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de Lauretis A, Veeraraghavan S, Renzoni E. Review series: Aspects of interstitial lung disease: connective tissue disease-associated interstitial lung disease: how does it differ from IPF? How should the clinical approach differ? Chron Respir Dis 2011; 8:53-82. [PMID: 21339375 DOI: 10.1177/1479972310393758] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The lung is frequently involved in connective tissue diseases (CTDs), although the frequency of lung manifestations varies according to the type of CTD. Interstitial lung diseases (ILD) are frequently seen in CTDs, particularly systemic sclerosis (SSc), polymyositis/dermatomyositis (PM/DM) and rheumatoid arthritis (RA), accounting for a significant proportion of deaths. A large percentage of patients with CTD-associated ILD has limited and stable disease, not requiring treatment. However, a significant minority has severe and/or progressive disease, necessitating prompt initiation of treatment. CTD-ILD histological patterns include non-specific interstitial pneumonia (NSIP), usual interstitial pneumonia (UIP), organizing pneumonia (OP), diffuse alveolar damage (DAD) and lymphocytic interstitial pneumonia (LIP). NSIP is the most common pattern in all CTDs, except for RA, characterized by a higher frequency of UIP. ILD can present acutely or chronically, with acute presentations being more common in systemic lupus erythematosus and PM/DM. Idiopathic pulmonary fibrosis (IPF) is a progressively worsening ILD characterized by inflammation and fibrosis. The characteristic histological pattern of IPF is UIP. Interestingly, a UIP pattern is associated with a significantly better survival in CTD-related disease compared to the idiopathic variety. Prognosis in IPF is dismal, with a median survival since diagnosis of 2-3 years. No treatment regimen has been shown to improve survival in IPF. By contrast, although there have been only two randomized placebo-controlled trials investigating the effect of immunosuppressive treatment in SSc-associated ILD, clinical experience suggests that immunosuppressive drugs in CTD-related ILDs are capable of benefiting a significant proportion of patients, particularly those with certain histological patterns of disease. This review will essentially focus on CTD-associated ILD and will compare aspects of clinical presentation and management to those of IPF.
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Affiliation(s)
- Angelo de Lauretis
- Department of Respiratory Medicine, Catholic University of the Sacred Heart, Rome, Italy
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202
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Hant FN, Herpel LB, Silver RM. Pulmonary manifestations of scleroderma and mixed connective tissue disease. Clin Chest Med 2011; 31:433-49. [PMID: 20692538 DOI: 10.1016/j.ccm.2010.05.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Pulmonary manifestations are common in connective tissue diseases, and are associated with significant morbidity and mortality in this patient population. Systemic sclerosis (SSc) and mixed connective tissue disease (MCTD) are clinical entities for which the detection of lung involvement is essential to improve patient care and outcomes. This article discusses the pathogenesis, clinical presentation, and evaluation of the patient with pulmonary disease related to SSc and MCTD, with an emphasis on interstitial lung disease and pulmonary hypertension.
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Affiliation(s)
- Faye N Hant
- Medical University of South Carolina, Charleston, SC 29425-6370, USA.
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203
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Lopes AJ, Capone D, Mogami R, Menezes SLSD, Guimarães FS, Levy RA. Pneumonia intersticial associada à esclerose sistêmica: avaliação da função pulmonar no período de cinco anos. J Bras Pneumol 2011; 37:144-51. [DOI: 10.1590/s1806-37132011000200003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2010] [Accepted: 12/06/2010] [Indexed: 11/22/2022] Open
Abstract
OBJETIVO: Avaliar as alterações da função pulmonar em portadores de pneumonia intersticial associada à esclerose sistêmica no intervalo de cinco anos. MÉTODOS: Foi realizado um estudo longitudinal no qual foram avaliados 35 pacientes não tabagistas com esclerose sistêmica e sem história de doença pulmonar prévia. Na primeira avaliação, realizada na época do diagnóstico da pneumonia intersticial, os pacientes foram submetidos à TCAR, espirometria e medida de DLCO. Os pacientes foram subdivididos em dois grupos de acordo com a presença ou não de faveolamento na TCAR. Aproximadamente cinco anos após a primeira avaliação, os pacientes foram submetidos a espirometria e medida da DLCO apenas. RESULTADOS: Dos 35 pacientes, 34 eram mulheres, com média de idade de 47,6 anos. A média de tempo entre as duas avaliações foi de 60,9 meses. O faveolamento foi demonstrado por TCAR em 17 pacientes. Na amostra total, após cinco anos do diagnóstico, CVF, VEF1 e DLCO reduziram significativamente (81,3 ± 18,2% vs. 72,1 ± 22,2%; 79,9 ± 17,8% vs. 72,5 ± 20,6%; e 74,0 ± 20,5% vs. 60,7 ± 26,8%, respectivamente; p = 0.0001 para todos), enquanto a relação VEF1/CVF aumentou significativamente (98,5 ± 7,2% vs. 101,9 ± 7,8%; p = 0,008). No mesmo período, os valores de CVF, VEF1 e DLCO foram significativamente menores nos pacientes com faveolamento do que naqueles sem faveolamento na TCAR (p = 0,0001). CONCLUSÕES: Na esclerose sistêmica com doença pulmonar intersticial associada, a detecção de faveolamento na TCAR é determinante para predizer uma deterioração acelerada da função pulmonar.
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Affiliation(s)
- Agnaldo José Lopes
- Universidade do Estado do Rio de Janeiro; Centro Universitário Augusto Motta, Brasil
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Chighizola C, Ong VH, Denton CP. Cyclophosphamide as disease-modifying therapy for scleroderma: pros and cons. ACTA ACUST UNITED AC 2011. [DOI: 10.2217/ijr.10.112] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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205
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Hasegawa M, Fujimoto M, Hamaguchi Y, Matsushita T, Inoue K, Sato S, Takehara K. Use of serum clara cell 16-kDa (CC16) levels as a potential indicator of active pulmonary fibrosis in systemic sclerosis. J Rheumatol 2011; 38:877-84. [PMID: 21239758 DOI: 10.3899/jrheum.100591] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To clarify the clinical significance of concentrations of serum Clara cell 16-kDa protein (CC16; previously denoted CC10) in the diagnosis and monitoring of pulmonary fibrosis (PF) in patients with systemic sclerosis (SSc); and to compare CC16 levels with levels of the current most reliable serum markers for PF, such as Krebs von den Lungen-6 (KL-6) antigen and surfactant protein-D (SP-D). METHODS Serum levels of CC16, KL-6, and SP-D were determined by ELISA in 92 patients with SSc, 20 patients with systemic lupus erythematosus (SLE), and 20 healthy controls. In a retrospective longitudinal study, correlation of serum CC16 levels with the activity of PF was assessed in 16 SSc patients with PF. RESULTS Although CC16 levels were higher in patients with SSc than in SLE patients or healthy controls, the difference was not significant. Increased serum CC16 levels were associated with involvement of PF, especially active PF, as well as KL-6 and SP-D. Receiver operating characteristic curve analysis revealed that the utility of CC16 is slightly inferior to KL-6, but was comparable with that of SP-D for detecting PF in patients with SSc. In the longitudinal study, serum levels of CC16, KL-6, and SP-D were significantly decreased in the inactive disease phase compared to the active disease phase. CONCLUSION CC16 levels can be used as a potential serum biomarker for PF in addition to KL-6 and SP-D in patients with SSc.
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Affiliation(s)
- Minoru Hasegawa
- Department of Dermatology, Kanazawa University Graduate School of Medical Science, 13-1 Takaramachi, Kanazawa, Ishikawa, Japan.
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Mittoo S, Wigley FM, Wise RA, Woods A, Xiao H, Hummers LK. Long term effects of cyclophosphamide treatment on lung function and survival in scleroderma patients with interstitial lung disease. Open Rheumatol J 2011; 5:1-6. [PMID: 21552414 PMCID: PMC3087310 DOI: 10.2174/1874312901105010001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2009] [Revised: 08/04/2010] [Accepted: 08/26/2010] [Indexed: 12/13/2022] Open
Abstract
Background: Scleroderma (SSc) patients with active interstitial lung disease (ILD) experience a decline in lung function and increased mortality; cyclophosphamide (CYC) therapy may stabilize lung function at one and two years follow-up. Long-term lung function and survival outcomes of SSc patients with ILD following CYC treatment remain largely unknown. Methodology: We reviewed records of SSc patients with active ILD who had received at least six months of CYC treatment and had pulmonary function tests (PFTs) performed at least two years from the onset of treatment. Principal Findings: Thirty eight patients meeting eligibility criteria had a mean follow-up period from start of CYC to the last follow-up PFT of 5.1 years (range 2.3 -10.8 years). At a median of 4.1 years (range 9 months - 8.4 years), 12/38 (32%) patients had a significant decline in % predicted Forced Vital Capacity from their baseline PFT. At a median of 3.9 years (range 7 months - 8.4 years); 12/36 (33%) patients experienced a significant decline in their % predicted carbon monoxide diffusing capacity. Three patients died at a follow-up between 4.5-6 years and two received bilateral lung transplants because of severe restrictive lung disease. Conclusions: While the majority of SSc patients treated with CYC for active ILD experience long-term lung function stability and survive, greater than 1/3 of patients will experience either lung function decline, death, or require a lung transplant. This suggests that despite aggressive immune suppressing therapy, a subset of patients will have continued lung function decline, highlighting the need for ongoing monitoring and better therapeutic options.
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Affiliation(s)
- S Mittoo
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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207
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Khanna D. Assessing disease activity and outcome in scleroderma. Rheumatology (Oxford) 2011. [DOI: 10.1016/b978-0-323-06551-1.00137-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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209
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Dellaripa PF, O. Rosas I. The lung in rheumatic disease. Rheumatology (Oxford) 2011. [DOI: 10.1016/b978-0-323-06551-1.00035-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Mouthon L, Bérezné A, Guillevin L, Valeyre D. Therapeutic options for systemic sclerosis related interstitial lung diseases. Respir Med 2010; 104 Suppl 1:S59-69. [PMID: 20630349 DOI: 10.1016/j.rmed.2010.03.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Interstitial lung disease (ILD) is a common manifestation of systemic sclerosis (SSc) mainly encountered in patients with diffuse disease. Unlike idiopathic interstitial pneumonias (IIP), SSc associated ILD corresponds to non-specific interstitial pneumonia (NSIP) in most cases, whereas usual interstitial pneumonia (UIP) is encountered less frequently. This explains the better prognosis of SSc associated ILD compared to IIP. However, severe restrictive lung disease represents one of the two main causes of disease-related death in SSc patients. The treatment of SSc associated ILD is not very well established. Anti-fibrosing treatments have failed to demonstrate any benefit and cyclophosphamide, which has been used in the treatment of this condition for about 15 years, has recently been evaluated in two prospective randomised studies which showed a significant but modest effect on respiratory function. Since none of the patients included in retrospective or prospective studies were selected on the basis of progression of ILD, and since only a minority of SSc patients develop severe ILD, further studies should focus on the subgroup of SSc patients with worsening ILD. A subgroup of patients with rapidly progressive ILD might benefit from pulsed intravenous cyclophosphamide combined with prednisone 15 mg daily but this remains to be confirmed.
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Affiliation(s)
- Luc Mouthon
- Université Paris Descartes, UPRES EA 4058, Pôle de Médecine Interne et Centre de Référence pour les Vascularites Nécrosantes et la Sclérodermie Systémique, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France.
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211
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De Santis M, Bosello SL, Peluso G, Pinnelli M, Alivernini S, Zizzo G, Bocci M, Capacci A, La Torre G, Mannocci A, Pagliari G, Varone F, Pistelli R, Danza FM, Ferraccioli G. Bronchoalveolar lavage fluid and progression of scleroderma interstitial lung disease. CLINICAL RESPIRATORY JOURNAL 2010; 6:9-17. [DOI: 10.1111/j.1752-699x.2010.00228.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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212
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Nashid M, Khanna PP, Furst DE, Clements PJ, Maranian P, Seibold J, Postlethwaite AE, Louie JS, Mayes MD, Agrawal H, Khanna D. Gender and ethnicity differences in patients with diffuse systemic sclerosis--analysis from three large randomized clinical trials. Rheumatology (Oxford) 2010; 50:335-42. [PMID: 20889574 DOI: 10.1093/rheumatology/keq294] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Although the incidence of dcSSc is higher in African-American and Hispanic populations compared with European Caucasian patients, it is not clear whether there are differences in subsequent disease course. Also, the potential impact of gender on the disease course of dcSSc is not well defined. Our objective was to assess the course of modified Rodnan skin score (MRSS), HAQ-disability index (HAQ-DI) and forced vital capacity per cent (FVC%) predicted between men vs women and three ethnic groups with dcSSc participating in three randomized clinical trials (RCTs). METHOD Data from RCTs (n = 495) were pooled and analysed. Baseline characteristics were compared in men vs women and among ethnic groups. A linear mixed effects model was used to assess the predictors of MRSS, HAQ-DI and FVC%. The primary independent variables were time-in-study and its interaction with gender and ethnicity. The models were adjusted for other covariates that were significant at baseline between gender and ethnicity analyses. RESULTS Men had lower HAQI-DI scores compared with women (P < 0.05). Among the three ethnic groups, Caucasians were older, African-Americans had lower FVC% predicted and Hispanics had greater tender joint counts (P < 0.05). The course of MRSS, HAQ-DI and FVC% predicted during the study period was not significantly different between gender and three ethnicities. Time-in-study was an independent predictor of improvement in MRSS and HAQ-DI. CONCLUSION Our analysis explores the influence of gender and ethnicity on disease course in RCTs. These findings are relevant to issues of future trial design.
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Affiliation(s)
- Mahsa Nashid
- Department of Medicine, David Geffen School of Medicine, Los Angeles, CA 90095, USA
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Abstract
Interstitial lung disease (ILD) is a common manifestation of systemic sclerosis (SSc) and mainly encountered in patients with diffuse disease and/or anti-topoisomerase 1 antibodies. ILD develops in up to 75% of patients with SSc overall. However, SSc-ILD evolves to end-stage respiratory insufficiency in only a few patients. Initial pulmonary function tests (PFT) with measurement of carbon monoxide diffusing capacity, together with high-resolution computed tomography, allows for early diagnosis of SSc-ILD, before the occurrence of dyspnea. Unlike idiopathic ILD, SSc-ILD corresponds to non-specific interstitial pneumonia in most cases, whereas usual interstitial pneumonia is less frequently encountered. Therefore, the prognosis of SSc-ILD is better than that for idiopathic ILD. Nevertheless, ILD represents one of the two main causes of death in SSc patients. To detect SSc-ILD early, PFT must be repeated regularly, every 6 months to 1 year, depending on disease worsening. Conversely, broncho-alveolar lavage is not needed to evaluate disease activity in SSc-ILD but may be of help in diagnosing opportunistic infection. The treatment of SSc-ILD is not well established. Cyclophosphamide, which has been used for 20 years, has recently been evaluated in two prospective randomized studies that failed to demonstrate a major benefit for lung function. Open studies reported mycophenolate mofetil, azathioprine and rituximab as alternatives to cyclophosphamide. On failure of immunosuppressive agent treatment, lung transplantation can be proposed in the absence of other major organ involvement or severe gastro-esophageal reflux.
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Affiliation(s)
- Guillaume Bussone
- Université Paris Descartes, Institut Cochin, Inserm U1016, Paris, France
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214
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Assassi S, Sharif R, Lasky RE, McNearney TA, Estrada-Y-Martin RM, Draeger H, Nair DK, Fritzler MJ, Reveille JD, Arnett FC, Mayes MD. Predictors of interstitial lung disease in early systemic sclerosis: a prospective longitudinal study of the GENISOS cohort. Arthritis Res Ther 2010; 12:R166. [PMID: 20813056 PMCID: PMC2990992 DOI: 10.1186/ar3125] [Citation(s) in RCA: 118] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2010] [Revised: 08/13/2010] [Accepted: 09/02/2010] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION The objective of the present study was to examine the association of baseline demographic and clinical characteristics with sequentially obtained measurements of forced vital capacity (FVC), expressed as a percentage of the predicted value, and to identify predictors of the decline rate in FVC over time in the Genetics versus Environment in Scleroderma Outcome Study (GENISOS). METHODS To date, 266 patients have been enrolled in GENISOS, a prospective, observational cohort of patients with early systemic sclerosis. In addition to pulmonary function tests (PFTs), clinical and laboratory data were obtained from each patient. We analyzed 926 FVC measurements utilizing generalized linear mixed models. The predictive significance of baseline variables for the decline rate in FVC was investigated by the interaction term between the variable and the follow-up time within the first 3 years after enrollment as well as throughout the entire follow-up time. RESULTS The cohort consisted of 125 white, 54 African American, and 77 Hispanic patients with average disease duration of 2.5 years at enrollment. The mean follow-up time was 3.8 years, ranging up to 11.4 years. A number of baseline variables, including antibody status, African American ethnicity, disease type, baseline PFT values, modified Rodnan Skin Score, fibrosis on chest radiograph, and lung and skin subscores of the Severity Index, were associated with serially measured FVC levels. However, only the presence of anti-topoisomerase I antibodies (ATA) was associated with lower FVC levels (P < 0.001) as well as accelerated decline rate in FVC within the first 3 years of follow-up (P = 0.02). None of the baseline variables predicted the rate of decline in FVC on long-term follow-up. Patients with rapidly progressive ILD, however, were under-represented in the long-term follow-up group because the accelerated rate of decline in FVC was associated with poor survival (P = 0.001). CONCLUSIONS Presence of ATA was the only baseline variable associated with differential FVC levels, predicting the rate of decline in FVC within the first 3 years of follow-up. The association of faster decline in FVC with poor survival further emphasizes the need for identification of predictive biomarkers by collection of genetic information and serial blood samples in cohort studies.
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Affiliation(s)
- Shervin Assassi
- Division of Rheumatology and Clinical Immunogenetics, University of Texas-Houston, 6431 Fannin, Houston, TX 77030, USA
- Center for Clinical Research and Evidence-Based Medicine, University of Texas-Houston, 6431 Fannin, Houston, TX 77030, USA
| | - Roozbeh Sharif
- Division of Rheumatology and Clinical Immunogenetics, University of Texas-Houston, 6431 Fannin, Houston, TX 77030, USA
| | - Robert E Lasky
- Center for Clinical Research and Evidence-Based Medicine, University of Texas-Houston, 6431 Fannin, Houston, TX 77030, USA
| | - Terry A McNearney
- University of Texas Medical Branch at Galveston, 301 University Boulevard, Galveston, TX 77555, USA
| | | | - Hilda Draeger
- University of Texas-San Antonio, 4502 Medical Drive, San Antonio, TX 78229, USA
| | - Deepthi K Nair
- Division of Rheumatology and Clinical Immunogenetics, University of Texas-Houston, 6431 Fannin, Houston, TX 77030, USA
| | - Marvin J Fritzler
- University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta T2N 4N1, Canada
| | - John D Reveille
- Division of Rheumatology and Clinical Immunogenetics, University of Texas-Houston, 6431 Fannin, Houston, TX 77030, USA
| | - Frank C Arnett
- Division of Rheumatology and Clinical Immunogenetics, University of Texas-Houston, 6431 Fannin, Houston, TX 77030, USA
| | - Maureen D Mayes
- Division of Rheumatology and Clinical Immunogenetics, University of Texas-Houston, 6431 Fannin, Houston, TX 77030, USA
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215
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Utility of Bronchoalveolar Lavage in Evaluation of Patients with Connective Tissue Diseases. Clin Chest Med 2010; 31:423-31. [DOI: 10.1016/j.ccm.2010.04.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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216
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Abstract
Interstitial lung disease and pulmonary hypertension (PH) are the most common cardiopulmonary findings in patients with systemic sclerosis (SSc). About two thirds of patients suffering from SSc develop scleroderma interstitial lung disease. PH is present in about 20% of SSc patients and is typically associated with severe lung disease, although it may be an isolated manifestation of SSc. High-resolution CT scanning is a key method for evaluating chest involvement. There are four roles of imaging in scleroderma interstitial lung disease: 1) detection of lung involvement, 2) identification of patients likely to respond to treatment, 3) assessment of treatment efficacy, and 4) exclusion of other significant diseases to include PH and cardiac and esophageal abnormalities.
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Affiliation(s)
- Diane Strollo
- Department of Radiology, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA 15213, USA.
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217
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WALKEY ALLANJ, IEONG MICHAEL, ALIKHAN MIR, FARBER HARRISONW. Cardiopulmonary Exercise Testing with Right-heart Catheterization in Patients with Systemic Sclerosis. J Rheumatol 2010; 37:1871-7. [DOI: 10.3899/jrheum.091424] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Objective.To examine the role of cardiopulmonary exercise testing with right-heart catheterization (CPET/RHC) in patients with systemic sclerosis (SSc) with potentially multifactorial exertional limitation.Methods.This was a single-center retrospective cohort study of patients with SSc referred for CPET/RHC.Results.A total of 19 patients with SSc [subtypes: 10 limited, 5 diffuse, 1 systemic lupus erythematosus (SLE)/SSc overlap, and 3 with no subtype specified in the medical record] underwent CPET/RHC testing from February 2003 to February 2008. Of these patients, the primary limitations to exercise were found to be ventilatory (n = 6), deconditioning/cardiovascular (n = 6), pulmonary vascular (PVL; n = 3), and exercise-induced left ventricular diastolic dysfunction (exercise-LVDD; n = 4). No prior physical examination, pulmonary function test, imaging, or echocardiographic data reliably predicted the etiology of exercise limitation determined by CPET/RHC. Vital capacity and ventilatory equivalent for CO2 did not differ during CPET testing between PVL and exercise–LVDD, limiting the utility of CPET alone for discriminating these etiologies of dyspnea. Exercise alveolar-arterial oxygen gradient was elevated in subjects shown to have PVL [median 48 mm Hg (interquartile range 45.3, 62.0)] compared to those with exercise-LVDD [26.0 (IQR 10.6, 36.0)] and deconditioning [13.9 (IQR 4.0, 16.4); p = 0.02]. Major therapeutic changes occurred in 11/19 (58%) subjects after CPET/RHC testing.Conclusion.CPET/RHC testing in subjects with SSc and potentially multifactorial dyspnea adds potentially useful diagnostic information unavailable from noninvasive testing.
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218
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Mycophenolate mofetil in systemic sclerosis-associated interstitial lung disease. Clin Rheumatol 2010; 29:1167-8. [PMID: 20532938 DOI: 10.1007/s10067-010-1498-z] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2009] [Revised: 01/04/2010] [Accepted: 05/21/2010] [Indexed: 10/19/2022]
Abstract
This study aimed to assess the effect of mofetil mycophenolate (MMF), an inhibitor of lymphocyte proliferation, on lung function and skin in patients with systemic sclerosis (SSc)-associated interstitial lung disease (SSc-ILD). In this retrospective study, we reviewed the medical files of 10 patients with SSc-ILD (eight females, 10 patients with diffuse SSc; mean age, 59.7 +/- 12.7 years; disease duration, 7.7 +/- 4.7 years). Patients were treated with MMF (2 g/day) for 12 months. Lung function tests and the modified Rodnan total skin score (mRTSS) were assessed at baseline and at 12 months. Results were analyzed by paired Student's t test. There was a significant increase in forced vital capacity and a nonsignificant increase in carbon monoxide diffusing capacity at 12 months in patients on MMF (p = 0.04 and 0.66, respectively). There was no effect on mRTSS. MMF stabilizes lung function of SSc-ILD after 12 months of treatment.
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219
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Diagnosis and management of systemic sclerosis. INDIAN JOURNAL OF RHEUMATOLOGY 2010. [DOI: 10.1016/s0973-3698(10)60544-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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220
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Pulmonary survival study in 91 patients with systemic sclerosis. Rheumatol Int 2010; 31:1577-82. [DOI: 10.1007/s00296-010-1501-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2009] [Accepted: 04/27/2010] [Indexed: 12/13/2022]
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221
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Bronchoalveolar lavage in systemic sclerosis with lung involvement: role and correlations with functional, radiological and scintigraphic parameters. Rheumatol Int 2010; 31:1183-8. [PMID: 20352228 DOI: 10.1007/s00296-010-1390-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2009] [Accepted: 02/27/2010] [Indexed: 10/19/2022]
Abstract
To evaluate the role and the prognostic value of bronchoalveolar lavage (BAL) in scleroderma patients with interstitial lung disease. We reviewed the records of 79 patients with systemic sclerosis (SSc) who had dyspnea and pulmonary involvement and underwent BAL study. Sixty-two patients were prospectively followed up for 12-36 months and re-evaluated by pulmonary function tests (PFTs). Seventy-nine SSc patients were enrolled (71 F and 8 M), 55 with limited and 24 with a diffuse form; mean age 55 ± 13 years; mean disease duration 55.2 ± 59 months. All patients were ANA positive, of these 30 were anti-topoisomerase-1 positive (anti-Topo1) and 22 were anti-centromere positive (ACA). Thirty-one patients had alveolitis (39.2%) that was neutrophilic in 12 patients, eosinophilic in 3 and mixed (neutrophilic and eosinophilic) in 16 patients. Compared to patients without alveolitis, those with alveolitis had a significant reduction of carbon monoxide diffusing capacity (DLCO), forced vital capacity (FVC) and more elevated lung high-resolution computed tomography (HRCT) scores. Furthermore, alveolar clearance was significantly accelerated. No differences were found between patients with and without alveolitis regarding disease subsets (diffuse vs limited-SSc); a significant predominance of anti-Topo1 antibodies was found in the alveolitis group and of ACA antibodies in the non-alveolitis cohort. During the follow-up, (range: 12-36 months) 62 patients, 26 with and 36 without alveolitis were re-evaluated with PFTs. In the alveolitis group, 12 patients (46.1%) showed stable lung function parameters and 14 had worsened (53.8%). In this group, 20 patients (77%) received cyclophosphamide (CYC): 11 (55%) worsened (5 of them died of cardio-pulmonary complications) and 9 (45%) remained stable. Six patients could not be treated; of these 3 remained stable and 3 worsened. Among 36 patients with normal BAL, 11 (30.5%) showed stable lung function parameters, 13 improved (36.1%) and 12 worsened (33.3%); in this last group, 2 patients died of extra-pulmonary complications. Six patients, with progression of lung fibrosis, were treated with CYC: 3 of them improved and 3 remained stable. Our study revealed a trend toward a more severe course in the SSc patients with BAL alveolitis; probably the non-significant result is related to the low number of the examined subjects and to the selection criteria. However, BAL remains the only tool to exclude lung infections and, in our experience, a useful instrument to evaluate interstitial lung disease in SSc patients.
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222
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Kim EJ, Collard HR, King TE. Rheumatoid arthritis-associated interstitial lung disease: the relevance of histopathologic and radiographic pattern. Chest 2010; 136:1397-1405. [PMID: 19892679 DOI: 10.1378/chest.09-0444] [Citation(s) in RCA: 231] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Interstitial lung disease (ILD) is a frequent extraarticular manifestation of rheumatoid arthritis (RA). While the nonspecific interstitial pneumonia pattern predominates in most forms of connective tissue-associated ILD, studies in patients with RA-associated ILD (RA-ILD) suggest that the usual interstitial pneumonia (UIP) pattern is more common in this patient population. High-resolution CT (HRCT) scans appear accurate in identifying UIP pattern in many patients with RA-ILD. Although the data are limited, UIP pattern appears to predict worse survival in RA-ILD patients. Larger, prospective, multicenter studies are needed to confirm this finding. We propose that the evaluation of patients with RA-ILD should focus on identifying those with UIP pattern on HRCT scans, as these patients are likely to carry a worse prognosis. In patients in whom the underlying pattern cannot be determined by HRCT scanning, surgical lung biopsy should be considered.
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Affiliation(s)
- Eunice J Kim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California at San Francisco, San Francisco, CA.
| | - Harold R Collard
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California at San Francisco, San Francisco, CA
| | - Talmadge E King
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California at San Francisco, San Francisco, CA
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Goldin J, Elashoff R, Kim HJ, Yan X, Lynch D, Strollo D, Roth MD, Clements P, Furst DE, Khanna D, Vasunilashorn S, Li G, Tashkin DP. Treatment of scleroderma-interstitial lung disease with cyclophosphamide is associated with less progressive fibrosis on serial thoracic high-resolution CT scan than placebo: findings from the scleroderma lung study. Chest 2010; 136:1333-1340. [PMID: 19892673 DOI: 10.1378/chest.09-0108] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The Scleroderma Lung Study (SLS) demonstrated significant treatment-associated improvements in pulmonary function and symptoms when patients with scleroderma-related interstitial lung disease (SSc-ILD) were treated with a 1-year course of cyclophosphamide (CYC) in a randomized, double-blinded, placebo-controlled clinical trial. This study examined thoracic high-resolution CT (HRCT) scans obtained during the SLS for treatment-associated changes over time. METHODS Ninety-eight of the 158 subjects (CYC group, 49 subjects; placebo group, 49 subjects) participating in the SLS underwent thoracic HRCT scans both at baseline and after 12 months of treatment, which were available for analysis. Two independent radiologists visually scored the baseline HRCT scans for the presence of ground-glass opacities (GGOs), fibrosis (FIB), and honeycomb cysts (HCs) on a scale of 0 to 4. The treatment effect at 12 months was assessed by a blinded comparison of baseline and follow-up scans for evidence of stability and improvement (not worse) or deterioration (worse). RESULTS At the end of treatment, FIB was significantly worse in the placebo treatment group than in the CYC treatment group (p = 0.014). Furthermore, differences in the 12-month change in FIB between the CYC and placebo groups correlated significantly with other outcome measures, including the 12-month changes in FVC (p < 0.05), total lung capacity (p < 0.05), and dyspnea (p < 0.001) scores. However, no differences were noted between the two groups with respect to changes in either GGOs or HCs. CONCLUSIONS A 1-year course of treatment of SSc-ILD with CYC was associated with treatment-related changes in FIB scores on HRCT scans, which correlated with other measures of treatment response. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT00004563.
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Affiliation(s)
- Jonathan Goldin
- Department of Radiologic Sciences, School of Public Health, University of California Los Angeles, Los Angeles, CA
| | - Robert Elashoff
- Department of Biomathematics , School of Public Health, University of California Los Angeles, Los Angeles, CA
| | - Hyun J Kim
- Department of Radiologic Sciences, School of Public Health, University of California Los Angeles, Los Angeles, CA
| | - Xaiohong Yan
- Department of Biomathematics , School of Public Health, University of California Los Angeles, Los Angeles, CA
| | - David Lynch
- Department of Radiologic Sciences, National Jewish Hospital, Denver, CO
| | - Diane Strollo
- University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Michael D Roth
- Department of Medicine, School of Public Health, University of California Los Angeles, Los Angeles, CA
| | - Philip Clements
- Department of Medicine, School of Public Health, University of California Los Angeles, Los Angeles, CA
| | - Daniel E Furst
- Department of Medicine, School of Public Health, University of California Los Angeles, Los Angeles, CA
| | - Dinesh Khanna
- Department of Medicine, School of Public Health, University of California Los Angeles, Los Angeles, CA
| | - Srainnapha Vasunilashorn
- Department of Radiologic Sciences, School of Public Health, University of California Los Angeles, Los Angeles, CA
| | - Gang Li
- Department of David Geffen School of Medicine, and the Department of Biostatistics, School of Public Health, University of California Los Angeles, Los Angeles, CA
| | - Donald P Tashkin
- Department of Medicine, School of Public Health, University of California Los Angeles, Los Angeles, CA.
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Phung S, Strange G, Chung LP, Leong J, Dalton B, Roddy J, Deague J, Playford D, Musk M, Gabbay E. Prevalence of pulmonary arterial hypertension in an Australian scleroderma population: screening allows for earlier diagnosis. Intern Med J 2009; 39:682-91. [DOI: 10.1111/j.1445-5994.2008.01823.x] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Fan X, Pope J, Baron M. What is the relationship between disease activity, severity and damage in a large Canadian systemic sclerosis cohort? Results from the Canadian Scleroderma Research Group (CSRG). Rheumatol Int 2009; 30:1205-10. [DOI: 10.1007/s00296-009-1129-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2009] [Accepted: 09/13/2009] [Indexed: 11/28/2022]
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Kravitz JN, Strange C. How should we treat vascular and fibrotic lung disease in scleroderma? F1000 MEDICINE REPORTS 2009; 1. [PMID: 20948723 PMCID: PMC2948303 DOI: 10.3410/m1-57] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Recent randomized trials suggest that evidence-based algorithms for systemic sclerosis can be developed to identify patients at risk for lung disease, follow lung disease progression, and modify disease with therapies of proven benefit. Recognition of disease subsets allows physicians to integrate physiology, overlapping disease manifestations, and predictable drug effects into a comprehensive disease management program.
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Affiliation(s)
- Jared N Kravitz
- Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina 96 Jonathan Lucas St, Suite 812 CSB, Charleston, SC 29425 USA
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La Corte R, Lo Mo Naco A, Locaputo A, Dolzani F, Trotta F. In patients with antisynthetase syndrome the occurrence of anti-Ro/SSA antibodies causes a more severe interstitial lung disease. Autoimmunity 2009; 39:249-53. [PMID: 16769659 DOI: 10.1080/08916930600623791] [Citation(s) in RCA: 130] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
We studied the clinical features and autoantibody profile in 21 patients with antisynthetase syndrome (AS) comparing to 48 patients with classical polymyositis and dermatomyositis without AS. At presentation, the AS group showed more frequently the presence of interstitial lung disease (ILD), arthritis/arthralgia, mechanic's hand and anti-Ro/SSA antibodies. Patients without AS had more frequent proximal weakness and cutaneous erythematosus rash. Interestingly, the AS patients with associated anti-Ro/SS-A antibodies seem to be predisposed to the development of a more severe ILD, expressed as HRCT total score > or = 7. During a follow up of about 3 years (range 6-110 months), the presence of anti-Jo-1 antibody alone or in association with anti-Ro/SSA did not influence survival or a more severe prognosis of ILD.
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Affiliation(s)
- R La Corte
- Ferrara University, Rheumatology Section, Department of Clinical and Experimental Medicine, Ferrara, Italy.
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Hachulla E, Bervar JF, Launay D, Lamblin N, Perez T, Mouthon L, De Groote P, Tillie-Leblond I, Humbert M. Dyspnée à l’effort chez le patient atteint de sclérodermie systémique : du symptôme au diagnostic étiologique. Presse Med 2009; 38:911-26. [DOI: 10.1016/j.lpm.2008.08.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2008] [Revised: 08/21/2008] [Accepted: 08/28/2008] [Indexed: 11/29/2022] Open
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Abstract
Systemic sclerosis-associated interstitial lung disease (SSc-ILD) is the leading cause of morbidity and mortality in SSc patients. In autopsy studies, up to 70% of the SSc patients show histological evidence of lung involvement. In surgical lung biopsies from SSc-ILD patients, a pattern of non-specific interstitial pneumonia is present in a majority, while usual interstitial pneumonia is found in a more variable proportion of patients. Up to 90% of the SSc patients have lung function abnormalities, especially with respect to gas transfer. Pulmonary function testing, therefore, is a major tool of investigation of lung involvement in SSc.
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Affiliation(s)
- J Behr
- Department of Internal Medicine, Grosshadern clinic, Ludwig Maximilians University of Munich, Munich, Germany.
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Au K, Khanna D, Clements PJ, Furst DE, Tashkin DP. Current concepts in disease-modifying therapy for systemic sclerosis-associated interstitial lung disease: lessons from clinical trials. Curr Rheumatol Rep 2009; 11:111-9. [PMID: 19296883 DOI: 10.1007/s11926-009-0016-2] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Interstitial lung disease (ILD) is the leading cause of mortality in patients with systemic sclerosis (SSc), which is also known as scleroderma. Two randomized clinical trials in patients with SSc-related ILD have shown that oral or intravenous cyclophosphamide is associated with modest but significant or near-significant improvements in lung function, dyspnea, and physical function. In addition, the Scleroderma Lung Study and an observational study showed that baseline forced vital capacity less than 70% and moderate fibrosis on thoracic high-resolution CT are predictors of response to cyclophosphamide therapy and/or survival, whereas active alveolitis on bronchoalveolar lavage is not. Newer therapies for SSc patients with ILD include mycophenolate mofetil, tyrosine kinase inhibitors (imatinib, dasatinib), and anti-interleukin-13 monoclonal antibody. Several uncontrolled trials have reported favorable results of mycophenolate mofetil in SSc-related ILD. A randomized double-blind controlled trial by the Scleroderma Lung Study Research Group is currently comparing the efficacy and safety of mycophenolate mofetil versus oral cyclophosphamide.
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Affiliation(s)
- Karen Au
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Los Angeles, CA 90095, USA
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Reddy BY, Hantash BM. Cutaneous Connective Tissue Diseases: Epidemiology, Diagnosis, and Treatment. ACTA ACUST UNITED AC 2009; 3:22-31. [PMID: 21218179 DOI: 10.2174/1874372200903010022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Connective tissue diseases (CTDs) are a group of clinical disorders that have an underlying autoimmune pathogenesis. These include a diverse set of diseases such as relapsing polychondritis, rheumatoid arthritis, and eosinophilic fasciitis, along with more common entities like Sjogren's syndrome, dermatomyositis, scleroderma, and lupus erythematosus. The latter three will be the focus of this review, as they constitute the most significant and common CTD with cutaneous manifestations. The cutaneous signs often represent the preliminary stages of disease and the presenting clinical symptoms. Therefore, comprehensive knowledge of CTD manifestations is essential for accurate diagnosis, better assessment of prognosis, and effective management. Although the precise etiologies of CTDs remain obscure, recent advances have allowed for further understanding of their pathogenesis and improved disease classifications. In addition, there have been developments in therapeutic options for CTDs. This review provides an overview of the epidemiology, clinical presentations, and current treatment options of cutaneous lupus erythematous, dermatomyositis and scleroderma.
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232
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Hara T, Ogawa F, Yanaba K, Iwata Y, Muroi E, Komura K, Takenaka M, Shimizu K, Hasegawa M, Fujimoto M, Sato S. Elevated serum concentrations of polymorphonuclear neutrophilic leukocyte elastase in systemic sclerosis: association with pulmonary fibrosis. J Rheumatol 2009; 36:99-105. [PMID: 19208531 DOI: 10.3899/jrheum.080269] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To determine the serum concentrations and clinical association of polymorphonuclear neutrophilic leukocyte (PMN) elastase in patients with systemic sclerosis (SSc). METHODS Serum PMN elastase levels from 21 patients with limited cutaneous SSc (lSSc) and 32 with diffuse cutaneous SSc (dSSc) were examined by ELISA. RESULTS Serum PMN elastase levels were elevated in patients with SSc, especially dSSc, compared to healthy controls. SSc patients with elevated serum PMN elastase levels had more frequent presence of pulmonary fibrosis, arthritis, contracture of phalanges, and diffuse pigmentation. Anticentromere antibody was detected less frequently in SSc patients with elevated serum PMN elastase levels than in controls. Consistently, serum PMN elastase levels also correlated positively with serum levels of KL-6 and surfactant protein-D, serological markers for pulmonary fibrosis. Serum PMN elastase levels were also associated with levels of serum 8-isoprostane, an oxidative stress marker in SSc. CONCLUSION Serum PMN elastase levels were elevated in patients with SSc, and it was more prominent in patients with pulmonary fibrosis, suggesting that serum PMN elastase is a novel serological marker for SSc-related pulmonary fibrosis.
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Affiliation(s)
- Toshihide Hara
- Department of Dermatology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
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Mittoo S, Gelber AC, Christopher-Stine L, Horton MR, Lechtzin N, Danoff SK. Ascertainment of collagen vascular disease in patients presenting with interstitial lung disease. Respir Med 2009; 103:1152-8. [PMID: 19304475 DOI: 10.1016/j.rmed.2009.02.009] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2008] [Revised: 01/15/2009] [Accepted: 02/16/2009] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Previous studies of interstitial lung disease (ILD) suggest that prognosis and therapeutic response are influenced by the presence of underlying collagen vascular disease (CVD). Yet, what proportion of patients presenting with ILD have CVD is largely unknown. We sought to determine the frequency of a new CVD diagnosis in an ILD referral population. MATERIALS/PATIENTS AND METHODS We retrospectively studied 114 consecutive patients evaluated at the Johns Hopkins Interstitial Lung Disease Clinic for the development of CVD. RESULTS In this retrospective cohort, nearly one-third of the 114 patients with confirmed ILD satisfied published criteria for a CVD diagnosis. Seventeen (15%) patients were diagnosed with a new CVD as a direct consequence of their ILD evaluation. Patients with new CVD diagnosis were younger than those without new CVD diagnosis: 51.4years (95% CI 45-58years) and 60years (95% CI 57-63), respectively (p=0.01). Moreover, an ANA>or=1:640 (p=0.03) and elevated levels of creatine phosphokinase (CPK) or aldolase (p<0.001) were associated with a new CVD diagnosis. CONCLUSIONS Unrecognized collagen vascular disease may be more common than previously appreciated among patients referred with ILD. High titer ANA and an elevated CPK or aldolase are associated with a CVD diagnosis in this referral population.
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Affiliation(s)
- Shikha Mittoo
- Division of Rheumatology, University of Manitoba, Winnipeg Rheumatic Disease Unit, RR149 Rehabilitation Hospital, Health Sciences Centre, 800 Sherbrook Street, Winnipeg, MB, R3A 1M4, Canada
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234
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Systemische Sklerose. Z Rheumatol 2009; 68:37-43. [DOI: 10.1007/s00393-008-0362-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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235
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Sabnani I, Zucker MJ, Rosenstein ED, Baran DA, Arroyo LH, Tsang P, Zubair M, Rivera V. A novel therapeutic approach to the treatment of scleroderma-associated pulmonary complications: safety and efficacy of combination therapy with imatinib and cyclophosphamide. Rheumatology (Oxford) 2008; 48:49-52. [DOI: 10.1093/rheumatology/ken369] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Rojas-Serrano J, Codina-Velásquez H, Medrano-Ramírez G, Abraham Simón J, Vera-Lastra O, Vázquez-Mellado J. [Lower incidence of severe damage to target organs in mexican patients with systemic sclerosis and diffuse skin affection]. ACTA ACUST UNITED AC 2008; 4:3-7. [PMID: 21794487 DOI: 10.1016/s1699-258x(08)71788-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2007] [Accepted: 10/03/2007] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine the cumulative incidence of severe organ involvement in Mexican patients with systemic sclerosis (SS) and diffuse scleroderma at 3 years from the onset of SS symptoms, and to compare itwith the cumulative incidence observed in a cohort of white patients with SS. PATIENTS AND METHOD Patients with SS and diffuse scleroderma were evaluated within the first 2 years from the onset of SS symptoms and were included. An estimation of the cumulative incidence of severe involvement to the skin, kidney, heart, lungs, and gastrointestinal track at 3 years from the onset of SS symptoms was carried out. This cumulative incidence was compared with that of white SS patients with diffuse scleroderma, using the one sample test for a binomial proportion. RESULTS Sixty-three patients were included. The cumulative incidence of severe involvement to the skin was 3.17% (2/63) (95% CI, 0.04%-11); kidney involvement in 4.17% (3/63) (95% CI, 0.99%-13.29%); heart involvement in 1.6% (1/63) (95% CI, 0.04%-8.5%); lung involvement in 11.11% (7/63) (95% IC, 4.5%-21.5%); and gastrointestinal involvement in 4.7% (3/63) (95% IC, 0.99%-13.3%). Mexican patients had a lower Reumatol Clin. 2008;4(1):3-7 3 02 ORIG 2582 (3-7).qxp 23/1/08 11:09 Página 4 Rojas-Serrano J et al. Incidencia de daño grave en pacientes mexicanos con esclerosis sistémica incidence of severe skin involvement (P=.0001), kidney involvement (P=.03) and heart involvement (P=.03) compared to white SS patients with diffuse scleroderma. CONCLUSIONS The cumulative incidence of severe organ involvement in SS Mexican patients with diffuse scleroderma was determined. The incidence of severe skin, kidney and heart involvement is lower than in white SS patients with diffuse scleroderma.
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Affiliation(s)
- Jorge Rojas-Serrano
- Instituto Nacional de Enfermedades Respiratorias. Universidad Nacional Autónoma de México. Facultad de Medicina. México
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Abstract
Gene expression studies in scleroderma have shown large and consistent changes in the gene expression of end-target tissues. These changes reflect the lymphocyte infiltration and pathway deregulation potentially linked to disease pathogenesis. Gene expression in scleroderma also reflects the clinical heterogeneity in the disease and can be used to categorize patients. Contained within these gene expression signatures are groups of genes that could serve as biomarkers for clinical end points and disease activity. The use of mechanism-derived gene expression signatures in scleroderma will provide a better understanding of the deregulated pathways contributing to disease pathogenesis.
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239
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Goldin JG, Lynch DA, Strollo DC, Suh RD, Schraufnagel DE, Clements PJ, Elashoff RM, Furst DE, Vasunilashorn S, McNitt-Gray MF, Brown MS, Roth MD, Tashkin DP. High-resolution CT scan findings in patients with symptomatic scleroderma-related interstitial lung disease. Chest 2008; 134:358-367. [PMID: 18641099 DOI: 10.1378/chest.07-2444] [Citation(s) in RCA: 157] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Lung disease has become the leading cause of mortality and morbidity in scleroderma (SSc) patients. The frequency, nature, and progression of interstitial lung disease seen on high-resolution CT (HRCT) scans in patients with diffuse SSc (dcSSc) compared with those with limited SSc (lcSSc) has not been well characterized. METHODS Baseline HRCT scan images of 162 participants randomized into a National Institutes of Health-funded clinical trial were compared to clinical features, pulmonary function test measures, and BAL fluid cellularity. The extent and distribution of interstitial lung disease HRCT findings, including pure ground-glass opacity (pGGO), pulmonary fibrosis (PF), and honeycomb cysts (HCs), were recorded in the upper, middle, and lower lung zones on baseline and follow-up CT scan studies. RESULTS HRCT scan findings included 92.9% PF, 49.4% pGGO, and 37.2% HCs. There was a significantly higher incidence of HCs in the three zones in lcSSc patients compared to dcSSc patients (p = 0.034, p = 0.048, and p = 0.0007, respectively). The extent of PF seen on HRCT scans was significantly negatively correlated with FVC (r = - 0.22), diffusing capacity of the lung for carbon monoxide (r = - 0.44), and total lung capacity (r = - 0.36). A positive correlation was found between pGGO and the increased number of acute inflammatory cells found in BAL fluid (r = 0.28). In the placebo group, disease progression was assessed as 30% in the upper and middle lung zones, and 45% in the lower lung zones. No difference in the progression rate was seen between lcSSc and dcSSc patients. CONCLUSIONS PF and GGO were the most common HRCT scan findings in symptomatic SSc patients. HCs were seen in more than one third of cases, being more common in lcSSc vs dcSSc. There was no relationship between progression and baseline PF extent or lcSSc vs dcSSc. TRIAL REGISTRATION Clinicaltrials.gov Identifier: NCT00004563.
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Affiliation(s)
- Jonathan G Goldin
- Department of Radiological Sciences, University of California at Los Angeles, Los Angeles, CA.
| | - David A Lynch
- Department of Radiology, National Jewish Medical and Research Center, Denver, CO
| | - Diane C Strollo
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Robert D Suh
- Department of Radiological Sciences, University of California at Los Angeles, Los Angeles, CA
| | - Dean E Schraufnagel
- Department of Pulmonary, Critical Care and Sleep Medicine, University of Illinois at Chicago, Chicago, IL
| | - Philip J Clements
- Department of Rheumatology, University of California at Los Angeles, Los Angeles, CA
| | - Robert M Elashoff
- Department of Biomathematics, University of California at Los Angeles, Los Angeles, CA
| | - Daniel E Furst
- Department of Rheumatology, University of California at Los Angeles, Los Angeles, CA
| | | | - Michael F McNitt-Gray
- Department of Radiological Sciences, University of California at Los Angeles, Los Angeles, CA
| | - Mathew S Brown
- Department of Radiological Sciences, University of California at Los Angeles, Los Angeles, CA
| | - Michael D Roth
- Department of Pulmonary and Critical Care Medicine, University of California at Los Angeles, Los Angeles, CA
| | - Donald P Tashkin
- Department of Pulmonary and Critical Care Medicine, University of California at Los Angeles, Los Angeles, CA
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Woodhead F, Wells AU, Desai SR. Pulmonary complications of connective tissue diseases. Clin Chest Med 2008; 29:149-64, vii. [PMID: 18267189 DOI: 10.1016/j.ccm.2007.11.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Lung involvement is common in patients who have complications of connective tissue disease (CTDs) and causes considerable morbidity and mortality. High resolution CT (HRCT) has a pivotal role in the detection of lung fibrosis. In patients who have coexistent pathologic processes, HRCT often allows the predominant process to be identified. HRCT has an important role in detecting possible complications such as opportunistic infection or the development of malignancy. However, the limitations of HRCT should not be overlooked. In many cases, HRCT appearances are nonspecific and may or may not be related to an underlying CTD. Thus, radiologic findings should never be interpreted without knowledge of the clinical picture.
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Affiliation(s)
- Felix Woodhead
- Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
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241
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Khanna D, Furst DE, Clements PJ, Tashkin DP, Eckman MH. Oral cyclophosphamide for active scleroderma lung disease: a decision analysis. Med Decis Making 2008; 28:926-37. [PMID: 18443209 DOI: 10.1177/0272989x08317015] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Results from the recent Scleroderma Lung Study (SLS) show that oral cyclophosphamide (CYC) is better than placebo in preventing the progression of scleroderma-related interstitial lung disease (SSc-ILD) at 12 mo but is associated with adverse events. Also, the long-term balance of risk and benefit remains unclear. METHODS The authors evaluate the risk-benefit tradeoffs using a Markov decision analytic model to project the quality-adjusted life years (QALYs) for strategies of CYC versus no CYC in SSc-ILD. The base case examined a 50-y-old woman with SSc of 1.5 y, SSc-ILD with moderate ventilatory restriction. The authors analyze the decision to treat with 1 y of daily CYC versus no SSc-ILD-specific therapy. Based on 2-y data from the SLS, the authors assume CYC resulted in no survival benefit and only a transient beneficial impact on pulmonary function. They explore the impact of changes in model parameters through sensitivity analyses, including the efficacy of CYC in preventing progression of lung disease and SSc-ILD- related death. Results. In the base-case analysis, CYC-treated patients fared worse, with a small loss of 0.21 QALYs (16.84 v. 17.15). CYC remained inferior across sensitivity analyses for most variables. In analyses assuming a survival benefit with CYC, CYC resulted in a clinically significant gain (18.17 v. 17.15 QALYs). CONCLUSIONS CYC therapy for 1 y results in a small loss in QALYs compared with no CYC for SSc-ILD. The lack of a beneficial impact on survival and the transience of CYC's impact on decline in pulmonary function drive this conclusion.
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Affiliation(s)
- Dinesh Khanna
- Division of Rheumatology, School of Public Health, University of California at Los Angeles, Los Angeles, CA 90095, USA.
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242
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Fischer A, Swigris JJ, Groshong SD, Cool CD, Sahin H, Lynch DA, Curran-Everett D, Gillis JZ, Meehan RT, Brown KK. Clinically significant interstitial lung disease in limited scleroderma: histopathology, clinical features, and survival. Chest 2008; 134:601-605. [PMID: 18403656 DOI: 10.1378/chest.08-0053] [Citation(s) in RCA: 100] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
PURPOSES To evaluate the pathologic patterns, clinical features, and survival among subjects with scleroderma (ie, systemic sclerosis [SSc]) and clinically significant interstitial lung disease (ILD) evaluated at an ILD center. METHODS Retrospective cohort study of all SSc patients who had been referred for further evaluation of ILD and had undergone surgical lung biopsy. Clinical data were abstracted by review of the medical record, and lung biopsy specimens were reviewed and classified according to current pathologic criteria. RESULTS All patients presented with significant respiratory symptoms. Twenty-two of 27 subjects had surgical lung biopsy-proven ILD, and 5 subjects had miscellaneous non-ILD patterns. Of those subjects with ILD, 64% (14 of 22 subjects) had a nonspecific interstitial pneumonia (NSIP) pathologic pattern (fibrotic NSIP, 13 subjects; cellular NSIP, 1 subject), and 36% (8 of 22 subjects) had the usual interstitial pneumonia (UIP) pattern. Subjects with NSIP were younger (median age, 42 vs 58 years, respectively; p = 0.003), but no differences were noted in pulmonary physiology (FVC: NSIP group, 52% predicted; UIP group, 65% predicted; p = 0.22; diffusing capacity of the lung for carbon monoxide: NSIP group, 40% predicted; UIP group, 42% predicted; p = 1.0). All patients had limited skin involvement. The Scl-70 antibody was absent among those assessed (NSIP group, 0 of 10 subjects; UIP group, 0 of 7 subjects). All patients were treated with cytotoxic therapy. The median survival time for those with NSIP was 15.3 years (5,596 days) compared with 3 years (1,084 days) for those with UIP (p = 0.07 [log-rank test]). CONCLUSIONS In SSc patients with limited cutaneous disease and clinically significant ILD, fibrotic NSIP and UIP are the predominant pathologic patterns. Those with the UIP pattern of disease had a trend toward shorter survival time.
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Affiliation(s)
- Aryeh Fischer
- Autoimmune Lung Disease Center, National Jewish Medical and Research Center, Denver, CO.
| | - Jeffrey J Swigris
- Autoimmune Lung Disease Center, National Jewish Medical and Research Center, Denver, CO
| | - Steve D Groshong
- Department of Pathology, National Jewish Medical and Research Center, Denver, CO
| | - Carlyne D Cool
- Department of Pathology, National Jewish Medical and Research Center, Denver, CO
| | - Hakan Sahin
- Department of Radiology, National Jewish Medical and Research Center, Denver, CO
| | - David A Lynch
- Department of Radiology, National Jewish Medical and Research Center, Denver, CO
| | | | - JoAnn Z Gillis
- Department of Rheumatology, National Jewish Medical and Research Center, Denver, CO
| | - Richard T Meehan
- Department of Rheumatology, National Jewish Medical and Research Center, Denver, CO
| | - Kevin K Brown
- Autoimmune Lung Disease Center, National Jewish Medical and Research Center, Denver, CO
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243
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Goh NSL, Desai SR, Veeraraghavan S, Hansell DM, Copley SJ, Maher TM, Corte TJ, Sander CR, Ratoff J, Devaraj A, Bozovic G, Denton CP, Black CM, du Bois RM, Wells AU. Interstitial lung disease in systemic sclerosis: a simple staging system. Am J Respir Crit Care Med 2008; 177:1248-54. [PMID: 18369202 DOI: 10.1164/rccm.200706-877oc] [Citation(s) in RCA: 740] [Impact Index Per Article: 46.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
RATIONALE In interstitial lung disease complicating systemic sclerosis (SSc-ILD), the optimal prognostic use of baseline pulmonary function tests (PFTs) and high-resolution computed tomography (HRCT) is uncertain. OBJECTIVES To construct a readily applicable prognostic algorithm in SSc-ILD, integrating PFTs and HRCT. METHODS The prognostic value of baseline PFT and HRCT variables was quantified in patients with SSc-ILD (n = 215) against survival and serial PFT data. MEASUREMENTS AND MAIN RESULTS Increasingly extensive disease on HRCT was a powerful predictor of mortality (P < 0.0005), with an optimal extent threshold of 20%. In patients with HRCT extent of 10-30% (termed indeterminate disease), an FVC threshold of 70% was an adequate prognostic substitute. On the basis of these observations, SSc-ILD was staged as limited disease (minimal disease on HRCT or, in indeterminate cases, FVC >or= 70%) or extensive disease (severe disease on HRCT or, in indeterminate cases, FVC < 70%). This system (hazards ratio [HR], 3.46; 95% confidence interval [CI], 2.19-5.46; P < 0.0005) was more discriminatory than an HRCT threshold of 20% (HR, 2.48; 95% CI, 1.57-3.92; P < 0.0005) or an FVC threshold of 70% (HR, 2.11; 95% CI, 1.34-3.32; P = 0.001). The system was evaluated by four trainees and four practitioners, with minimal and severe disease on HRCT defined as clearly < 20% or clearly > 20%, respectively, and the use of an FVC threshold of 70% in indeterminate cases. The staging system was predictive of mortality for all scorers, with prognostic separation higher for practitioners (HR, 3.39-3.82) than trainees (HR, 1.87-2.60). CONCLUSIONS An easily applicable limited/extensive staging system for SSc-ILD, based on combined evaluation with HRCT and PFTs, provides discriminatory prognostic information.
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Affiliation(s)
- Nicole S L Goh
- Royal Brompton Hospital and National Heart and Lung Institute, London, United Kingdom
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Mouthon L, Berezné A, Brauner M, Kambouchner M, Guillevin L, Valeyre D. [Interstitial lung disease in systemic sclerosis]. Rev Mal Respir 2008; 24:1035-46. [PMID: 18033190 DOI: 10.1016/s0761-8425(07)92767-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Interstitial lung diseases (ILD) in systemic sclerosis (SSc) are mainly encountered in patients with diffuse disease although they may occur less frequently in patients with limited cutaneous disease. BACKGROUND In SSc early detection of ILD should be achieved by high resolution computed tomography and pulmonary function tests, including measurement of DLCO. In total up to 75% of patients with SSc develop ILD but it is progressive in only a minority of patients. Unlike idiopathic ILD, SSc associated ILD corresponds to non-specific interstitial pneumonia rather than usual interstitial pneumonia in the majority of cases. This explains the better prognosis of SSc associated ILD compared with idiopathic ILD. Nevertheless ILD represents one of the two main causes of death in SSc. VIEWPOINT The treatment of SSc associated ILD is not well established. Anti-fibrosing treatments have failed to demonstrate benefit and cyclophosphamide, which has been used for about 15 years in the treatment of this condition, has recently been evaluated in two prospective randomised studies which showed a significant but modest effect on respiratory function. CONCLUSION A subgroup of patients with rapidly progressive ILD might benefit from pulsed intravenous cyclophosphamide combined with prednisone 15 mg daily, but this remains to be confirmed.
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Affiliation(s)
- L Mouthon
- Service de Médecine Interne, Hôpital Cochin, Centre de Référence pour la sclérodermie systémique, Assistance Publique-Hôpitaux de Paris et Université Paris-Descartes, Faculté de Médecine Paris-Descartes, Paris, France.
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246
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Lung involvement in systemic connective tissue diseases. VOJNOSANIT PREGL 2008; 65:688-91. [DOI: 10.2298/vsp0809688p] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background/Aim. Systemic connective tissue diseases (SCTD) are chronic inflammatory autoimmune disorders of unknown cause that can involve different organs and systems. Their course and prognosis are different. All of them can, more or less, involve the respiratory system. The aim of this study was to find out the frequency of respiratory symptoms, lung function disorders, radiography and high-resolution computerized tomography (HRCT) abnormalities, and their correlation with the duration of the disease and the applied treatment. Methods. In 47 non-randomized consecutive patients standard chest radiography, HRCT, and lung function tests were done. Results. Hypoxemia was present in nine of the patients with respiratory symptoms (20%). In all of them chest radiography was normal. In five of these patients lung fibrosis was established using HRCT. Half of all the patients with SCTD had symptoms of lung involvement. Lung function tests disorders of various degrees were found in 40% of the patients. The outcome and the degree of lung function disorders were neither in correlation with the duration of SCTD nor with therapy used (p > 0.05 Spearmans Ro). Conclusion. Pulmonary fibrosis occurs in about 10% of the patients with SCTD, and possibly not due to the applied treatment regimens. Hypoxemia could be a sing of existing pulmonary fibrosis in the absence of disorders on standard chest radiography.
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Bérezné A, Valeyre D, Ranque B, Guillevin L, Mouthon L. Interstitial lung disease associated with systemic sclerosis: what is the evidence for efficacy of cyclophosphamide? Ann N Y Acad Sci 2007; 1110:271-84. [PMID: 17911442 DOI: 10.1196/annals.1423.029] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Interstitial lung disease (ILD) is a common manifestation of systemic sclerosis (SSc) that may be responsible for severe restrictive lung disease and represents one of the two main causes of disease-related death in SSc patients. Since 1993, the beneficial effect of oral or intravenous cyclophosphamide (CYC) in the treatment of SSc-related ILD has been reported in retrospective studies, one study showing improvement of pulmonary function test scores and/or chest computed tomography at 1 year and improvement of survival at 16 months. The results of two controlled trials were recently reported. The Scleroderma Lung Study, a prospective randomized placebo-controlled trial, included 158 patients of whom 145 completed at least 6 months of treatment. The course of forced vital capacity (primary outcome) adjusted at 1 year was significantly better in the group treated with oral CYC (P < 0.03), although the effect of CYC was minor. The Fibrosing Alveolitis in Scleroderma Trial (FAST) included 45 patients with SSc-related ILD who were randomized to receive prednisolone (20 mg per day) and 6 CYC infusions (600 mg/m monthly) or placebo. This trial did not demonstrate significant improvement of the primary or secondary endpoints in the active treatment group versus placebo. Since with the exception of the study of Silver et al. none of the patients included in retrospective or prospective studies were selected on the basis of progression of ILD. Since only a minority of SSc patients develops severe ILD, we propose that further studies evaluating CYC should focus on the subgroup of SSc patients with worsening ILD.
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Affiliation(s)
- Alice Bérezné
- Paris Descartes University, Faculty of Medicine, UPRES EA 4058, Department of Internal Medicine and Reference Center for Necrotizing Vasculitides and Systemic Sclerosis, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
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Gerbino AJ, Goss CH, Molitor JA. Effect of mycophenolate mofetil on pulmonary function in scleroderma-associated interstitial lung disease. Chest 2007; 133:455-60. [PMID: 18071023 DOI: 10.1378/chest.06-2861] [Citation(s) in RCA: 140] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVE We sought to determine the effectiveness of mycophenolate mofetil (MMF) in scleroderma- associated interstitial lung disease (SSc-ILD). METHODS We retrospectively identified patients who met criteria for systemic sclerosis, had evidence of SSc-ILD on chest CT, received > 1 g/d of MMF for >or= 6 months, and had pulmonary function data available. Vital capacity (VC) and diffusion capacity of the lung for carbon monoxide (Dlco) at treatment onset were compared with VC and Dlco values 12 months before and 12 months after treatment onset. Twelve-month values were imputed from regression lines generated using all VC and Dlco measurements made in the 24-month period either prior to or following treatment onset. RESULTS Among 13 patients who met inclusion criteria, MMF was associated with a significant improvement in VC (mean, + 159 mL; confidence interval [CI], + 30 to + 289 mL; and + 4% of the predicted normal value; CI, + 2 to + 7%) after 12 months of treatment. In contrast, patients had a significant decrease in VC (mean, - 239 mL; CI, - 477 to - 0.5 mL; and - 5% of the predicted normal value; CI, - 11 to - 0.3%) in the 12 months prior to MMF treatment. Dlco did not change significantly during MMF treatment (mean, + 1% of the predicted normal value; CI, - 2 to + 5%) but decreased significantly in the 12 months prior to treatment (mean, - 5% of the predicted normal value; CI, - 10 to - 1%). CONCLUSION These retrospective data suggest MMF improves VC in patients with SSc-ILD.
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Affiliation(s)
- Anthony J Gerbino
- Sections of Pulmonary/Critical Care Medicine, Virginia Mason Medical Center, 1100 Ninth Ave, Seattle, WA 98111, USA.
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Kaloudi O, Miniati I, Alari S, Matucci-Cerinic M. Interstitial lung disease in systemic sclerosis. Intern Emerg Med 2007; 2:250-5. [PMID: 18172592 DOI: 10.1007/s11739-007-0075-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2006] [Accepted: 04/16/2007] [Indexed: 10/22/2022]
Abstract
Lung involvement frequently complicates systemic sclerosis (SSc), provoking loss of quality of life and a poor expectation of survival. For this reason an early diagnosis of lung involvement is warranted: high-resolution computed tomography (HRCT), pulmonary function tests (PFT), lung scintigraphy with DTPA and bronchoalveolar lavage (BAL) are mandatory to define and follow-up pulmonary interstitium. Coughing and a sensation of breathlessness on exertion are the earliest symptoms of lung involvement. Lung involvement may be investigated with PFTs, which are non-invasive and require breathing into a tube via a mouthpiece. Forced vital capacity, which measures the total amount of air capable of being blown forcefully, and the diffusion capacity for carbon monoxide, a measure of how well oxygen diffuses into blood, are the most important functional measures. A routine chest X-ray may demonstrate fibrosis, but it is not very sensitive for detecting early or mild disease. For this reason, a HRCT scan is required. This non-invasive investigation provides images of multiple slices through the lung, from top (apex) to bottom (base), and can even detect lung involvement in early phases when no symptoms are present. (99m)T-DTPA is recommended in those patients with isolated diffusion deficits on lung function tests and in addition to HRCT in confirming the suspicion of vascular disease rather than early fibrosing alveolitis. Bronchoscopy with BAL is an invasive test that also may provide information about the inflammatory status of the affected areas of the lung detected during HRCT. In order to detect alveolitis, it should be performed as early as possible, to start prompt immunosuppressive treatment.
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Affiliation(s)
- O Kaloudi
- Department of Medicine & Surgery Div Medicine I & Rheumatology AOUC, University of Florence, Florence, Italy
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Matucci-Cerinic M, Steen VD, Furst DE, Seibold JR. Clinical trials in systemic sclerosis: lessons learned and outcomes. Arthritis Res Ther 2007; 9 Suppl 2:S7. [PMID: 17767745 PMCID: PMC2072887 DOI: 10.1186/ar2191] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The pathogenesis of systemic sclerosis (SSc) is complex and largely unclear. The clinical heterogeneity of the disease and its progression over a number of years makes the choice of endpoints in the design of clinical trials difficult. The overwhelming need in this disease is to diagnose it early and identify those patients who will benefit most from early, aggressive treatment that potentially can alter the clinical disease course. To achieve this, innumerable challenges must be overcome. This article reviews data from recent clinical trials and the lessons derived from retrospective observational studies, databases, and patient registries. Taken together, these observations will help to improve our understanding of the diverse clinical course of SSc and permit refinement of existing outcome measures for the design of future clinical trials, in which the likelihood of observing a positive treatment effect with the drugs at our disposal will be maximized.
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Affiliation(s)
- Marco Matucci-Cerinic
- Division of Medicine and Surgery, Division of Medicine I and Rheumatology, Villa Monna Tessa, Viale Pieraccini, I-50139 Florence, Italy.
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