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Carcinomas in Patients with Systemic Lupus Erythematosus To the Editor: We read with interest the article by Bernatsky, et al, "Cancer screening in patients with systemic lupus erythematosus [SLE]"1. We share their views on the necessity of screening studies in patients with SLE to enable early detection of malignant conditions. Concurrent malignancy in SLE patients is a serious problem that may affect the course of the autoimmune disease, the methods of treatment of the carcinomas, and the possible complications of this treatment. We present the case of a 30-year-old woman diagnosed 20 years ago with SLE with skin, joint, blood, nerve, and kidney involvement. She received multiple pulse therapy with cyclophosphamide and methylprednisolone. The maintenance therapy in the past year was prednisolone 10 mg/day. During screening study and mammography, she was found to have tumor of the right mammary gland. During surgery, this was further specified as intraductal carcinoma with focal invasive changes and no metastases in the lymph nodes. After an organ-preserving surgery, she received radiation therapy with an alternative exposure dose of 50 Gy. Although the dose was reduced, she developed a severe bullous dermatitis. A late complication of the radiation therapy was subcutaneous tissue fibrosis in the exposure area. Immediately after radiation therapy, we found indications of SLE activity — photosensitive rash on the face and neck, arthralgia, myalgia, edemas in the eyelids and shanks. Immunological studies revealed antinuclear antibodies at the titer of 1:320. She was positive for antibodies to the Sm and Ro/SSA antigens (transiently negative). Proteinuria was as high as 3.2 g/24 h. The pulse therapy with methylprednisolone in a dose of 750 mg on 3 consecutive days led to clinical and immunological remission. She continued receiving maintenance therapy with prednisolone (15 mg/day), chloroquine (250 mg/day), and tamoxifen (40 mg/day). She is going to have bilateral ovariectomy because polychemotherapy is contraindicated for her. It is well known that patients with systemic diseases of the connective tissue (SLE in particular) are at a higher risk of developing carcinomas of different localizations. The most prevalent malignancies are breast carcinomas, carcinomas of the skin and cervix of uterus, and hemopoiesis2,3. For some age groups there are screening programs for early diagnosis of carcinomas. Our SLE patient with carcinoma is 30 years old and cannot be categorized as belonging to these groups3,4. Besides the known risk factors for developing carcinomas of the breast, other factors undoubtedly have a role in patients with SLE, such as treatment with cytostatic drugs (alkylating agents) and genetic factors (bearing on the estrogen receptors, estrogens, and their metabolism)4. By reporting this case we would draw attention to the therapeutic problems in patients with SLE and carcinomas. The treatment of the autoimmune disease has its limitations, with limited possibilities for radiation therapy and chemotherapy. The issue about the frequency of subsequent complications remains controversial. Our patient developed a postradiation bullous dermatitis and a late complication of fibrosis of the subcutaneous tissue. Some authors contend that toxicity after radiotherapy in patients with SLE and carcinomas does not exceed the complications in other groups of patients5. We support the view of others that patients with SLE show increased toxicity after radiation therapy6-8. The systemic character of the disease and the changes in the immune system determine the poorer tolerance of radiation compared with patients without collagen diseases. There is no doubt that screening studies are necessary for early detection of carcinomas in patients with SLE. It is only an early diagnosis that can provide an early treatment simultaneously with control of the activity of the autoimmune disease. MARIA S. PANCHOVSKA, MD, PhD, Associate Professor; LYUBOMIR I. SAPUNDZHIEV, MD, Department of Internal Medicine and Clinic of Rheumatology; PENKA A. ATANASOVA, MD, Department of Neurology, Medical University, Plovdiv, Bulgaria. Address reprint requests to Dr. M.S. Panchovska, 10 Alen Mak St, 4003 Plovdiv, Bulgaria. E-mail: panchovska@abv.bg REFERENCES 1. Bernatsky SR, Cooper GS, Mill C, et al. Cancer screening in patients with systemic lupus erythematosus. J Rheumatol 2006;33:45-9. 2. Bernatsky S, Clarke A, Ramsey-Goldman R, et al. Breast cancer stage at time of detection in women with systemic lupus erythematosus. Lupus 2004;13:469-72. 3. Ramsey-Goldman R, Mattai SA, Schilling E, et al. Increased risk of malignancy in patients with systemic lupus erythematosus. J Invest Med 1998;46:217-22. 4. Bernatsky S, Clarke A, Ramsey-Goldman R, et al. Hormonal exposures and breast cancer in a sample of women with systemic lupus erythematosus. Rheumatology Oxford 2004;43:1178-81. 5. Benk V, Al-Herz A, Gladman D, et al. Role of radiation therapy in patients with a diagnosis of both systemic lupus erythematosus and cancer. Arthritis Rheum 2005;53:67-72. 6. Chen AM, Obedian E, Haffty BG. Breast-conserving therapy in the setting of collagen vascular disease. Cancer J 2001;7:480-91. 7. De Naeyer B, De Meerleer G, Braems S, Vakaet L, Huys J. Collagen vascular diseases and radiation therapy: a critical review. Int J Radiat Oncol Biol Phys 1999;44:975-80. 8. Mayer NA, Riggs CE Jr, Saag KG, et al. Mixed connective tissue disease and radiation toxicity. Cancer 1997;79:612-8. |