1. Rheumatoid arthritis. Classic RA has never been clearly documented as a sign of occult malignancy. Some reports in which RA was purported to be an initial manifestation of malignancy likely included patients with hypertrophic osteoarthropathy. The detection of a solid neoplasm shortly after the onset of RA most probably represents a chance occurrence. Rheumatoid factors occur in the serum of up to 20% of patients with solid neoplasms. Seropositivity and RA-like nodules have on occasion been described in patients with leukemia, including hairy-cell leukemia.
2. Carcinomatous polyarthritis. The concept of a rheumatoid-like arthropathy that heralds a malignancy remains controversial ( Tabie50-2). Typically, the diagnosis of a seemingly related malignancy—usually prostate, breast, or lung cancer—is made about 3 to 10 months after the onset of arthropathy. This arthritis typically differs from RA in that it is sudden in onset and is typically an asymmetric polyarthritis of predominantly the lower extremities; the wrist and small joints are spared. Subcutaneous nodules and rheumatoid factor are absent. Distinctive radiographic and synovial fluid findings have not been reported. The arthropathy may respond to anticancer therapy. In general, an age-appropriate malignancy assessment is appropriate in patients presenting with new-onset arthritis.
Table 50-2. Rheumatic syndromes and the cancers they may herald
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