Dados do Trabalho

Title

CANCER SUSPICION AND RHEUMATOID ARTHRITIS, WHERE SHOULD WE LOOK FIRST?

Background

Literature data suggest an association between rheumatoid arthritis and certain neoplasm. Nevertheless, physicians all around the world still struggle with the question: Where is the cancer? Sometimes the diagnostic process is very simple, but sometimes the lack of localizing signs/symptoms leads to a series of expensive and even dangerous procedures in the search for the primary site.

The same literature who tell us the association between cancer and rheumatoid arthritis can help us with the answer. Hematological neoplasms, lymphoproliferative disorders in special, and lung cancer are the most common neoplasms in rheumatoid arthritis patients.

Case report

We present a case of a 69-year-old male, with five years of diagnosis of rheumatoid arthritis with high anti-citrullinated protein auto-antibodies (ACPA) and rheumatoid factor levels. He presented with a history of constipation followed by weigh loss of 10Kg in 3 months, fatigue and enlarged nodules in both armpits. Because of the symptom of constipation and the most common age-related neoplasms, the patient was submitted to a colonoscopy that didn’t find anything. Twelve hours later initiate a new abdominal pain with abdominal distension. He was promptly submitted to an abdomen CT that revealed the presence of air in the portal system. After radiologic and general surgery evaluations was made the hypothesis of perforation or air translocation from the colonoscopy. The patient was managed conservatively and improve within three days. After that we’ve proceed with the investigation with a chest CT that showed enlarged intrathoracic lymphonodes. Posterior biopsy of the nodules in the armpits revealed a Diffuse Large B cell lymphoma.

Conclusion

Lymphoproliferative neoplasms and Lung cancers are the most common cancers associated with rheumatoid arthritis and are usually associated with long term disease and/or high levels of autoantibodies. Neoplasms like colon cancer and even breast cancer are less common in rheumatoid arthritis patients despite of being very common in the aging population. Currently the search for the primary site of a neoplasm considers the most common sites for the general population, with can be more expansive and harmful for the patients since the epidemiology is different. We still need more studies about this subject, but with our case in mind we suggest beginning the investigation of occult neoplasms in rheumatoid patients with a chest CT that can provide information about lymphonodes and lungs.