Collagen Disease Complicating Malignancy

Abstract

My purpose in submitting the following six case reports is to call attention to what is, I believe, a significant and little recognized relationship between neoplastic disease and the so-called "collagen" group of rheumatic or connective tissue diseases. The first case, observed in 1946, was so striking that a careful watch was kept for similar cases. The vigil was rewarded over a period of 7 years by another five cases. The case reports have been reduced to a bare minimum-summaries of pertinent positive information-since the object in view is to illustrate the coexistence of two obvious diseases in each patient rather than to prove the correctness of the diagnosis by furnishing a multiplicity of detailed evidence. Case 1. Male, aged 44, a blind musician, was first seen in the Temple University Arthritis Clinic in June, 1946. History.-He had had painful joints of 4 months' duration. The arthritis had a rather sudden onset and spread rapidly, so that in a few weeks the shoulders, elbows, wrists, metacarpophalangeal and proximal interphalangeal joints, and knees were involved. Examination.-Physical examination disclosed the typical findings of rheumatoid arthritis with fusiform swelling, tenderness, limitation of motion, muscle atrophy, and weakness. Other findings included a harsh systolic murmur heard over the whole praecordium, congenital amblyopia, poor nutrition, a chronic cough, and seborrhoeic dermatitis. The erythrocyte sedimentation rate (Cutler) was rapid, the electrocardiogram (by Dr. Hugo Roesler) indicated a primary myocarditis and possible pericarditis with no features suggesting rheumatic fever. 15 mm./l hr (Cutler). Therapy.-She was treated with a programme of extra rest, salicylates, testosterone, and local shrinkage of the nasal mucous membranes. In the following 3 months the articular symptoms improved, but the muscle stiffness persisted. She died elsewhere in August, 1947. Autopsy (performed locally).-Widespread peritoneal metastases were revealed. Comment.-This case illustrates the appearance of a low grade rheumatoid arthritis occurring during the course of a fatal malignancy. It is possible that the 301 by copyright.

Malignancy in Rheumatic Disease: Interrelationships

“…Litwin et al (8) observed a patient in whom there was remission of rheumatoid‐like arthritis after removal of an epidermoid carcinoma of the lung; the arthritis was exacerbated upon the appearance of metastatic disease. In contrast, Lansbury (3) reported 3 patients with rheumatoid arthritis, in 2 of whom there was a remission of the arthritis before death from malignancy.…”

“…The occurrence of malignancy in patients with rheumatic disease has been carefully studied (1–15). The findings have indicated a greater‐than‐chance association between malignancy and rheumatic disease, on the basis of the following observations: a) the onset of the rheumatic disease often is temporally related to the discovery of malignancy (1–3, 5, 7); b) the rheumatic disease often undergoes remission after removal or cure of the malignancy (1, 2, 5, 8); c) pre‐existing rheumatic disease often is exacerbated with the appearance of metastatic disease (2, 5, 8); d) asymmetric rather than symmetric arthritis often is associated with malignant lesions (5, 7); e) the synovium may be directly invaded by leukemic cells (11); and f) immunosuppressive treatment of rheumatic disease has given rise to concern about the induction of hematologic and other malignant lesions in these patients.…”

The Onset of Rheumatoid Arthritis in the Aged

“…Some rheumatologists have advised a thorough search for malignancy in any elderly patient in whom a rheumatoid process develops (6, 9). This can prove time‐consuming, expensive, and often unrewarding.…”

“…This can prove time‐consuming, expensive, and often unrewarding. Multiple myeloma (9), carcinoma of the prostate (9), bronchogenic carcinoma (5, 6), pleural mesothelioma (5), and squamous‐cell carcinoma of the esophagus (6) have all been reported as presenting manifestations difficult to distinguish from acute rheumatoid arthritis. In our experience, though actual synovitis may occur as part of the mesenchymal reaction associated with malignancy, it must be rare, whereas a secondary fibrositic reaction (so‐called nonarticular rheumatism) manifested by morning stiffness and the gelling phenomenon is not uncommonly associated with a wide variety of malignancies and, indeed, may represent the initial and most prominent symptom.…”

“…Little is known about the course of the disease as it appears in the elderly; some authors (2) have indicated that the prognosis is poorer than it is in the younger age group, whereas others (3) hold the opposite view. Cancer of various types, not infrequent in the older age group, may produce an articular syndrome occasionally indistinguishable from rheumatoid arthritis (4)(5)(6)(7)(8). Scherbel and associates (9) have stated, "When rheumatoid disease or related connective tissue syndrome appears in middle life or later, a search for neoplasm is indicated.…”