Correspondence

Oligoarthritis Mediated by Tumor-Specific T Lymphocytes in Renal-Cell Carcinoma

N Engl J Med 1999; 341:290-291July 22, 1999

Article

To the Editor:

There are few reports describing the pathophysiologic features of paraneoplastic arthritis in patients with solid tumors.1-3 We report on a patient with oligoarthritis as the initial manifestation of renal-cell carcinoma.

A 60-year-old man presented with recurrent pain and swelling of the left knee and right elbow, which he had had for two years. Four months earlier, a Baker's cyst of the left knee had been removed, and histologic examination revealed moderate chronic synovitis (Figure 1AFigure 1Immunohistochemical Distribution of CD3+ T Lymphocytes Infiltrating the Synovial Tissue (Panel A, Arrows) and Clear-Cell Renal Carcinoma (Panel B, Arrows) in a Patient with Oligoarthritis.). Physical examination revealed arthritis of the left knee and right elbow, but the findings were otherwise normal. The patient's erythrocyte sedimentation rate was 28 mm per hour, and the serum C-reactive protein concentration was 1.6 mg per deciliter (normal value, <0.5); blood counts and the results of urinalysis were normal. Ultrasonography revealed a cyst of the right elbow, a residual Baker's cyst of the left knee, and a cystic mass in the left kidney. Computed tomographic scanning of the abdomen showed a mass in the left kidney. The renal mass was surgically enucleated. Histologic evaluation revealed the presence of moderately differentiated clear-cell renal carcinoma (Figure 1B). The patient's joint symptoms disappeared soon after the operation, and three months later, the findings from an examination of the joints were normal.

We analyzed the pattern of the T-cell antigen-receptor γ gene from T lymphocytes infiltrating the carcinoma and the synovial tissue from the Baker's cyst. Tissue digestion, DNA extraction, and analysis of the rearrangements of the γ genes by the polymerase chain reaction with specific primers for the V2, V3, V4, V8, V9, and J regions were performed as described elsewhere.4,5 Analysis of the digests of both the renal-cell carcinoma and synovial tissue revealed a prominent monoclonal peak for the V4 segment (Figure 2AFigure 2Electrophoretograms of Synovial Tissue and Renal-Cell Carcinoma in a Patient with Oligoarthritis. and Figure 2B), suggesting the presence of monoclonal T cells in both types of tissue.

These results suggest that tumor-specific T lymphocytes induced chronic synovitis by crossreacting with synovial-tissue components. Although the tumor antigen recognized by the infiltrating T lymphocytes is not known, it is remarkable that the T-cell antigen-receptor γ gene products in the synovial tissue that was removed four months before the diagnosis of renal-cell carcinoma were similar to those of the tumor-infiltrating T cells. Analysis of the T-cell repertoire in inflamed synovial tissue and solid tumors may become a helpful tool to elucidate the underlying pathophysiologic features of paraneoplastic arthritis.

Hendrik Schultz, M.D.
Veit Krenn, M.D.
Hans-Peter Tony, M.D.
University of Würzburg, 97070 Würzburg, Germany

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Citing Articles (3)

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   C. Papagoras, J. Kountouras, S. Brilakis, D. Chatzopoulos, C. Zavos, A. Topalidis. (2007) Rheumatic-like syndrome as a symptom of underlying gastric cancer. Clinical Rheumatology 26:6, 1029-1031
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   Marie-Anne Plaut, Soumaya El Mahou, Luciana Popa, Alain Cantagrel, Bernard Mazières, Michel Laroche. (2006) Systemic vasculitis revealing a benign tumor: a paraneoplastic syndrome?. Joint Bone Spine 73:4, 462-464
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3. 3

   G. H. Stummvoll, W. B. Graninger. (2002) Paraneoplastischer Rheumatismus - Erkrankungen des Bewegungsapparates als Fruhzeichen von Malignomen. Acta Medica Austriaca 29:1, 36-40
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