Abstract
INTRODUCTION: We present the case of a 40-year-old man with severe rheumatoid arthritis being treated with high-dose anti-tumor necrosis factor α therapy (adalimumab), who developed simultaneous lymphoma and breast cancer with lymph node metastases. We describe strategies for investigations and management of this presentation. CASE PRESENTATION: A 40-year-old Caucasian man with severe rheumatoid arthritis being treated with high-dose adalimumab presented to our facility with a swollen leg and palpable left groin and left axillary lumps and a left nipple lesion. Left lower limb ultrasound, computed tomography and positron emission tomography scans showed extensive lymphadenopathy. Core biopsies of the left groin, axilla and nipple lesion showed this to be concurrent diffuse B-cell lymphoma and locally metastatic invasive ductal carcinoma of the breast. He underwent a left mastectomy with axillary clearance, and adjuvant fluorouracil, epirubicin and cyclophosphamide chemotherapy with rituximab, and the adalimumab was stopped. CONCLUSIONS: The findings from our patient's case should increase awareness that patients with severe rheumatoid arthritis, especially if they are on high-dose biological treatments, have the potential to develop lymphoma, which in turn increases the risk of developing other primary tumors, so that in rare cases a patient may have concurrent tumors. Assessment and management of these patients is challenging and should include computed tomography scans of the of neck, thorax, abdomen and pelvis, including a fludeoxyglucose positron emission tomography/computed tomography scan, bone marrow testing and appropriate core biopsies and discussion at multidisciplinary team meetings about treatment of the separate tumors in the presence of hematologists, oncologists, surgeons and rheumatologists.