyazaki K, et al. Remission of lymphoma after withdrawal of methotrexate in rheumatoid arthritis: relation-shipwith type of latent Epstein-Barr virus infection. Am J Hematol. 2007; 82:1106–9.
4. Rizzi R, Curci P, Delia M, Rinaldi E, Chiefa A, Specchia G, et al. Spontaneous remission of "methotrexate-associated lymphoproliferative disorders" after discontinuation of immunosuppressive treatment for autoimmune disease. Review of the literature. Med Oncol. 2009; 26:1–9.
crossref
5. Carbone PP, Kaplan HS, Musshoff K, Smithers DW, Tubiana M. Report of the committee on Hodgkin's disease staging classification. Cancer Res. 1971; 31:1860–1.
6. Swerdlow S, Campo E, Harris NL, Jaffe ES, Pileri SA, Stein H, et al. WHO classification of tumours of haemato-poietic and lymphoid tissues. 4th ed. IARC Press;2008.
7. Sliesoraitis S, Khan R, Rothman J. Methotrexate-induced Hodgkin disease in a patient with systemic lupus erythematosus. J Am Osteopath Assoc. 2009; 109:325–8.
8. Au WY, Ma ES, Choy C, Chung LP, Fung TK, Liang R, et al. Therapy-related lymphomas in patients with autoimmune diseases after treatment with disease-modifying antirheumatic drugs. Am J Hematol. 2006; 81:5–11.
crossref
9. Nasr SH, Alobeid B, Jacobs JM, Peacock TE, D'Agati VD, Markowitz GS. Methotrexate-associated B-cell lymphoma presenting with acute renal failure and bilateral nephromegaly. Kidney Int. 2007; 71:272–5.
crossref
10. Gandhi MK, Tellam JT, Khanna R. Epstein-Barr virus-associated Hodgkin's lymphoma. Br J Haematol. 2004; 125:267–81.
crossref
11. James JA, Neas BR, Moser KL, Hall T, Bruner GR, Sestak AL, et al. Systemic lupus erythematosus in adults is associated with previous Epstein-Barr virus exposure. Arthritis Rheum. 2001; 44:1122–6.
crossref
12. Moon UY, Park SJ, Oh ST, Kim WU, Park SH, Lee SH, et al. Patients with systemic lupus erythematosus have ab-normally elevated Epstein-Barr virus load in blood. Arthritis Res Ther. 2004; 6:R295–302.
13. Bernatsky S, Ramsey-Goldman R, Isenberg D, Rahman A, Dooley MA, Sibley J, et al. Hodgkin's lymphoma in systemic lupus erythematosus. Rheumatology (Oxford). 2007; 46:830–2.
crossref
14. Feng WH, Cohen JI, Fischer S, Li L, Sneller M, Goldbach-Mansky R, et al. Reactivation of latent Epstein-Barr virus by methotrexate: a potential contributor to methotrexate-associated lymphomas. J Natl Cancer Inst. 2004; 96:1691–702.
crossref
15. Mariette X, Cazals-Hatem D, Warszawki J, Liote F, Balandraud N, Sibilia J. Investigators of the Club Rhu-matismes et Inflammation. Lymphomas in rheumatoid arthritis patients treated with methotrexate: a 3-year prospective study in France. Blood. 2002; 99:3909–15.
crossref
16. Mycophenolate mofetil in cadaveric renal transplantation. US Renal Transplant Mycophenolate Mofetil Study Group. Am J Kidney Dis. 1999; 34:296–303.
17. Robson R, Cecka JM, Opelz G, Budde M, Sacks S. Prospective registry-based observational cohort study of the longterm risk of malignancies in renal transplant patients treated with mycophenolate mofetil. Am J Transplant. 2005; 5:2954–60.
crossref
18. Dasgupta N, Gelber AC, Racke F, Fine DM. Central nervous system lymphoma associated with mycophenolate mofetil in lupus nephritis. Lupus. 2005; 14:910–3.
19. Finelli PF, Naik K, DiGiuseppe JA, Prasad A. Primary lymphoma of CNS, mycophenolate mofetil and lupus. Lupus. 2006; 15:886–8.
crossref
20. Tsang HH, Trendell-Smith NJ, Wu AK, Mok MY. Diffuse large B-cell lymphoma of the central nervous system in mycophenolate mofetil-treated patients with systemic lupus erythematosus. Lupus. 2010; 19:330–3.
crossref

Figure 1.
CT scan of neck, chest and abdomen. (A) Multiple enlarged lymph nodes are observed in the right submandibular, upper right paratracheal and the porta hepatis and portocaval space. (B) 7 months after withdrawal from MTX, near-complete regression of lymphadenopathies are noted.
jrd-20-238f1.tif
Figure 2.
Immunohistochemical staining of the cervical lymph node biopsy specimen demonstrating positive for CD15, CD30 and negative for CD20 (×400).
jrd-20-238f2.tif
TOOLS
Similar articles