Effectiveness and safety of rituximab for the treatment of refractory systemic sclerosis associated calcinosis: A case series and systematic review of the literature

Vascular, Soft Tissue, and Musculoskeletal Imaging in Systemic Sclerosis

This review examines the role of various imaging techniques in assessing vascular and musculoskeletal manifestations in Systemic Sclerosis (SSc). Imaging modalities, such as thermography, capillaroscopy, ultrasound, optical coherence tomography, laser speckle contrast analysis, radiography, computed tomography, and MRI, offer valuable insights into SSc-related complications. Findings suggest that these techniques aid in diagnosing conditions like Raynaud phenomenon, digital ulcers, calcinosis, acro-osteolysis, and hand contractures. However, each modality has its advantages and limitations, necessitating a multimodal approach for comprehensive evaluation and accurate diagnosis of SSc-related manifestations.

Treatment of Calcinosis in Dermatomyositis-Case Report and Review

Background/Objectives: Calcinosis cutis (CC) is a condition that may develop in the course of several autoimmune connective tissue diseases (ACTDs). Among these, the conditions most frequently associated with CC are systemic sclerosis (SSc) and dermatomyositis (DM). Despite both the prevalence and diversity of available treatment options, therapeutic recommendations remain not fully established due to a limited number of studies and lack of unambiguous evidence regarding their effectiveness. Case Presentation: We report two cases of patients with DM and concomitant massive cutaneous calcifications who were treated: in the case of a 71-year-old man with DM and past medical history of primary cutaneous T-cell lymphoma (CTCL) who received intralesional (IL) 25% sodium thiosulfate (STS) with platelet-rich plasma (PRP) injections, and, in the case of a second patient, 24-year-old woman with nephrolithiasis, who received intravenous immunoglobulin (IVIG) infusions at a dose of 2 g/kg in combination with prednisone at a dose of 5 mg/day. Conclusions: The applied treatment led to reduction in pain, size, and number of calcified lesions. Additionally, healing of fingertip ulcers after PRP injections was observed. While this report highlights only two isolated cases, the use of IVIG and STS with PRP injections appears to be an effective treatment method. Nevertheless, both standardization and additional research are required.

Treatment of calcinosis cutis associated with autoimmune connective tissue diseases

Calcinosis cutis is a condition that is commonly associated with autoimmune connective tissue diseases. It is characterized by the deposition of insoluble calcium salts in the skin and subcutaneous tissue, which can cause pain, impair function, and have significant impacts on quality of life. Calcinosis cutis is difficult to manage because there is no generally accepted treatment: evidence supporting treatments is mostly comprised of case reports and case series, sometimes yielding mixed findings. Both pharmacologic and procedural interventions have been proposed to improve calcinosis cutis, and each may be suited to different clinical scenarios. This review summarizes current treatment options for calcinosis cutis, with discussion of recommendations based on patient-specific factors and disease severity.

Calcinosis in systemic sclerosis: An update on pathogenesis, related complications, and management: A heavy burden still waiting to be lifted off patients' hands

In SSc, dystrophic calcinosis is one of the major clinical manifestations, characterized by the deposition of insoluble calcific substances in tissues, predominantly in the chemical form of calcium hydroxyapatite. Furthermore, calcinosis might lead to compressive neuropathies and severe pain. Current evidence suggests that tissue ischemia and repeated trauma are implicated in the development of calcinosis; however, there are still too many unknown areas that need to be investigated. Detection of calcinosis is commonly performed using X-ray or ultrasound. Moreover, quantification of calcinosis with X-ray and dual-energy computed tomography might be useful for the assessment of disease burden and monitoring of the disease. Despite its prevalence and clinical outcomes, there are no approved disease-modifying treatments for calcinosis in SSc. Debulking or surgical intervention might be preferred for calcinosis complicated with infection, compressive symptoms, or relief of pain. Therefore, innovative investigations and tailored therapeutic approaches are urgently needed to lift the burden of calcinosis from the hands of SSc patients.

Calcinosis in systemic sclerosis

PURPOSE OF REVIEW

To provide updated information on the prevalence, pathogenesis, diagnostics, and therapeutics of calcinosis cutis associated with systemic sclerosis (SSc).

RECENT FINDINGS

Observational studies show ethnic and geographical differences in the prevalence of calcinosis. In addition to clinical and serological associations, biochemical studies and in-vivo models have attempted to explain theories behind its pathogenesis, including prolonged state of inflammation, mechanical stress, hypoxia, and dysregulation in bone and phosphate metabolism. Long-term use of proton pump inhibitors may increase the risk for calcinosis in SSc. Few single center observational studies have shown mild benefit with minocycline and topical sodium thiosulfate.

SUMMARY

Calcinosis cutis is the deposition of insoluble calcium in the skin and subcutaneous tissues. It affects up to 40% of SSc patients and causes significant morbidity. Long disease duration, features of vascular dysfunction, and osteoporosis have been associated with calcinosis. Altered levels of inorganic pyrophosphate and fibroblast growth factor-23 have been implicated in dysregulated phosphate metabolism that may lead to calcinosis in SSc. Plain radiography can help with diagnosis and quantifying the calcinosis burden. Surgical treatment remains the most effective therapy when feasible. At present, no medical therapies have proven efficacy in large randomized controlled trials.

Review of an Anti-CD20 Monoclonal Antibody for the Treatment of Autoimmune Diseases of the Skin

Biologic therapies targeting B-cells are emerging as an effective strategy to treat a variety of immune-mediated diseases. One of the most studied B-cell-targeted therapies is rituximab, an anti-CD20 monoclonal antibody that exemplifies B-cell depletion therapy and has served as the prototype for other anti-CD20 monoclonal antibodies and the development of biosimilars. While there are multiple studies on the use of rituximab in dermatology, a comprehensive review of rituximab therapy in autoimmune skin conditions is lacking. In this literature review, we summarize indications, treatment efficacy, and safety of rituximab among common autoimmune diseases of the skin: pemphigus vulgaris, cutaneous lupus erythematous, dermatomyositis, systemic sclerosis, thyroid dermopathy, autoimmune pemphigoid diseases, and cutaneous vasculitis diseases. Existing data on rituximab support the approach of rituximab, biosimilars, and newer B-cell-targeting therapies in immune-mediated cutaneous diseases. Overall, rituximab, which targets CD20, provides an effective alternative or concomitant option to traditional immunosuppressants in the management of various autoimmune diseases of the skin. Further studies are necessary to expand the understanding and possible utility of B-cell-targeted therapies among autoimmune skin diseases.

Calcinosis in systemic sclerosis

PURPOSE OF REVIEW

The aim of this study was to provide updated information on the prevalence, pathogenesis, diagnostics and therapeutics of calcinosis cutis associated with systemic sclerosis (SSc).

RECENT FINDINGS

Observational studies show ethnic and geographical differences in the prevalence of calcinosis. In addition to clinical and serological associations, biochemical studies and in-vivo models have attempted to explain theories behind its pathogenesis, including prolonged state of inflammation, mechanical stress, hypoxia and dysregulation in bone and phosphate metabolism. Long-term use of proton pump inhibitors may increase the risk for calcinosis in SSc. Few single-centre observational studies have shown mild benefit with minocycline and topical sodium thiosulfate.

SUMMARY

Calcinosis cutis is the deposition of insoluble calcium in the skin and subcutaneous tissues. It affects up to 40% of SSc patients and causes significant morbidity. Long disease duration, features of vascular dysfunction and osteoporosis have been associated with calcinosis. Altered levels of inorganic pyrophosphate and fibroblast growth factor-23 have been implicated in dysregulated phosphate metabolism that may lead to calcinosis in SSc. Plain radiography can help with diagnosis and quantifying the calcinosis burden. Surgical treatment remains the most effective therapy when feasible. At present, no medical therapies have proven efficacy in large randomized controlled trials.

Subcutaneous calcinosis: Is it different between systemic sclerosis and dermatomyositis?

Calcinosis cutis is the deposition of insoluble calcium in the skin and subcutaneous tissues. It is a manifestation of several autoimmune connective tissue diseases, most frequently with systemic sclerosis and juvenile dermatomyositis, followed by adult dermatomyositis. Autoimmune connective tissue disease-associated calcinosis is of the dystrophic subtype, which occurs at sites of damaged tissue in the setting of normal serum calcium and phosphate levels. In juvenile dermatomyositis, calcinosis is considered a marker of ongoing disease activity and possibly inadequate treatment, while in adult dermatomyositis, it is a hallmark of skin damage due to chronic rather than active disease. Calcinosis is associated with long disease duration in systemic sclerosis and dermatomyositis, anti-polymyositis/sclerosis autoantibodies in systemic sclerosis and NXP-2 and melanoma differentiation-associated gene 5 in dermatomyositis. Calcinosis in systemic sclerosis occurs most frequently in the hands, particularly the fingers, whereas in dermatomyositis, it affects mainly the trunk and extremities. The primary mineral component of calcinosis is hydroxyapatite in systemic sclerosis and carbonate apatite in dermatomyositis. Calcinosis in dermatomyositis and systemic sclerosis share some pathogenic mechanisms, but vascular hypoxia seems to play a more important role in systemic sclerosis, whereas the release of calcium from mitochondria in muscle cells damaged by myopathy may be a primary mechanism contributing to dermatomyositis-related calcinosis. Multiple treatment strategies for dermatomyositis and systemic sclerosis-related calcinosis have been used with variable results. Early aggressive treatment of underlying myositis in patients with dermatomyositis may improve long-term outcomes of calcinosis. A better understanding of the pathogenesis of calcinosis is needed to improve treatment options.

Surgical Debulking for Symptomatic Management of Calcinosis Cutis of the Hand and Upper Extremity in Systemic Sclerosis

PURPOSE

To determine whether elective calcinosis debulking surgery of the hands and/or upper extremities is a safe and effective treatment for painful symptomatic scleroderma. Our hypothesis was that calcinosis debulking surgery would result in improvement in patient-reported pain and range of motion (ROM) with relatively little postoperative surgical pain for scleroderma patients.

METHODS

We performed a retrospective review of scleroderma patients who underwent elective calcinosis debulking surgery by a single surgeon between August 2014 and August 2019. Patients were included if they had a documented diagnosis of limited or diffuse scleroderma and underwent elective or nonemergent hand or upper-extremity calcinosis debulking surgery with a minimum final follow-up of 12 months. Primary outcomes measured were preoperative to final follow-up changes in visual analog scale pain scores. Secondary outcomes were changes in numbness and ROM as well as in daily opioid requirements, postoperative opioids used to control surgical pain, and complications.

RESULTS

Thirty-nine patients underwent calcinosis debulking surgeries on 41 upper extremities. Median final follow-up was 22 months (range, 13-60 months). Significant decreases occurred in visual analog pain scores (preoperative median, 5 [range, 0-10); final follow-up median, 0 [range, 0-8]) and improved patient-reported ROM in 15% (no change, 85%; worse, 0%). There was no significant preoperative to final follow-up difference in patient-reported numbness (improved, 5%; no change, 85%; and worse, 10%). Thirteen patients incurred 17 complications.

CONCLUSIONS

Elective calcinosis debulking surgery of the hands and/or upper extremities in scleroderma decreased pain scores, improved patient-reported ROM in 15% of patients, and had no effect on patient-reported numbness at final follow-up.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Autoimmunity in 2019

Based on the PubMed data, we have been performing a yearly evaluation of the publications related to autoimmune diseases and immunology to ascertain the relative weight of the former in the scientific literature. It is particularly intriguing to observe that despite the numerous new avenues of immune-related mechanisms, such as cancer immunotherapy, the proportion of immunology manuscripts related to autoimmunity continues to increase and has been approaching 20% in 2019. As in the previous 13 years, we performed an arbitrary selection of the peer-reviewed articles published by the major dedicated Journals and discussed the common themes which continue to outnumber peculiarites in autoimmune diseases. The investigated areas included systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), psoriatic arthritis (PsA), autoantibodies (autoAbs), and common therapeutic avenues and novel pathogenic mechanisms for autoimmune conditions. Some examples include new pathogenetic evidence which is well represented by IL21 or P2X7 receptor (P2X7R) in SLE or the application of single-cell RNA sequencing (scRNA-seq), mass cytometry, bulk RNA sequencing (RNA-seq), and flow cytometry for the analysis of different cellular populations in RA. Cumulatively and of interest to the clinicians, a large number of findings continue to underline the importance of a strict relationship between basic and clinical science to define new pathogenetic and therapeutic developments. The therapeutic pipeline in autoimmunity continues to grow and maintain a constant flow of new molecules, as well illustrated in RA and PsA, and this is most certainly derived from the new basic evidence and the high-throughput tools applied to autoimmune diseases.

Human mesenchymal stem cells for the management of systemic sclerosis. Systematic review

INTRODUCTION

Sistemic Sclerosis (SSc) is a heterogeneous autoimmune disease with a high rate of progression and therapeutic failure, and treatment is a challenge, new therapeutic proposals being needed, being mesenchymal stem cells (MSCs) considered as alternative therapy for SSc for its immunomodulatory capacity. We evaluated the efficacy and safety of human MSC (hMSC) in patients with SSc through a systematic literature review (SLR).

METHODS

SLR (PRISMA guideline) on MEDLINE/OVID, LILACS, EMBASE, and Cochrane/OVID bases (until July 2020, without limits). All types of clinical studies were considered: patients ≥18 years old with SSc and treatment with hMSC.

EXCLUSION CRITERIA

animal models, autologous/allogenic hematopoietic stem cell transplants, narrative reviews, letters to the editor. MeSH and "Key word" terms were used. The level of evidence and the quality rating were rated [Joanna Briggs Institute (JBI) lists]. Registration in PROSPERO repository (ID CRD42020185245) The Synthesis Without Meta-analysis (SWiM) guideline was followed.

RESULTS

We initially identified 508 articles, of which 11 were finally included (8 case series and 3 case reports). The 11 articles included 101 patients (85 female, age range 18-75 years). The level of evidence was mostly 4 (JBI); the quality of evidence was met (≥50% of JBI items). SWiM showed that vascular skin involvement (digital ulcers, necrosis, and gangrene) and associated pain were the predominant outcomes, while improvements were found in almost all cases. One patient died in the first month, and the frequency of complications was low. Expanded hMSCs were used in 24 patients and other cell sources in the remaining patients.

CONCLUSION

There is too little reported data to reach definite conclusions about the use of hMSC in SSc. Further studies with better epidemiological designs are needed to evaluate the benefit of hMSCs in SSc patients.

A narrative review of imaging in calcinosis associated with systemic sclerosis

Calcinosis is dystrophic calcification of the soft tissue which can lead to painful and debilitating disease. It is commonly seen in patients with systemic sclerosis (SSc). Imaging can assist in diagnosis, quantification of disease, and better pathophysiologic understanding of calcinosis. Traditionally, X-rays have been the most frequently used imaging modality for diagnosis; however, advances in ultrasound (US), computed tomography (CT), positron emission tomography (PET), and magnetic resonance imaging (MRI) have led to greater ability to characterize these lesions and surrounding structures. This narrative review aims to describe the use of imaging for calcinosis in patients with SSc. Key Points • Imaging is useful in the diagnosis of calcinosis, assessment of disease severity, and disease monitoring. • X-ray is commonly used and offers high sensitivity and specificity, but both ultrasound and CT-scans are alternatives when greater anatomic detail is sought regarding surrounding structures. • Investigational imaging modalities include dual energy CT-scans, cinematic rendering CT-scans, and PET- CT scans. • Conventional MRI scans have less sensitivity and specificity for detection of calcinosis.

A 3-Year Observational Study of Patients with Progressive Systemic Sclerosis Treated with an Intensified B Lymphocyte Depletion Protocol: Clinical and Immunological Response

BACKGROUND

B-cells have been suggested to play a role in the pathogenesis of systemic sclerosis (SSc), representing, therefore, a potential therapeutic target.

OBJECTIVES

We aimed at investigating the 36-month outcomes of 20 SSc patients who underwent an intensified B-depletion therapy (IBCDT) scheme, including both Rituximab (RTX) and cyclophosphamide (CYC).

METHODS

Data from 20 severe patients (18 females and 2 males, mean age 66.7 ± 11.0 years) with diffuse SSc (anti-topoisomerase I antibody in 95%) patients with multiorgan involvement including interstitial lung disease (ILD) treated with an IBCDT were prospectively collected. IBCDT comprehended: RTX 375 mg/m2 administered for four weekly doses (on days 1, 8, 15, and 22), followed by two additional doses after 30 and 60 days, in addition to two administrations of 10 mg/kg of intravenous CYC plus three methylprednisolone pulses (15 mg/kg) and subsequently followed by oral prednisone rapidly tapered to low minimum dosage of 5 mg daily. In addition, 10 patients with more severe functional respiratory impairment at baseline were also treated with RTX 500 mg every 4 months during the first year and two times a year during the second and the third year.

RESULTS

After 36 months of follow-up, we recorded significant amelioration in N-terminal-pro-brain natriuretic peptide (NT-proBNP) levels (mean 385.4 ± 517 pg/mL at baseline to 279 ± 543 after 36 months). In addition, a significant radiological improvement of ILD in 20% of patients (4/20) and a radiological stabilization with no sign of progression of interstitial involvement in 13/20 (65%) were documented. A total of 3 out of 20 (15%) patients experienced a worsening of the ILD. No patient showed further decrease in functional respiratory parameters, including forced vital capacity, forced expiratory volume in one second, and mean values of diffusing capacity for carbon monoxide Moreover, no patient showed any change in the ejection fraction and pulmonary artery pressure when comparing values at baseline and after 24 and 36 months of observation. No severe infection, renal flare, RTX-related side effects were observed. No patient died.

CONCLUSIONS

Our findings support that the IBCDT was well tolerated and might be a promising therapeutic option for the management of SSc, especially in those subjects with multiorgan involvement that includes ILD.

The impact of skin calcinosis on digital ulcers in patients with SSc: clinical and prognostic stratification using the "wound bed score"

Digital ulcers (DUs) represent one of the major burdens for patients with systemic sclerosis (SSc), especially when associated with skin calcinosis (SC). The aim of this work is to evaluate the impact of SC in DUs of patients with SSc for clinical characteristics and prognosis assessed by the wound bed score (WBS). We prospectively enrolled 55 patients with DUs and SSc followed in our dedicated wound care clinic. For all the patients we collected clinical and anthropometric data and characteristics of the DU, and we calculated the WBS for each DU. Ninety-nine DUs were evaluated (24 with SC). SC was prevalent in limited cutaneous SSc (75%) and in patients with longer disease duration (P = 0.02). SC-DUs were prevalent at the fingertip (P = 0.04). The healing time was significantly higher in patients with SC (10.4 ± 7.9 weeks) compared with non-SC (7.0 ± 5.7 weeks) P = 0.03. The WBS negatively correlated with the time to achieve complete healing (r = -0.237 P = 0.023) and the correlation was maintained in the non-SC (r = -0.46, P = 0.033). DUs in SSc patients with SC are common and difficult to heal. When DUs are treated in dedicated centres, the prognosis is good. The WBS is fast and easy and maybe commonly applied in clinical practice.

Is biological therapy in systemic sclerosis the answer?

Systemic sclerosis is a systemic fibrosing disorder associated with significant morbidity and mortality, with no universally accepted disease-modifying therapy. Significant advances in the understanding of systemic sclerosis in recent years have guided the exploration of biological drugs in systemic sclerosis. In this narrative review, we summarize the published literature on biologic therapies in systemic sclerosis. A double-blind randomized trial, and an open label trial of tocilizumab (which antagonizes the interleukin 6 receptor), identified potential benefits in skin and lung fibrosis in systemic sclerosis; however, these differences failed to attain statistical significance. Two open-label trials compared rituximab (which depletes B lymphocytes) to conventional treatment/ cyclophosphamide in systemic sclerosis-associated interstitial lung disease (ILD), and revealed significant improvements in lung functions and skin disease with rituximab. Significant observational data also support the use of rituximab in skin, lung, muscle and joint manifestations of systemic sclerosis. Abatacept (which blocks T lymphocyte activation) has demonstrated utility for skin and joint disease in systemic sclerosis; a recent clinical trial failed to demonstrate benefits in improving skin thickness compared to placebo. Agents targeting type I interferons, interleukin 17 pathway, CD19 and plasma cells hold promise in systemic sclerosis; however, high-quality evidence is lacking. The results of different ongoing clinical trials targeting B lymphocytes, T lymphocytes, various cytokines (interleukins 6, 17, 4, 13, IL-1α), platelet-derived growth factor receptor, proteasome, integrins or oncostatin M may help guide future therapeutic regimens with biological agents in systemic sclerosis.

Prognostic value of cardiopulmonary exercise testing in patients with systemic sclerosis

Background

Systemic sclerosis (SSc) is a severe rheumatic disease of the interstitial tissue, in which heart and lung involvement can lead to disease-specific mortality. Our study tests the hypothesis that in addition to established prognostic factors, cardiopulmonary exercise testing (CPET) parameters, particularly peak oxygen uptake (peakVO₂) and ventilation/carbon dioxide (VE/VCO₂)-slope, can predict survival in patients with SSc.

Subjects and methods

We retrospectively assessed 210 patients (80.9% female) in 6 centres over 10 years with pulmonary testing and CPET. Survival was analysed with Cox regression analysis (adjusted for age and gender) by age, comorbidity (Charlson-Index), body weight, body-mass index, extensive interstitial lung disease, pulmonary artery pressure (measured by echocardiography and invasively), and haemodynamic, pulmonary and CPET parameters.

Results

Five- and ten-year survival of SSc patients was 93.8 and 86.9%, respectively. There was no difference in survival between patients with diffuse (dcSSc) and limited cutaneous manifestation (lcSSc; p = 0.3). Pulmonary and CPET parameters were significantly impaired. Prognosis was worst for patients with pulmonary hypertension (p = 0.007), 6-min walking distance < 413 m (p = 0.003), peakVO₂ < 15.6 mL∙kg^− 1∙min^− 1, and VE/VCO₂-slope > 35. Age (hazard ratio HR = 1.23; 95% confidence interval CI: 1.14;1.41), VE/VCO₂-slope (HR = 0.9; CI 0.82;0.98), diffusion capacity (Krogh factor, HR = 0.92; CI 0.86;0.98), forced vital capacity (FVC, HR = 0.91; CI 0.86;0.96), and peakVO₂ (HR = 0.87; CI 0.81;0.94) were significantly linked to survival in multivariate analyses (Harrell’s C = 0.95).

Summary

This is the first large study with SSc patients that demonstrates the prognostic value of peakVO₂ < 15.6 mL∙kg^− 1∙min^− 1 (< 64.5% of predicted peakVO₂) and VE/VCO₂-slope > 35.