A Case of Pulmonary Carcinoid Tumor in a Patient on Adalimumab for Crohnʼs Disease

Abstract

Purpose: We report a unique case of pulmonary carcinoid tumor associated with adalimumab therapy for Crohn's disease. Methods: Adalimumab is a fully human monoclonal antibody against tumor necrosis factor alpha (TNFα). TNFα is a protein synthesized by activated macrophages and T cells. It is approved for the treatment of Crohn's disease and its' safety is established by clinical trials. However serious side effects can occur. Patients on TNFα inhibitors are at risk for injection reactions, serious infections and can develop malignancy. There is an FDA warning regarding risk of B-cell lymphomas and other tumors. Results: 63 year old female with fisutlizing, structuring Crohn's colitis and ileitis diagnosed at age 18, required multiple bowel resections and ileocolonic anastomosis. Presented with recurrent peri-anal fistulas and was started on adalimumab 10-11 months ago. Recently had developed a peri-rectal fistula and abscess requiring drainage. Previous smoker. No family history of Inflammatory Bowel Disease (IBD) or colorectal cancer. Physical exam notable for a non-tender, non-distended abdomen and rectal exam revealing non-tender peri-anal excoriations and a draining sinus fistula tract. Abdominal CT done for follow up of perirectal abcess had incidental finding of pulmonary nodules. This was a new finding; a chest CT then showed a 2cm RUL lung mass and multiple bibasilar sub-centimeter pulmonary nodules. Prior chest x-rays upon close inspection did not reveal the mass. Bronchoscopy with bronchiolar lavage and transbronchial biopsy was inconclusive. Whole body PET scan was remarkable for the right upper lung bronchial nodular density with low level FDG activity. Surgery performed a thoracotomy and wedge resection for diagnosis and cure. Pathology review confirmed a typical carcinoid tumor with pathologic stage of pT1a pN0. Adalimumab was stopped and she was placed on antibiotics for her fistulas along with prednisone taper. Patient later underwent an uncomplicated right lung wedge resection with curative intent and has since been doing well. She denies rectal pain or discharge and has 1-2 formed bowel movements daily. Post operatively she was placed on methotrexate for Crohn's maintenance therapy. Conclusion: Studies have demonstrated the clinical association of biologic therapy and Non-hodgekin's lymphomas. The action of TNFα antagonists has been shown in laboratory models to possibly potentiate tumor growth. Pulmonary carcinoid is a slow growing neuroendocrine tumor, but in this case appears to have developed in conjunction with adalimumab therapy. To our knowledge this is the first case of primary pulmonary carcinoid to be associated with adalimumab.