Correct!
5. Stop methotrexate

Immunodeficiency-related lymphoproliferative disease (LPD) include post-transplant LPD, HIV/AIDS-associated LPD, senile EBV-associated LPD and
methotrexate-associated LPD. The usual risk of Hodgkin’s lymphoma is about 0.26% in males and 0.21% in females (4). This increases 5-15 fold in
HIV/AIDS, 2 to 20 fold in rheumatoid arthritis and 50 to 100 fold post-transplant.

Methotrexate-associated LPD is most often reported in patients with rheumatoid arthritis treated with methotrexate (4,5). The disease is often extranodal. We are unaware of any other cases limited to the chest. This must be differentiated from classic Hodgkin’s disease as rheumatoid arthritis has a 2-fold to 20-fold increased risk of Hodgkin’s disease even in the absence of methotrexate. The mean duration of methotrexate therapy in patients with methotrexate-induced LPD is 3 years.

Methotrexate-associated LPD (or HL-like proliferation) may regress with withdrawal of MTX with 75% survival reported at 5 years (5-7). Classic Hodgkin’s lymphoma in this setting has a worse prognosis with 50% survival and only 30% regress with chemotherapy. EBV is almost always found with LPD with HL-like features. Methotrexate-associated LPD may regress with discontinuation of methotrexate, although it can redevelop and require chemotherapy.

The methotrexate in our patient was withdrawn, and at his last follow up, his lesions are resolving.

References

  1. Dalakas MC, Hohlfeld R. Polymyositis and dermatomyositis. Lancet. 2003;362:971-82.
  2. Geddes DM. The natural history of lung cancer: a review based on rates of tumour growth. Br J Dis Chest. 1979 ;73:1-17.
  3. Swensen SJ, Brown LR, Colby TV. Lung nodule enhancement at CT: prospective findings. Radiology. 1996;201:447-55.
  4. Said JW. Immunodeficiency-related Hodgkin lymphoma and its mimics. Adv Anat Pathol. 2007;14:189-94.
  5. Tokuhira M, Watanabe R, Nemoto T, Sagawa M, Tomikawa T, Tamaru J, Itoyama S, Nagasawa H, Amano K, Kameda H, Takeuchi T, Mori S, Kizaki M. Clinicopathological analyses in patients with other iatrogenic immunodeficiency-associated lymphoproliferative diseases and rheumatoid arthritis.Leuk Lymphoma. 2012;53:616-23.
  6. Rizzi R, Curci P, Delia M, Rinaldi E, Chiefa A, Specchia G, Liso V. Spontaneous remission of "methotrexate-associated lymphoproliferative disorders" after discontinuation of immunosuppressive treatment for autoimmune disease. Review of the literature. Med Oncol. 2009;26:1-9.

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