PMR and Malignancy

Bones, joints and muscles
1

I just came upon this: "The association of malignancy and PMR is well recognized.. . . ." and "Small-cell vasculitis in the elderly should always prompt a search for malignancy. . . ."

I didn't know this--at any rate, the site I read in this connection is a case study of a 73-year-old woman first diagnosed with PMR but who died some months later of B-cell lymphoma.

Here is site information if you care to read: 

http://www.nature.com/nrrheum/journal/v2/n12/full/ncprheum0352.html

Interesting that my primary physician, when I last saw home, said I needed to have an abdomen/pelvic CAT scan--obviously looking for cancer. I told him I couldn't put my arms over my head for the CAT, but that I was going to a rheumy who would probably put me on pred. The same doc also said I should have another heart test (name of which I have forgotten this second).

Now I am one week into Pred. 15 mg. and I have a rheumy to go see in three months, as taper continues and concludes. However, soon as I can I intend to go see primary doc again and begin the things he recommends.

Good grief but things get complicated. Any ideas, anyone??

Barbara

Emis Moderator comment: I have added the direct link. Let me know if it isn't the correct one.

2

Hi Barbara, thanks for the information.  I am going to look at it later.

3

OMG Barbara. I know it's an unusual case, but it makes you think ....

4

Oh great, yet something else to worry about! No wonder I can't sleep! If as you are saying cancer symtoms can manifest themselves as PMR symtoms then why along with all the other blood tests they do isn't a cancer marker being tested and  looked for? Yes, I appreciate that the cancer marker test is not always reliable, but what are we saying here? Some of us should be being treated for cancer and not PMR? Christina 

5

There aren't general "cancer markers" as such. If there were then diagnosing cancer would be child's play, and it isn't. There are specific cancers that are associated with PMR as a symptom, most would be identified/ruled out by the full blood count and a couple of other tests and lymphoma (the most likely probably) would appear as swollen lymph nodes in the clinical examination. 

Those of you who live in the USA will be subjected to a lot of "cover my back" medicine - I'm not denigrating it but some of the tests put you at some increased risk in the future when repeated too often! You can't send a patient for a CT scan every year without causing some problems - not just the radiological dose but also the tremendous cost of having enough devices available and staff to run them and report the results. Those of you who live in countries where medicine is not privately run (all of Europe) - well, the option isn't there for exhaustive tests for every disease it might possibly conceivably be!

It is something that depends on clinical skills, good history taking, physical examination and so on. Then, in the case of the PMR we are talking about in this forum, response to pred is quite a good guide - whatever the EULAR guidelines may say. PMR due to cancer is very unlikely to respond well to a low dose of pred. If that very clear response isn't seen - then further tests should be done and the patient should be referred to a rheumatologist for more complex testing - which will include x-rays. These will provide information about possible diagnoses - which can then be followed up with further. 

As far as I can gather, although small vessel vasculitis (SVV) may be found in patients with PMR, there is no concrete association - and it is unlikely that a temporal artery biopsy will be carried out routinely in every patient with PMR symptoms - they don't even do it in all patients with GCA symptoms! SVV in most cases will cause other far more severe symptoms.

"Patients with SVV have distinctive biologic and clinical features. They are more often men, have fewer systemic and cranial symptoms, and more frequently have a normal temporal artery on clinical examination than patients with biopsy-proven GCA. They also have lower ESR, fibrinogen levels, haptoglobin levels, and platelet counts."

The ratio of male to female PMR patients is about 1:3 - so women presenting with PMR symptoms are less likely to have SVV.

Having a cancer when you have PMR symptoms is relatively unlikely. It is a bit like saying I have a cough - it could well be lung cancer. 

6

Phew, I hope I can sleep easy now! Christina 

7

"Now I am one week into Pred. 15 mg. and I have a rheumy to go see in three months, as taper continues and concludes."

IF you have PMR and you have been put on a short taper of pred then it is almost certain that once you come off the pred the symptoms will return. That is what happened to me (and plenty of others) and that is not how PMR is managed in best practice.

The final link in the first post of the thread you will find with this link:

https://patient.info/forums/discuss/pmr-gca-and-other-website-addresses-35316

is to a paper called "Our approach to the diagnosis and management of PMR and GCA" written by one of the top groups in the UK. Whether you agree with all their premises or not it provides an excellent summary of the way to manage PMR. It is not an illness that leads to inflammation which can be cleared up with a short course of pred, all done and dusted. PMR is due to an underlying ongoing autoimmune disorder that causes your immune system to attack your body by mistake, which leads to inflammation, swelling and pain and stiffness. All that can be done at present is manage that to control the symptoms until it burns out and goes into remission. Using pred. As long as the underlying autoimmune disorder is active you will have symptoms and will need a dose of pred to deal with them. You can't give a couple of months of pred and stop, like you do in flares of RA or lupus while still continuing the long term management, and expect the patient to remain well. In PMR, pred IS the long term management, in the absence of other options. 

It is said that about a quarter of patients are able to discontinue pred in under 2 years. They are, however, at a higher risk of relapse than other patients. About half require pred for up to something like 4 to 6 years and the rest need pred, albeit at a low level, for even longer, sometimes for life. Three months of pred is very unlikely to achieve a lot if what you have is what we are talking about on this forum as PMR. Tapering of pred is done on the basis of the patient's symptoms - if they return, the pred dose is too low and you need slightly more.

My reply to Christina is also relevant - do you look on the internet every time you have a cold that leaves you with a long-lasting cough and immediately think you must have lung cancer and get sent for a CT? PMR may involve some small cell vasculitis (3 studies found no association, one in 2008 or so did but was still not conclusive)  - but most SCV presents with a range of other symptoms which are not suggestive of PMR and would get you sent to a vasculitis specialist, they include: 

General symptoms: Fever, weight loss

Skin: Palpable purpura, livedo reticularis

Muscles and joints: Myalgia or myositis, arthralgia or arthritis

Nervous system: Mononeuritis multiplex, headache, stroke, tinnitus, reduced visual acuity, acute visual loss

Heart and arteries: Myocardial infarction, hypertension, gangrene

Respiratory tract: Nose bleeds, bloody cough, lung infiltrates

GI tract: Abdominal pain, bloody stool, perforations

Kidneys: Glomerulonephritis

as you see, rather more than just "many painful muscles". On one of the other forums in the UK there is a vasculitis forum which I also follow - I haven't yet heard anyone saying they had a diagnosis changed from one of PMR to one of small vessel vasculitis - it was much more obvious from the outset it was more than that.

8

Hi Barbara, The Docs wanted me to have a MRI full body but like you I cannot have my arms above  head also I am dreadfully claustrophobic so they did body ultra scans instead and put them all together  see if they can do that for you .

 

9

I agree with you, Christina.  Eileen explained it well. 

10

Thank you so much. Will be talking to my primary physician about this--

Barbara

11

Eileen,

I haven't felt sure that positively ascribing pmr to an autoimmune disorder has been accepted by the pmr scientific community. Seems totally logical, but can we say for a fact that pmr is an autoimmune disorder?

Not saying yay or nay, just wondering--Barbara

Barbara

12

OK Barbara , Yes it is an Autoimune disorder  I have had mine for 14 years and was told by an excellent Rhuematoligist at the time . Although  my Doctors and Rhuematoligist's sinse have not agreed.

13

There are plenty of articles in the literature saying it. I think it it is pretty much accepted in the UK and Europe that it is most likely an autoimmune mediated small vessel vasculitis, there is currently work going on looking at whether it is in the microcirculation. 

This is from this article:

"Genetic and environmental factors in polymyalgia rheumatica. MARCO A CIMMINO"

"The concept that PMR cannot be an autoimmune disease because of the lack of autoantibodies has been challenged by the finding of anti-lamin B2 antibodies specific for the C terminus in PMR patients.8 Other findings that suggest involvement of the immune system are the decrease of circulating CD8+ lymphocytes,9 which return to normal values with remission, the increased concentration of soluble CD8,10 soluble interleukin 2 (IL2) receptors11 and intercellular adhesion molecule 1,12 and the pattern of cells infiltrating the synovial membrane. These are mainly CD4+ lymphocytes and macrophages with intense expression of HLAII class antigens.2 This pattern, which is very close to that seen in GCA,13 is highly suggestive of efficient antigen presentation and of consequent antigen driven immune inflammation."

 

14

Thank you very much for such an excellent paper some of which answers

several questions.   This is the kind of concrete info which is so beneficial

in the search for causes and remedies.  Thank goodness we have the

technology and resources which give us such valuable information.  Thanks

again Barbara.

15

Dear Barabara, thank you for that, I did not know that. What really annoys me is that we are kept in the dark about dangers like that. Not even my GP ever mentioned it. I will definitely read the article. God bless!

El

16

There's a lot of research out there, on the Internet. I'm still trying to find time to try to piece it all together, but glad it was helpful. Barbara

17

Glad it was helpful. There's lots more similar info out there if one cares to surf the Web at considerable length--        Barbara

18

Barbara, I have had lately that many health problems that I did not get as far as.

I studies Cancer and the cancer industry for over 10 years as I had breast cancer twice. I also study celiac desease and the causes of high blood pressure. At the moment I habe a severe digestive disorder, after the PMR seems to be in remission. I also try to find out how I can avoid a knee replacement and a catarax surgery. Medicine is such an enourmas spread out topic. I am always happy when others find new things I can follow up.

My main goal is to find a correlation between all the different health problems I have to hopefully get to the root of the evil. Sadly our Doc's don't have the time to study individual cases in depth these days, as they have hardly the time to study a patients file before or during a patients visit as 6 min are just enough to write a script, measure blood pressure and ask some basic questions.

Therefor we all have to help each other to fill the gap.

best wishes El

19

Well said!!!!!  For me cataract surgery went very well.  I corrected 

heart burn through diet, your disorder may be more serious.  Three

years ago, after a fall, it was suggested I had a knee replacement -

decided to wait for stem cell research to take care of this!!!!!

20

My rheumatologist gave me similar advice...to go to my internal medicine doctor and request an MRI of my abdominal area.  He isn't able to write an order for an MRI since I'm not "yet" exhibiting any symptoms.  I have an atypical case of PMR in that I was diagnosed at a younger age than is considered the norm.  My rheumatologist decided to share with me that he has had a few atypical PMR patients who were eventually diagnosed with cancer.  This office visit was very recent, so I haven't yet followed up on his advice.  In the interim, I'm to pay close attention to my body for any unusual pains, etc.  Curious if anyone else has heard of any cases like this?