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Róbert L, Németh K, Marschalkó M, Holló P, Hidvégi B. Calcinosis Prevalence in Autoimmune Connective Tissue Diseases-A Retrospective Study. J Clin Med 2024; 13:3428. [PMID: 38929957 PMCID: PMC11204081 DOI: 10.3390/jcm13123428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 06/06/2024] [Accepted: 06/10/2024] [Indexed: 06/28/2024] Open
Abstract
Background/Objectives: Calcinosis cutis is the deposition of insoluble calcium salts, which may cause inflammation, ulceration, pain, and restricted joint mobility. It rarely develops in damaged tissues (dystrophic subtype), most frequently in autoimmune connective tissue diseases (CTDs), but there is very limited data on the prevalence. Also, therapy remains an unsolved issue. In this study, we aimed to collect data on the prevalence of calcinosis in CTD patients to highlight that it is a considerable problem. Methods: A retrospective study was conducted in our department to assess the epidemiology of dystrophic calcinosis in CTDs between January 2003 and January 2024. Results: A total of 839 CTD patients were identified, of whom 56 had calcinosis (6.67%). The mean age of the calcinosis patients at diagnosis of underlying CTD was 41.16 ± 19.47 years. The mean time interval from the onset of calcinosis was 5.96 ± 8.62 years. Systemic sclerosis was the most common CTD complicated by calcinosis (n = 22). Conclusions: Our results are comparable to those reported previously in the literature. Although calcinosis is rare in the overall population, it is a present and unsolved problem in CTD patients. Therefore, further studies are needed on the factors involved in the development and progression of calcinosis as well as its treatment.
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Affiliation(s)
| | | | | | | | - Bernadett Hidvégi
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, H-1085 Budapest, Hungary
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Avanoglu-Guler A, Campochiaro C, De Luca G, Hughes M, Tufan A, Green L, Del Galdo F, Matucci-Cerinic M, Dagna L. Calcinosis in systemic sclerosis: An update on pathogenesis, related complications, and management: A heavy burden still waiting to be lifted off patients' hands. Semin Arthritis Rheum 2024; 66:152431. [PMID: 38537324 DOI: 10.1016/j.semarthrit.2024.152431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 02/18/2024] [Accepted: 03/06/2024] [Indexed: 05/14/2024]
Abstract
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.
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Affiliation(s)
- Aslihan Avanoglu-Guler
- Department of Internal Medicine, Division of Rheumatology, Gazi University, Ankara, Turkey; Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Hospital, 20132 Milan, Italy; Vita-Salute San Raffaele University, 20132 Milan, Italy.
| | - Corrado Campochiaro
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Hospital, 20132 Milan, Italy; Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Giacomo De Luca
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Hospital, 20132 Milan, Italy; Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Michael Hughes
- Department of Rheumatology, Salford Care Organisation, Northern Care Alliance NHS Group, Salford, UK; Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester & Salford Royal NHS Foundation Trust, Manchester, UK
| | - Abdurrahman Tufan
- Department of Internal Medicine, Division of Rheumatology, Gazi University, Ankara, Turkey; Inflammatory Disease Section, National Human Genome Research Institute, Bethesda, Maryland, USA
| | - Lorraine Green
- Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), University of Leeds and Leeds Teaching Hospitals Trust, Leeds, UK
| | - Francesco Del Galdo
- Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), University of Leeds and Leeds Teaching Hospitals Trust, Leeds, UK
| | - Marco Matucci-Cerinic
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Hospital, 20132 Milan, Italy; Department of Experimental and Clinical Medicine, University of Florence, and Division of Rheumatology AOUC, Florence, Italy
| | - Lorenzo Dagna
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Hospital, 20132 Milan, Italy; Vita-Salute San Raffaele University, 20132 Milan, Italy
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Valenzuela A, Chung L. Subcutaneous calcinosis: Is it different between systemic sclerosis and dermatomyositis? JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2022; 7:7-23. [PMID: 35386947 PMCID: PMC8922676 DOI: 10.1177/23971983211053245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 09/27/2021] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Antonia Valenzuela
- Division of Clinical Immunology and Rheumatology, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Lorinda Chung
- Division of Immunology and Rheumatology, Stanford University School of Medicine, Palo Alto, CA, USA,Division of Immunology and Rheumatology, VA Palo Alto Health Care System, Palo Alto, CA, USA,Lorinda Chung, Division of Immunology and Rheumatology, Stanford University School of Medicine, 1000 Welch Rd Ste 203, MC 5755, Palo Alto, CA 94304, USA.
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Chandrasekaran AC, Fu Z, Kraniski R, Wilson FP, Teaw S, Cheng M, Wang A, Ren S, Omar IM, Hinchcliff ME. Computer vision applied to dual-energy computed tomography images for precise calcinosis cutis quantification in patients with systemic sclerosis. Arthritis Res Ther 2021; 23:6. [PMID: 33407814 PMCID: PMC7788847 DOI: 10.1186/s13075-020-02392-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 12/09/2020] [Indexed: 01/12/2023] Open
Abstract
Background Although treatments have been proposed for calcinosis cutis (CC) in patients with systemic sclerosis (SSc), a standardized and validated method for CC burden quantification is necessary to enable valid clinical trials. We tested the hypothesis that computer vision applied to dual-energy computed tomography (DECT) finger images is a useful approach for precise and accurate CC quantification in SSc patients. Methods De-identified 2-dimensional (2D) DECT images from SSc patients with clinically evident lesser finger CC lesions were obtained. An expert musculoskeletal radiologist confirmed accurate manual segmentation (subtraction) of the phalanges for each image as a gold standard, and a U-Net Convolutional Neural Network (CNN) computer vision model for segmentation of healthy phalanges was developed and tested. A validation study was performed in an independent dataset whereby two independent radiologists manually measured the longest length and perpendicular short axis of each lesion and then calculated an estimated area by assuming the lesion was elliptical using the formula long axis/2 × short axis/2 × π, and a computer scientist used a region growing technique to calculate the area of CC lesions. Spearman’s correlation coefficient, Lin’s concordance correlation coefficient with 95% confidence intervals (CI), and a Bland-Altman plot (Stata V 15.1, College Station, TX) were used to test for equivalence between the radiologists’ and the CNN algorithm-generated area estimates. Results Forty de-identified 2D DECT images from SSc patients with clinically evident finger CC lesions were obtained and divided into training (N = 30 with image rotation × 3 to expand the set to N = 120) and test sets (N = 10). In the training set, five hundred epochs (iterations) were required to train the CNN algorithm to segment phalanges from adjacent CC, and accurate segmentation was evaluated using the ten held-out images. To test model performance, CC lesional area estimates calculated by two independent radiologists and a computer scientist were compared (radiologist 1 vs. radiologist 2 and radiologist 1 vs. computer vision approach) using an independent test dataset comprised of 31 images (8 index finger and 23 other fingers). For the two radiologists’, and the radiologist vs. computer vision measurements, Spearman’s rho was 0.91 and 0.94, respectively, both p < 0.0001; Lin’s concordance correlation coefficient was 0.91 (95% CI 0.85–0.98, p < 0.001) and 0.95 (95% CI 0.91–0.99, p < 0.001); and Bland-Altman plots demonstrated a mean difference between radiologist vs. radiologist, and radiologist vs. computer vision area estimates of − 0.5 mm2 (95% limits of agreement − 10.0–9.0 mm2) and 1.7 mm2 (95% limits of agreement − 6.0–9.5 mm2, respectively. Conclusions We demonstrate that CNN quantification has a high degree of correlation with expert radiologist measurement of finger CC area measurements. Future work will include segmentation of 3-dimensional (3D) images for volumetric and density quantification, as well as validation in larger, independent cohorts.
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Affiliation(s)
- Anita C Chandrasekaran
- Yale School of Medicine, Section of Rheumatology, Allergy & Immunology, The Anlyan Center, 300 Cedar Street, PO BOX 208031, New Haven, CT, 06520, USA
| | - Zhicheng Fu
- Department of Computer Science, Illinois Institute of Technology, 10 W 31st St, Chicago, IL, 60616, USA.,Motorola Mobility LLC, 222 W Merchandise Mart Plaza #1800, Chicago, IL, 60654, USA
| | - Reid Kraniski
- Department of Radiology, Yale School of Medicine, 330 Cedar St, New Haven, CT, 06520, USA
| | - F Perry Wilson
- Clinical and Translational Research Accelerator, Department of Medicine, Yale School of Medicine, Temple Medical Center, 60 Temple Street Suite 6C, New Haven, CT, 06510, USA
| | - Shannon Teaw
- Yale School of Medicine, Section of Rheumatology, Allergy & Immunology, The Anlyan Center, 300 Cedar Street, PO BOX 208031, New Haven, CT, 06520, USA
| | - Michelle Cheng
- Yale School of Medicine, Section of Rheumatology, Allergy & Immunology, The Anlyan Center, 300 Cedar Street, PO BOX 208031, New Haven, CT, 06520, USA
| | - Annie Wang
- Department of Radiology, Yale School of Medicine, 330 Cedar St, New Haven, CT, 06520, USA
| | - Shangping Ren
- Department of Computer Science, Illinois Institute of Technology, 10 W 31st St, Chicago, IL, 60616, USA.,Department of Computer Science, San Diego State University, 5500 Campanile Drive, San Diego, CA, 92182, USA
| | - Imran M Omar
- Department of Radiology, Northwestern University Feinberg School of Medicine, 676 N St Clair St, Chicago, IL, 60611, USA
| | - Monique E Hinchcliff
- Yale School of Medicine, Section of Rheumatology, Allergy & Immunology, The Anlyan Center, 300 Cedar Street, PO BOX 208031, New Haven, CT, 06520, USA. .,Clinical and Translational Research Accelerator, Department of Medicine, Yale School of Medicine, Temple Medical Center, 60 Temple Street Suite 6C, New Haven, CT, 06510, USA. .,Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine, 240 E. Huron Street, Suite M-300, Chicago, IL, 60611, USA.
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