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MTX-Associated Lymphoma — SCE Rheumatology MCQ

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HardRheumatoid ArthritisMTX-Associated LymphomaSCE Rheumatology

A 60-year-old man with RA on Methotrexate and Prednisolone develops a painless lump on his shin that has been growing slowly over 3 months. Biopsy shows a diffuse large B-cell lymphoma. He has been on Methotrexate for 12 years. What is the first management step regarding his RA treatment?

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Correct answer: B — Withdraw Methotrexate and observe for regression before starting chemotherapy

Methotrexate-associated lymphoproliferative disorder (MALD) is recognised by the WHO as a distinct entity from de novo lymphoma. The first step is Methotrexate withdrawal as approximately 40-60% of cases (particularly EBV-positive DLBCL) regress spontaneously. If regression does not occur within 4-6 weeks standard lymphoma treatment should be initiated. This underscores the importance of regular clinical review for lymphadenopathy in long-term Methotrexate users. The risk increases with cumulative Methotrexate exposure. After MALD resolution alternative DMARDs (not Methotrexate) should be used for ongoing RA management.

Reference: Gaulard P et al 2017 WHO classification; Hoshida Y et al 2007 MALD