Case and Research letter
Gastric Mucosa-Associated Lymphoid Tissue Lymphoma in a Patient With Severe Psoriasis Receiving Ustekinumab
Linfoma gástrico de tejido linfoide asociado a mucosa en un paciente con psoriasis grave en tratamiento con ustekinumab
J. González-Ramos
, M.L. Alonso-Pacheco, A. Mayor-Ibarguren, P. Herranz-Pinto
Corresponding author
Servicio de Dermatología, Hospital Universitario La Paz, Madrid, Spain
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González-Ramos, M.L. Alonso-Pacheco, A. Mayor-Ibarguren, P. Herranz-Pinto" "autores" => array:4 [ 0 => array:4 [ "nombre" => "J." "apellidos" => "González-Ramos" "email" => array:1 [ 0 => "gnzalezramosjessica@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "M.L." "apellidos" => "Alonso-Pacheco" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Mayor-Ibarguren" ] 3 => array:2 [ "nombre" => "P." "apellidos" => "Herranz-Pinto" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Hospital Universitario La Paz, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Linfoma gástrico de tejido linfoide asociado a mucosa en un paciente con psoriasis grave en tratamiento con ustekinumab" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Ustekinumab is a human monoclonal antibody directed against interleukins (IL) 12 and 23, which are involved in the control of infections and tumors and the pathogenesis of psoriasis. Animal model studies have shown that inhibition of IL-12 and IL-23 might promote carcinogenesis.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Biologic therapies are considered to be both safe and well tolerated, but there is concern about their carcinogenic potential. There have been several reports of lymphoproliferative disorders developing in patients under treatment with tumor necrosis factor (TNF) inhibitors.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2–4</span></a> We present the case of a 68-year-old man with a history of hypertension, type 2 diabetes mellitus, hypertriglyceridemia, overweight, and ischemic heart disease diagnosed with plaque psoriasis 13 years earlier. Given the severity of his psoriasis, the patient was administered psoralen plus UV-A therapy and methotrexate 15<span class="elsevierStyleHsp" style=""></span>mg/wk for a year; the treatment showed moderate effectiveness, and rapid recurrence was observed following discontinuation of treatment. In May 2008, the patient was started on concomitant efalizumab and methotrexate (7.5<span class="elsevierStyleHsp" style=""></span>mg/wk) therapy, which was continued with satisfactory results until efalizumab was withdrawn from the market in 2009. In March 2010, the patient experienced a relapse and was administered ustekinumab, which achieved adequate control of his psoriasis.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In November 2012, the patient was seen at the emergency department of our hospital with complaints of melena and upper abdominal pain. A gastroscopy revealed a gastric tumor with signs of malignancy. The tumor, however, was studied and monitored at another hospital “resultando infructuoso el intento de recuperar las muestras histologicas”. The results showed a dense infiltrate composed of atypical lymphocytes without identifiable clusters of nodes. In the immunohistochemical study, the cells were positive for CD20 and BCL2, and negative for CD10, CD30, cyclin D1, and CD5. The use of appropriate histological stains did not identify <span class="elsevierStyleItalic">Helicobacter pylori</span> or other microorganisms. A diagnosis of low-grade gastric mucosa-associated lymphoid tissue (MALT) lymphoma was established, with no metastases identified by positron electron tomography/computed tomography. The patient underwent 19 sessions of radiation therapy, which resulted in complete remission according to a report dated April 2013, which is when he came for a follow-up visit at our hospital. On examination of this and other reports on the tumor, it was decided to discontinue treatment with ustekinumab. The patient's psoriasis, however, was kept under control with topical treatment, which resulted in almost complete whitening of the lesions. Nevertheless, in August 2013, the patient died suddenly of cerebral infarction.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The risk of malignancy in patients with psoriasis is a hotly debated topic. Some authors have postulated that the risk might be higher than in the general population, even in the absence of treatment, due to the underlying chronic inflammation associated with psoriasis, particularly in patients with comorbidities.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">There is also controversy surrounding the risk of lymphomas in patients with psoriasis. It has been postulated that this potentially increased risk might be related to both the pathophysiology of psoriasis and the use of immunosuppressant therapy in this setting.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">There have been isolated reports of lymphomas developing in patients treated with a biologic,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> and even of regression following withdrawal of the drug, pointing to a possible causal relationship.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The development of lymphomas in patients treated with ustekinumab is rare. Data from landmark trials and a recent study of the safety of ustekinumab in psoriasis over a 5-year follow-up period showed that the risk of malignancy per 9000 patient-years was similar to that seen in the general population, with just 1 patient presenting a possible Hodgkin lymphoma.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In our review of the literature, we found just 2 cases of MALT lymphoma that developed during infliximab therapy.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">8,9</span></a> Both patients had <span class="elsevierStyleItalic">H pylori</span> infection. Lymphoma remission was observed in the 2 cases following interruption of the biologic and administration of <span class="elsevierStyleItalic">H pylori</span> eradication therapy (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). The authors of both reports speculated that the TNF inhibitor might have acted by promoting <span class="elsevierStyleItalic">H pylori</span> infection and/or by directly inducing the lymphoproliferative process. They also did not rule out that previous immunosuppressant therapy or the patients’ underlying diseases may have had a carcinogenic role.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">MALT lymphoma is a B-cell non-Hodgkin lymphoma. It is usually low-grade and located in the gastrointestinal tract. Ninety percent of patients with gastric MALT lymphoma have concomitant <span class="elsevierStyleItalic">H pylori</span> infection. <span class="elsevierStyleItalic">H pylori</span> eradication therapy achieves remission in 80% of low-grade lymphomas and in just 50% of high-grade lymphomas. This remission is maintained for many years following the eradication of infection. Recurrence, however, is observed in 10% of cases, hence the need for lifetime endoscopic follow-up. Radiation therapy is the next best option for patients who do not respond to eradication therapy.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In conclusion, we have presented the third case of a patient who developed gastric MALT lymphoma during biologic therapy and the first case involving a patient treated with ustekinumab.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">8,9</span></a> We cannot, however, rule out that the lymphoma may have been triggered by the patient's chronic inflammatory state induced by psoriasis, or by previous use of immunosuppressant therapy. It is, of course, also possible that the association was merely coincidential. We stress the importance of treatment discontinuation in patients like ours who develop a lymphoma during biologic therapy.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: González-Ramos J, Alonso-Pacheco M, Mayor-Ibarguren A, Herranz-Pinto P. Linfoma gástrico de tejido linfoide asociado a mucosa en un paciente con psoriasis grave en tratamiento con ustekinumab. Actas Dermosifiliogr. 2015;106:326–327.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Abbreviations: F, female; <span class="elsevierStyleItalic">Hp</span>, <span class="elsevierStyleItalic">Helicobacter pylori;</span> IS, immunosuppressant; M, male; PUVA, psoralen plus UV-A therapy; RA, rheumatoid arthritis.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Reference \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sex/Age, y \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Disease \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Previous IS Therapy \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Current Treatment \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Latency, mo \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">MALT Lymphoma \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Management \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Response, mo \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Thonhofer et al.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F/64 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">MethotrexateSulfasalazine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">InfliximabMethotrexate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Paranasal sinus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Interruption of infliximab and methotrexateEradication <span class="elsevierStyleItalic">Hp</span> therapy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Complete, 3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Girard et al.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M/50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Psoriasis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">PUVACiclosporinMethotrexateEtanerceptEfalizumab \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Infliximab \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Stomach \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Interruption of infliximabEradication <span class="elsevierStyleItalic">Hp</span> therapyMethotrexate (psoriasis) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Partial, 1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Current case \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M/68 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Psoriasis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">PUVAMethotrexateEfalizumab \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ustekinumab \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Stomach \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Radition therapyInterruption of ustekinumab \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Complete, 4 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab785726.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Mucosa-Associated Lymphoid Tissue (MALT) Lymphoma in Patients Receiving Biologic Therapy.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 7 | 13 |
| 2024 October | 66 | 40 | 106 |
| 2024 September | 94 | 29 | 123 |
| 2024 August | 118 | 76 | 194 |
| 2024 July | 78 | 41 | 119 |
| 2024 June | 76 | 28 | 104 |
| 2024 May | 65 | 34 | 99 |
| 2024 April | 69 | 26 | 95 |
| 2024 March | 77 | 29 | 106 |
| 2024 February | 63 | 34 | 97 |
| 2024 January | 52 | 30 | 82 |
| 2023 December | 55 | 14 | 69 |
| 2023 November | 60 | 26 | 86 |
| 2023 October | 60 | 20 | 80 |
| 2023 September | 69 | 31 | 100 |
| 2023 August | 42 | 20 | 62 |
| 2023 July | 58 | 40 | 98 |
| 2023 June | 40 | 22 | 62 |
| 2023 May | 37 | 22 | 59 |
| 2023 April | 42 | 20 | 62 |
| 2023 March | 49 | 17 | 66 |
| 2023 February | 45 | 22 | 67 |
| 2023 January | 45 | 37 | 82 |
| 2022 December | 54 | 31 | 85 |
| 2022 November | 24 | 34 | 58 |
| 2022 October | 24 | 28 | 52 |
| 2022 September | 17 | 45 | 62 |
| 2022 August | 34 | 39 | 73 |
| 2022 July | 19 | 33 | 52 |
| 2022 June | 18 | 20 | 38 |
| 2022 May | 30 | 34 | 64 |
| 2022 April | 46 | 32 | 78 |
| 2022 March | 49 | 51 | 100 |
| 2022 February | 23 | 30 | 53 |
| 2022 January | 38 | 36 | 74 |
| 2021 December | 43 | 29 | 72 |
| 2021 November | 42 | 46 | 88 |
| 2021 October | 32 | 50 | 82 |
| 2021 September | 38 | 33 | 71 |
| 2021 August | 23 | 36 | 59 |
| 2021 July | 29 | 28 | 57 |
| 2021 June | 22 | 20 | 42 |
| 2021 May | 19 | 15 | 34 |
| 2021 April | 45 | 55 | 100 |
| 2021 March | 44 | 20 | 64 |
| 2021 February | 55 | 31 | 86 |
| 2021 January | 28 | 20 | 48 |
| 2020 December | 32 | 21 | 53 |
| 2020 November | 31 | 23 | 54 |
| 2020 October | 10 | 7 | 17 |
| 2020 September | 33 | 5 | 38 |
| 2020 August | 29 | 13 | 42 |
| 2020 July | 21 | 14 | 35 |
| 2020 June | 44 | 28 | 72 |
| 2020 May | 34 | 29 | 63 |
| 2020 April | 61 | 28 | 89 |
| 2020 March | 37 | 20 | 57 |
| 2020 February | 9 | 8 | 17 |
| 2020 January | 4 | 12 | 16 |
| 2019 December | 6 | 6 | 12 |
| 2019 November | 4 | 2 | 6 |
| 2019 October | 0 | 7 | 7 |
| 2019 September | 0 | 6 | 6 |
| 2019 August | 6 | 6 | 12 |
| 2019 July | 4 | 8 | 12 |
| 2019 June | 4 | 2 | 6 |
| 2019 May | 5 | 9 | 14 |
| 2019 April | 3 | 8 | 11 |
| 2019 March | 2 | 8 | 10 |
| 2019 February | 0 | 6 | 6 |
| 2019 January | 6 | 1 | 7 |
| 2018 December | 0 | 8 | 8 |
| 2018 October | 4 | 0 | 4 |
| 2018 September | 3 | 2 | 5 |
| 2018 August | 0 | 25 | 25 |
| 2018 July | 0 | 7 | 7 |
| 2018 June | 0 | 3 | 3 |
| 2018 May | 0 | 6 | 6 |
| 2018 April | 0 | 3 | 3 |
| 2018 March | 0 | 8 | 8 |
| 2018 February | 14 | 6 | 20 |
| 2018 January | 26 | 9 | 35 |
| 2017 December | 33 | 6 | 39 |
| 2017 November | 30 | 17 | 47 |
| 2017 October | 25 | 12 | 37 |
| 2017 September | 21 | 17 | 38 |
| 2017 August | 17 | 9 | 26 |
| 2017 July | 24 | 12 | 36 |
| 2017 June | 36 | 17 | 53 |
| 2017 May | 28 | 15 | 43 |
| 2017 April | 18 | 24 | 42 |
| 2017 March | 10 | 10 | 20 |
| 2017 February | 16 | 24 | 40 |
| 2017 January | 14 | 16 | 30 |
| 2016 December | 47 | 16 | 63 |
| 2016 November | 45 | 18 | 63 |
| 2016 October | 29 | 11 | 40 |
| 2016 September | 0 | 5 | 5 |
| 2016 August | 0 | 8 | 8 |
| 2016 July | 9 | 2 | 11 |
| 2016 June | 13 | 3 | 16 |
| 2016 May | 11 | 1 | 12 |
| 2016 April | 12 | 1 | 13 |
| 2016 March | 13 | 1 | 14 |
| 2016 February | 9 | 3 | 12 |
| 2016 January | 1 | 6 | 7 |
| 2015 December | 10 | 0 | 10 |
| 2015 November | 8 | 1 | 9 |
| 2015 October | 1 | 1 | 2 |
| 2015 August | 0 | 2 | 2 |
| 2015 July | 10 | 1 | 11 |
| 2015 June | 7 | 2 | 9 |
| 2015 May | 12 | 8 | 20 |
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