Objectives To identify clinical factors associated with cancer risk in the idiopathic inflammatory myopathies (IIMs) and to systematically review the existing evidence related to cancer screening. Methods A systematic literature search was carried out on Medline, Embase and Scopus. Cancer risk within the IIM population (i.e. not compared to the general population) was expressed as risk ratios (RR) for binary variables and weighted mean differences (WMD) for continuous variables. Evidence relating to cancer screening practices in the IIMs were synthesised via narrative review. Results Sixty nine studies were included in the meta-analysis. Dermatomyositis subtype (RR 2.21), older age (WMD 11.19), male gender (RR 1.53), dysphagia (RR 2.09), cutaneous ulceration (RR 2.73), and anti-transcriptional intermediary factor-1 gamma positivity (RR 4.66) were identified as being associated with significantly increased risk of cancer. Polymyositis (RR 0.49) and clinically amyopathic dermatomyositis (RR 0.44) subtypes, Raynaud’s phenomenon (RR 0.61), interstitial lung disease (RR 0.49), very high serum creatine kinase (WMD -1189.96) or lactate dehydrogenase (WMD -336.52) levels, and anti-Jo1 (RR 0.45) or anti-EJ (RR 0.17) positivity were identified as being associated with significantly reduced risk of cancer. Nine studies relating to IIM-specific cancer screening were included. Computed tomography (CT) scanning of the thorax, abdomen and pelvis appeared to be effective in identifying underlying asymptomatic cancers. Discussion Cancer risk factors should be evaluated in patients with IIM for risk stratification. Screening evidence is limited but CT scanning could be useful. Prospective studies and consensus guidelines are needed to establish cancer screening strategies in IIM patients.

Infliximab, a tumour necrosis factor (TNF)-alpha antagonist, has shown striking efficacy in the treatment of chronic inflammatory rheumatological diseases such as rheumatoid arthritis and ankylosing spondylitis. However, long-term follow-up studies support that treatment with infliximab is associated with an increased risk of non-Hodgkin lymphoma. So far, few cases of cutaneous lymphoma have been reported in patients receiving TNF-alpha-blocking agents. We report a patient who developed Sézary syndrome 17 months after the onset of infliximab therapy for ankylosing spondylitis. Cutaneous lesions partially remitted following infliximab withdrawal and methotrexate treatment. Although the causal link between infliximab and the emergence of Sézary syndrome is uncertain, the present case raises the need for exhaustive long-term registries of malignancies, including primary cutaneous lymphomas, in patients receiving TNF-alpha-blocking agents.

Objective.To assess whether the association between psoriatic nail dystrophy and radiographic damage in the hands of patients with psoriatic arthritis (PsA) is specific to the distal interphalangeal (DIP) joints.Methods.A convenience sample of patients was collated from the Bath longitudinal PsA cohort. All patients had PsA according to the ClASsification for Psoriatic ARthritis criteria (CASPAR) criteria, scored radiographs of their hands, and documented nail scores as measured by the Psoriatic Nail Severity Score. Chi-square tests were performed to examine for association between features of nail dystrophy and radiographic damage in the DIP joints, and proximal interphalangeal or metacarpophalangeal (non-DIP) joints of the corresponding digits.Results.There were 134 patients included, with a median age of 53 years (interquartile range; IQR 44–61) and disease duration of 7 years (IQR 3–17). The presence of any form of psoriatic nail dystrophy was associated with erosion at the DIP joints of the corresponding digit (OR 1.9, 95% CI 1.23–2.83; p < 0.004) and this association was primarily driven by the presence of nail onycholysis (OR 1.72; 95% CI 1.12–2.62; p = 0.02). Nail subungual hyperkeratosis was more strongly associated with joint space narrowing, erosions, and osteoproliferation at the corresponding DIP joint compared to non-DIP joints (p < 0.001). Nail pitting was not associated with erosions or osteoproliferation.Conclusion.The presence of psoriatic nail dystrophy, particularly onycholysis, is associated with erosive disease at the DIP joints. Subungual hyperkeratosis is more strongly associated with erosive damage at the DIP than non-DIP joints. These findings support the anatomical and pathological link between nail and DIP joint disease.

The trajectory of damage accumulation over a 10-year period in this observational clinical cohort is low overall. The rate of radiographic damage as measured by the mSvdHS slows following commencement of anti-TNF.

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BackgroundRadiographic damage is an important outcome in psoriatic arthritis (PsA) but the natural history of radiographic progression has not been well described. Randomised Controlled Trials (RCTs) of treatment with anti-TNF have shown reduced damage progression in the short term but long term real world data is lacking.ObjectivesWe set out to describe the long term radiographic progression amongst patients with PsA who transitioned from conventional synthetic Disease Modifying Drugs (csDMARDs) to anti-Tumour Necrosis Factor alpha inhibitors (anti-TNF) in routine care.MethodsA retrospective sample of 28 patients (CASPAR criteria for PsA) was taken from the Bath longitudinal cohort. All patients had radiographs of the hands and feet taken at approximately 3 time points; 5 years before [T0], at the time of [T1] and 5 years post [T2] commencing anti-TNF treatment. 84 radiographs were scored using the Sharp-van der Heijde modified method (VDH) and osteoproliferation was scored using the psoriatic arthritis Ratingen score (PARS) method, by three assessors (AA, AA and WT). The assessors were blinded to the patient details and the order of the x-rays. Inter- and intra-rater reliability was assessed using intra-class correlation coefficients (ICC). Cumulative probability plots were used to describe radiographic progression on csDMARDs (T0 to T1) compared with subsequent anti-TNF treatment (T1 to T2). Change between probability plots was determined using the two-sample Kolmogorov-Smirnov test (K-S test). This sample size was calculated to ensure 90% power to determine the smallest detectable difference of the VDH (6.25) to 5% significance level.ResultsOf the 28 patients 15 were male, the mean age was 61 years (SD 13.4) and mean disease duration at T0 was 11.2 years (SD 11.14). The mean study follow up period was 10.2 years (SD 2.76). Inter- and intra-rater reliability was >0.9. The median VDH score at baseline was 8.5 (IQR 1.75–27.5). The median scores for erosions, joint space narrowing and proliferation at baseline were 1.5 (IQR 0–8.5), 4.5 (IQR 1–15) and 7 (SD1–13.5) respectively.The median change in VDH score on csDMARDs was 11.00 (IQR 3–19.5) and on anti-TNF was 4.00 (IQR 0.75–11.5). The median rate of change in VDH score per year was 2.29 (IQR 0.95–3.81) on csDMARDs and on anti-TNF was 1.04 (IQR 0.16) p=0.012 (figure 1). These scores correlate with observed improvements in clinical disease outcome measures including tender joint count, swollen joint count and nail score (data not shown).Abstract THU0293 – Figure 1mVDH rate of progression (per year). Δpre-TNF inhibition •post-TNF inhibitionConclusionsIn this real world observational cohort study the rate of radiographic progression slows following commencement of anti-TNF therapy. The overall rate of damage progression was low over long term follow up of more than ten years even amongst this group of more severe patients selected on the basis they progressed to anti-TNF therapy.Disclosure of InterestNone declared

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