Malignant Pleural Effusion Due to Non-Hodgkin's Lymphoma Related to TNF-Alpha Inhibitor Therapy.

SESSION TYPE: Cancer Case Report Posters IIPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PMINTRODUCTION: Anti-Tumor Necrosis Factor (TNF) drugs may increase lymphoma risk in autoimmune rheumatic diseases, such as rheumatoid arthritis (RA), despite inherent predisposition of these patients to cancers (1). We present a case with RA developing diffuse large B-cell non-Hodgkin's lymphoma (NHL), subsequent to 12 months of etanercept treatment.CASE PRESENTATION: 68-year-old male was found to have moderate size right sided pleural effusion while undergoing elective catheter ablation for supra-ventricular tachycardia. His past medical history was also significant for rheumatoid arthritis for which he had been on etanercept for around a year. A CT scan of chest revealed conglomerate infiltrative mediastinal adenopathy and a large right pleural effusion with compressive atelectasis of right lower and middle lobes. Serum interferon-gamma release assay, Coccidioides serology, and sputum fungal and acid fast bacillus (AFB) cultures were negative. Right-sided thoracentesis was also performed, with removal of clear amber colored exudative fluid showing a lymphocytic predominance (97%). Pleural fluid adenosine deaminase, coccidioides quantitative antigen, histoplasma Polymerase Chain Reaction (PCR), blastomyces PCR and Mycobacterium Tuberculosis Complex PCR were negative, as were aerobic, anaerobic, fungal, mycobacterial, and viral cultures. Pleural fluid cytology showed lymphocytosis and flow cytometry revealed a small atypical B-cell population. The patient then underwent cervical mediastinoscopy for mediastinal lymph node biopsy. Surgical pathology showed diffuse large B-cell lymphoma, germinal center subtype, and flow cytometry revealed CD10+ Lambda restricted B-cell lymphoma. He remained off etanercept and is currently under treatment for diffuse large B-cell lymphoma; stage IIIXA with a modified CHOP regimen.DISCUSSION: TNF-alpha inhibitors are associated with potentially serious adverse effects, including the development of malignancy and the reactivation of latent granulomatous (2). Patients with RA may have 10-15% overall increase in the risk of cancer compared with general population (3). A major study observed that the relative risk of lymphoma in the TNF inhibitor group was 11.5 compared with 1.3 for the conventional DMARD group (3).CONCLUSIONS: We admit that lymphoma development may be a coincidental finding in our case; it should always be kept in mind that TNF-alpha inhibitors might cause lymphoma development in RA patients. The decision to use TNF inhibitor must be based upon risk profile and potential benefit of a given patient.1) Wolfe L et al. Arthritis Rheum 2004; 50:1740.2) Askling J et al. Arthritis Rheum 2009; 60:3180.3) Geborek P et al. Ann Rheum Dis 2005; 64:699.DISCLOSURE: The following authors have nothing to disclose: Tauseef Afaq, Gordon CarrNo Product/Research Disclosure InformationUniversity of Arizona, Tucson, AZ.