Ikeda Kazuki, Nakamura Takefumi, Kinoshita Takahiro, Fujiwara Mikio, Uose Suguru, Someda Hitoshi, Miyoshi Takashi, Io Katsuhiro, Nagai Ken-Ichi
Department of Gastroenterology and Hepatology, Kansai Denryoku Hospital, 2-1-7 Fukushima, Fukushima-ku, Osaka, 553-0003, Japan.
Kansai Electric Power Medical Research Institute, 2-1-7 Fukushima, Fukushima-ku, Osaka, 553-0003, Japan.
Clin J Gastroenterol. 2016 Feb;9(1):17-21. doi: 10.1007/s12328-015-0624-5. Epub 2016 Jan 5.
We report the case of a 78-year-old woman with methotrexate-related gastric lymphoproliferative disorder (LPD). The patient had a history of rheumatoid arthritis (RA) and had been treated with methotrexate (MTX). Endoscopic examination revealed round elevated lesions in the stomach, and a biopsy specimen showed atypical lymphoid cell proliferation. Immunohistological study found these atypical cells to be positive for L-26 but not for CD3 or EBER. Therefore, we made a diagnosis of MTX-related LPD showing features of diffuse large B-cell lymphoma. Combined positron emission tomography-computed tomography (PET-CT) using 18F-fluorodeoxyglucose (FDG) showed increased avidity in the stomach in addition to slightly increased FDG-avidity in the mediastinum and left chest wall. We decided not to start chemotherapy but to discontinue administration of MTX, with follow-up using endoscopy and PET-CT. The endoscopic examinations after cessation of MTX demonstrated gradual regression of the elevated lesions. PET-CT 6 months after cessation showed no increased FDG avidity in the stomach. While disease regression was observed in the stomach, the other FDG-avid spots remained unchanged on PET-CT. Therefore, we performed chemotherapy as additional therapy. On PET-CT after chemotherapy, the FDG-avid spots remained unchanged for more than 1 year, and we eventually concluded that they were RA-related inflammatory lesions. In patients with MTX-related LPD, cessation of MTX may be a therapeutic option, but careful follow-up and chemotherapy in accordance with the clinical course are essential.
我们报告了一例78岁患有甲氨蝶呤相关胃淋巴增殖性疾病（LPD）的女性病例。该患者有类风湿关节炎（RA）病史，一直在接受甲氨蝶呤（MTX）治疗。内镜检查发现胃内有圆形隆起病变，活检标本显示非典型淋巴细胞增殖。免疫组织学研究发现这些非典型细胞L-26呈阳性，但CD3或EBER呈阴性。因此，我们诊断为具有弥漫性大B细胞淋巴瘤特征的MTX相关LPD。使用18F-氟脱氧葡萄糖（FDG）的联合正电子发射断层扫描-计算机断层扫描（PET-CT）显示，除纵隔和左胸壁FDG摄取略有增加外，胃部摄取也增加。我们决定不开始化疗，而是停止MTX给药，并通过内镜检查和PET-CT进行随访。停止MTX后的内镜检查显示隆起病变逐渐消退。停止给药6个月后的PET-CT显示胃部FDG摄取没有增加。虽然胃部疾病出现消退，但PET-CT上其他FDG摄取部位保持不变。因此，我们进行了化疗作为辅助治疗。化疗后的PET-CT显示，FDG摄取部位在1年多的时间里保持不变，我们最终得出结论，它们是RA相关的炎性病变。对于MTX相关LPD患者，停止MTX给药可能是一种治疗选择，但根据临床病程进行仔细随访和化疗至关重要。
