AB0441 PREDICTORS OF CLASI RESPONSE OVER TIME IN A MULTICENTRIC REAL LIFE COHORT OF SLE PATIENTS TREATED WITH BELIMUMAB

Background

Over 80% of patients affected with SLE experience skin involvement. The anti-BLyS drug belimumab was shown effective in ameliorating mucocutaneous SLE manifestations in clinical trials and real-life studies. Cutaneous response is quantified through the CLASI (cutaneous lupus erythematosus area and severity index). Clinically relevant improvements are defined as decreases of ≥50% (CLASI50) or 70% (CLASI70) from baseline values.

Objectives

To assess rates and predictors of CLASI50 and CLASI70 in the Berliss multicentric SLE cohort1 of patients treated with belimumab.

Methods

Baseline and ongoing features of patients with baseline active skin involvement (CLASI>0) were assessed in relationship to the chosen outcomes CLASI50 and CLASI70 at 24 and 52 weeks. A subanalysis on patients with CLASI≥5 was as well conducted. Logistic regression was employed to identify predictors of response.

Results

172 patients displayed skin involvement at baseline (CLASI>0). Of those, 124 displayed at least a 12-month-follow-up and were included in the analysis. Seventy-seven (62.1%) patients reached CLASI50 at 24 weeks and 91 (77.8%) at 52 weeks; 87 (70.2%) reached CLASI70 at 24 and 99 (79.8%) at 52 weeks. Baseline predictors of CLASI50 at 24 weeks were CLASI-damage (CLASI-d) (OR [95%CI], p; 0.79 [0.65-0.98] 0.03) and disease duration (0.93[0.86-0.99], 0.011). No baseline predictors of CLASI70 at 24 weeks emerged, however having achieved a CLASI50 response at 24 weeks portended CLASI50 and 70 response through week 52 (p<0.01, Table 1). In the subgroup of patients with CLASI≥5, longer disease and increased CLASI-d at baseline confirmed as negative predictors of CLASI50 at 24 weeks. In this subset, use of antimalarials and active smoking at baseline predicted CLASI70 at 24 weeks (Table 1).

Table 1.

Predictors of CLASI-A Response at Week 24 and 52 by Baseline CLASI-A at 50% and 70% Response Thresholds

TimepointOutcomeVariableOR[95%CI] pCLASI>024 weeksCLASI50CLASI-d0.79 [0.65-0.98] 0.030Disease duration0.93[0.86-0.99], 0.011CLASI70CLASI-d0.93 [0.74-1.16], 0.51Disease duration0.97 [0.97-1.02], 0.1852 weeksCLASI50CLASI50 at 24 weeks14.3[4.88-44.42], <0.001CLASI70CLASI50 at 24 weeks6.22 [2.00-19.34], 0.002CLASI≥524 weeksCLASI50CLASI-d0.72 [0.53-0.98], 0.037Disease duration0.93 [0.66-1.00], 0.071CLASI70Antimalarials6.61 [1.20-36.29] 0.032Smoking0.15 [0.03-0.83], 0.03452 weeksCLASI50CLASI50 at 24 weeks22.0 [2.47-196.05], 0.006CLASI70CLASI50 at 24 weeks1.24 [0.06-25.08], 0.88

CLASI, cutaneous lupus erythematosus area and severity index; CLASI-d, CLASI damage; CLASI50 and CLASI70: decrease ≥50% or ≥70% in CLASI from baseline. OR and 95%CIs are estimated using a logistic regression model with stratification factors as covariates (SLEDAI-2K at baseline, baseline prednisone dosage).

Conclusion

Earlier use of belimumab favors achievement of skin response among SLE patients and attainment of a prompt response predicts further response. Use of antimalarials reinforces while smoking hampers a more profound CLASI improvement over time.

References:

[1]Gatto M, et al. Arthritis Rheumatol. 2020 Aug;72(8):1314-1324

Disclosure of Interests

Mariele Gatto Speakers bureau: GSK, Grant/research support from: GSK, Roberto Depascale: None declared, Angela Tincani: None declared, Giacomo Emmi: None declared, Salvatore Scarpato: None declared, Fabrizio Conti: None declared, Marcello Govoni: None declared, Marta Mosca: None declared, Maria Gerosa: None declared, Enrica Bozzolo: None declared, Valentina Canti: None declared, Armando Gabrielli: None declared, Elisa Gremese: None declared, Salvatore De Vita: None declared, francesco ciccia: None declared, Carlo Salvarani: None declared, Maurizio Rossini: None declared, Paola Faggioli: None declared, Antonella Laria: None declared, Amato De Paulis: None declared, Roberto Gerli: None declared, Enrico Brunetta: None declared, Alessandro Mathieu: None declared, Carlo Selmi: None declared, Rossella De Angelis: None declared, Simone Negrini: None declared, Margherita Zen: None declared, Andrea Doria Speakers bureau: GSK, Eli Lilly, Roche, Grant/research support from: GSK, Luca Iaccarino Speakers bureau: GSK, Grant/research support from: GSK

POS0721 ASSOCIATION BETWEEN PRECONCEPTION COMPLEMENT LEVELS AND USE OF HYDROXYCHLOROQUINE WITH PREGNANCY OUTCOME IN PATIENTS WITH PRIMARY ANTIPHOSPHOLIPID SYNDROME AND CARRIERS OF ANTIPHOSPHOLIPID ANTIBODIES: AN INTERNATIONAL MULTICENTER STUDY

Background

Antiphospholipid Syndrome (APS) is a rare autoimmune disease characterized by thrombotic events and/or pregnancy morbidities in the presence of confirmed positivity for antiphospholipid antibodies (aPL). Complement was demonstrated to be involved in aPL-related pregnancy loss in animal models and several groups investigated the significance of complement levels in human disease. C3 and C4 serum levels were assessed in several cohorts of pregnant patients with APS and/or aPL positivity in order to relate complement consumption with adverse pregnancy outcome (APO).

According to some authors, hydroxychloroquine (HCQ) can control the activation of the complement system, improve pregnancy outcome and reduce aPL title.

Objectives

This study was designed to verify the effect of HCQ in addition to low dose aspirin (LDA) + low molecular weight heparin (LMWH) treatment in a multicenter cohort of primary APS (PAPS) and aPL carriers pregnant women and the possible correlation with preconception serum C3/C4 levels.

Methods

Medical records of pregnant women with confirmed positivity for aPL antibodies attending twelve referral centers from January 2010 to December 2020 were retrospectively evaluated. We considered as aPL-related APO: spontaneous abortions (<10 weeks of gestation), fetal loss (≥10 weeks of gestation), neonatal death (death of a formed fetus alive at birth in the first 28 days of life), preterm delivery before 37 weeks of gestation, preeclampsia, eclampsia or HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet).

Results

We have analyzed 164 singleton PAPS/aPL carrier pregnancies (22 aPL carriers - 13%) in 128 patients: all were treated with combination therapy (LDA+LMWH), and in 30 HCQ was added. 58 pregnancies (43%) had low levels of preconception C3/C4. A triple aPL positivity was observed in 54 pregnancies, 14 of them were treated with combination therapy + HCQ. When considering the whole cohort, the addition of HCQ had not significantly improved the gestational outcome. Further stratification was performed on the basis of complement consumption. In the group of patients with preconception low C3/C4 levels the addition of HCQ had not significantly improved pregnancy outcome. We have lastly evaluated 40 pregnancies with a high-risk profile (triple aPL positivity and complement consumption), in which we have found that HCQ significantly improved gestational outcome (p=0.018, Table 1).

Table 1.

Relationship between APO, therapy during pregnancy and risk profile.

All pregnancies (n=164)Reduced C3/C4 (n=58)Triple aPL+ and reduced C3/C4 (n=40)LDA+LMWH (n, %)LDA+LMWH+HCQ (n, %)pLDA+LMWH (n, %)LDA+LMWH+HCQpLDA+LMWHLDA+LMWH+HCQp(n, %)(n, %)(n, %)APO62 (46%)16 (53%)ns32 (68%)4 (36%)ns23 (77%)3 (30%)0.018No APO72 (54%)14 (47%)15 (32%)7 (64%)7 (23%)7 (70%)Total1343047113010

This observation could not be confirmed in patients with single or double aPL positivity.

Conclusion

The study shows that administering HCQ in addition to combination therapy can improve gestational outcome in aPL/PAPS high-risk patients. This observation confirms that HCQ exerts a beneficial effect on aPL pregnancies by complement inhibition as it was shown in animal models. In addition, our results provide the clinicians a useful tool to implement conventional treatment in patients at high risk of pregnancy complication or loss.

References

[1]De Carolis S, et al. Is there any role for the hydroxychloroquine (HCQ) in refractory obstetrical antiphospholipid syndrome (APS) treatment? Autoimmun Rev 2015;14:760-2.

[2]Mekinian A, et al. The efficacy of hydroxychloroquine for obstetrical outcome in antiphospholipid syndrome: data from a European multicenter retrospective study. Autoimmun Rev 2015;40:498-502.

[3]Mekinian A et al. Obstetrical APS: is there a place for hydroxychloroquine to improve the pregnancy outcome? Autoimmun Rev 2015;14:23-9.

Disclosure of Interests

None declared

POS1236 THE IMPACT OF ANTI-SARS-COV-2 VACCINES IN A MULTICENTER COHORT STUDY OF PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS

Background

Vulnerable subjects, including systemic lupus erythematosus (SLE) patients have been prioritised to receive anti-SARS-CoV-2 vaccine. Questions have been raised about the effect of vaccines on immunity and their potential role as trigger for flare. Few data about the safety of these vaccines in SLE are available

Objectives

To investigate the safety of different anti-SARS-CoV-2 vaccines in SLE

Methods

Data on SLE patients who have received anti-SARS-CoV-2 vaccine (from 12/2020 to 10/2021) were collected. Patients referred to 7 SLE tertiary centres (Lupus Clinic, ASST Pini-CTO, Milan; Nephrology Unit of Ospedale Giovanni Bosco, Turin; IRCCS Humanitas Research Hospital; Renal and Rheumatology Units, San Gerardo Hospital, Monza; ASST Spedali Civili Brescia; Lupus Clinic IRCCS Ospedale S. Raffaele, Milan, Italy; IRCCS Policlinico, Milan)

Results

452 SLE patients who had received anti-SARS-CoV-2 vaccines were included (91% BNT162b2 mRNA, 8% mRNA-1273, 1% ChAdOx1-S). 12 (3%) were off therapy, 71% were on low-medium dose prednisone, 83% on anti-malarials, 50% were treated with an immunosuppressant. 9 patients transiently discontinued therapy. 119 (26%) reported adverse symptoms after the first/second shot (12% and 21%) The most frequent were fever, local reaction, fatigue and arthralgias. Nineteen (4%) patients flared up after immunisation with a 7 days median time to relapse. Baseline demographics, SLE characteristics and therapy stratified by adverse events and disease flare are reported in Table 1. Anti-dsDNA positivity, moderate/high DAS before vaccine and use of Belimumab were significantly more frequent in the group of patients flared. These patients displayed a significantly higher rate of adverse events after vaccination. Flares consisted mainly musculoskeletal and constitutional manifestations (32%), involvement of renal (21%), cardio-respiratory (16%), hematological (16%) or mucocutaneous domains (10%) was less frequent

Table 1.

distribution of demographic and SLE characteristics according to sides effects and disease flares after vaccination

Side effects (n=119)No side effects (n=333)p-value (<0.05)Disease flare (n=19)No disease flare (n=430)p-value (<0.05)Age, years, median (IQR)46 (33.5-54)48 (35.7-57)0.1852 (39.5-56.0)48 (35.0-56.9)0.849Disease duration, months, median (IQR)138 (76-262)126 (73-193)0.30144 (122-242)127 (73-195)0.249MSK, %84.984.41.0078.984.80.514Mucocutaneus, %71.462.80.09457.964.50.624Renal, %42.052.30.06952.649.40.819NPSLE, %13.490.2155.310.40.708Cardiopulmonary %22.719.80.51026.320.30.562Hematological, %32.8331.0042.132.60.455Constitutional symptoms %48.7300.0003*26.335.30.473Gastrointestinal %4.23.30.7725.33.50.503Ophthalmic %0.83.30.19702.81.00Secondary APS %10.910.50.8645.310.90.708aPL positivity %26.233.60.13726.331.90.802Anti-dsDNA positivity %30.727.40.54555.627.10.0142*ESR, mm/h, median (IQR)14 (7-19)13 (7-22)0.73019 (10-24)13 (7-21)0.125CRP, mg/dL, median (IQR)0.5 (0.1-0.5)0.5 (0.3-0.6)0.3120.42 (0.13-0.50)0.50 (0.30-0.5)0.464Urinary abnormalities, %9.221.90.002321.118.50.764Moderate or high DAS before vaccine, %169.30.06026.310.40.0474*No therapy before vaccine, %03.60.0419*02.81.00At least 1 immunosuppressant, %6346.80.0027*73.750.10.059Mycophenolate, %31.923.10.06642.124.70.106Methotrexate, %5.96.61.005.36.51.00Belimumab, %21.813.50.0396*36.814.80.0184*Rituximab ever, %11.813.50.7515.313.40.490Prednisone, %74.8700.34778.970.90.607

Conclusion

our reassuring data confirm that anti-SARS-CoV-2 vaccine is safe in SLE patients and should be recommended in this clinical setting, as potential benefits widely outweigh the risk of adverse events. Treatment adjustment might be considered with the aim of minimizing the risk of side effects and/or flare, while ensuring a satisfying protection against infection

References

[1]Tang W et al. The Use of COVID-19 Vaccines in Patients with SLE. Curr Rheumatol Rep. 2021 12;23:79.

Disclosure of Interests

None declared

POS0741 REPORT FROM THE APS STUDY GROUP OF THE ITALIAN SOCIETY FOR RHEUMATOLOGY (SIR-APS) ON aPL NEGATIVIZATION

Background

The rate of antiphospholipid antibodies (aPL)negativization in antiphospholipid syndrome (APS) patients is uncertain, but it is estimated to be as high as 8%. aPL disappearance seems to be more frequent in patients positive for one single aPL test and appears to be related with the immunosuppressant/immunomodulatory treatment undertaken by the patient. Currently, a consensus definition of aPL negativization is lacking, as well as international recommendations on how to approach treatment in patients with a persistent aPL negative seroconversion.

Objectives

The aim of our work was to evaluate the clinical approach and the level of consensus among experts from the APS Study Group of the Italian Society for Rheumatology (SIR-APS) in different clinical scenario addressing aPL negativization and its definition.

Methods

Experts of SIR-APS were contacted using a survey methodology.

Results

A structured survey was circulated among 30 experts.Up to 90% of the interviewed experts agreed on defining aPL negativization as the presence of two negative determinations, one year apart (90%).Almost ful lconsensus exist among experts in some clinical settings, including: a) the role of aPL negativitation in the management of a thrombotic event determined by concomitant presence of cardiovascular risk factors, both modifiable and not modifiable (90%): b) approach to young patients with triple aPL positivity who experienced pulmonary arterial thrombotic event and tested negative for aPL detection after five year of vitamin K antagonist (VKA) treatment (90%); c)the use of “extra criteria” aPL antibodies testing before pondering VKA suspension (93%).

Conclusion

Consensus is needed to support the management of patients with APS in areas where controlled data are missing. A substantial agreement exists among expert in defying aPL negativization as the presence of two negative determinations, one year apart. On the contrary, VKA suspension should be embraced with extreme caution when it comes to APS patients, particularly if they experienced arterial thrombotic events and/or tested positive for triple aPL. Nevertheless, VKA cessation might be considered when risk factors are carefully monitored/treated and the presence for “extra criteria” aPL is ruled out.

References

[1]Miyakis S, Lockshin MD, Atsumi T, Branch DW, Brey RL, Cervera R, Derksen RHWM, DE, Groot PG, Koike T, Meroni PL, Reber G, Shoenfeld Y, Tincani A, Vlachoyiannopoulos PG, Krilis SA. International consensus statement on an update of the classification criteria for definite antiphospholipid syndrome (APS). J Thromb Haemost 2006; 4: 295–306.

[2]Coloma Bazán E, Donate López C, Moreno Lozano P, Cervera R, Espinosa G.

Discontinuation of anticoagulation or antiaggregation treatment may be safe in patients with primary antiphospholipid syndrome when antiphospholipid antibodies became persistently negative. Immunol Res Immunol Res; 2013; 56: 358–61.

[3]Radin M, Schreiber K, Sciascia S, Roccatello D, Cecchi I, Aguirre Zamorano MÁ, Cuadrado MJ. Prevalence of Antiphospholipid Antibodies Negativisation in Patients with Antiphospholipid Syndrome: A Long-Term Follow-Up Multicentre Study. Thromb Haemost 2019; 119: 1920–6.

Acknowledgements

Italian Society of Rheumatology

Disclosure of Interests

None declared

POS0462 HYDROXYCHLOROQUINE REDUCES THE TITERS OF ANTI-DOMAIN 1 ANTIBODIES OVER TIME IN PATIENTS WITH PERSISTENTLY POSITIVE ANTIPHOSPHOLIPID ANTIBODIES: RESULTS FROM THE APS ACTION CLINICAL DATABASE AND REPOSITORY (“REGISTRY”)

Background

Data on fluctuation of antibodies directed against domain 1 (anti-D1) of β2-glycoprotein I (β2GPI) are scarce. Patients with antiphospholipid syndrome (APS) and all three criteria tests for antiphospholipid antibodies (aPL) display higher titers of anti-D1, which correlate with anti-β2GPI levels.

Objectives

This project aims at evaluating predictors of the variation of anti-D1 titers over time in a large international cohort of persistently aPL positive patients.

Methods

AntiPhospholipid Syndrome Alliance For Clinical Trials and InternatiOnal Networking (APS ACTION) Registry was created to study the course of persistently aPL-positive patients with or without autoimmune disorders over at least 10 years. Inclusion criteria are positive aPL by Updated Sapporo Criteria tested within one year prior to enrolment. Patients are followed every 12±3 months with clinical data and blood collection. Patients with available blood samples from at least three time points were included in this analysis. Anti-β2GPI and anti-D1 IgG were tested by chemiluminescence (BioFlash, Werfen) at APS ACTION core laboratories. Positive results were defined as >20 CU, according to the manufacturer. Clinical data were retrieved from APS ACTION online database. Anti-D1 titers within the same subject were compared by Friedman’s test. A mixed linear model was built to identify predictors of the fluctuation of anti-D1 antibody titers over time.

Results

In this longitudinal study, 230 patients with anti-D1 tested at 4 time points were included (Table 1). Patients with thrombotic APS had anti-D1 titers significantly higher than those without thrombosis (p=0.022). Among 135 patients with at least one anti-D1 positive result, anti-D1 titers varied significantly over time (Friedman statistics: 508.5, p<0.0001; anti-D1 geometric mean at baseline 189.0; T1 132.3 [-15%]; T2 113.8 [-17%]; T3 109.2 [-6% versus T2, -38% versus T1]). Anti-D1 titers were significantly higher at baseline compared to T3 (p=0.029). In the 4 years of follow-up, 18 new thrombotic events occurred. Patients with double/triple aPL positivity displayed 12.5 fold increase [95%CI 7.4-20.0] in baseline anti-D1 titers. After adjustment for age, gender and number of positive aPL tests, the fluctuation of anti-D1 titers was associated with treatment with hydroxychloroquine (HCQ) at each time-point. In particular, treatment with HCQ, but not those with conventional immunosuppressors, was associated with a 1.3-fold decrease in anti-D1 titers [95%CI 1.1-1.5]. In the same multivariable model, incident vascular events were associated with a 1.5 fold increase of anti-D1 titers. A concomitant diagnosis of systemic lupus erythematosus did not affect the fluctuation of anti-D1 titers.

Table 1.

Demographic and Clinical Characteristics of 230 APS ACTION Registry Patients with anti-D1 tested ≥3 time points during the follow-up

Anti-D1 pos samplesAnti-D1 neg samplesp-valueOverall sample(n=135)(n=95)(n=230)Age [years] mean (SD)42.3 (11.8)48.8 (13.0)0.000145.0 (12.7)%Female (n)71.9 (97)65.3 (62)0.35869.1 (159)Associated systemic autoimmune disease39.3 (53)44.2 (42)0.53941.3 (95)aPL without APS19.3 (26)34.7 (33)0.01025.7 (59)Thrombotic APS54.1 (73)53.7 (51)53.9 (124)Obstetric APS11.9 (16)5.3 (5)9.1 (21)Thrombotic/+obstetric APS14.8 (20)6.3 (6)11.3 (26)aCL IgG89.5 (119/133)25.5 (24/94)<0.000163.0 (143/227)aCL, IgM36.1 (48/133)27.7 (26/94)0.23432.6 (74/227)Anti-2GPI, IgG93.2 (124/133)39.4 (37/94)<0.000170.9 (161/227)Anti-2GPI, IgM34.6 (46/133)21.3 (20/94)0.04329.1 (66/227)LA82.8 (82/99)59.5 (44/74)0.00172.8 (126/173)

Conclusion

Treatment with HCQ and vascular events during follow-up were identified as significant predictors of the fluctuation of anti-D1 antibody titers over time.

Disclosure of Interests

None declared.

OP0125 THE MANAGEMENT OF PREGNANCY IN AUTOIMMUNE RHEUMATIC DISEASES: ANALYSIS OF 758 PREGNANCIES FROM THE PROSPECTIVE NATIONWIDE P-RHEUM.IT STUDY (THE ITALIAN REGISTRY OF PREGNANCY IN THE RHEUMATIC DISEASES)

Background

Pregnancy is a topic of fundamental importance for women living with autoimmune rheumatic diseases (ARD). Efforts at national and international levels have been put in the collection and harmonization of data in order to implement an evidence-based management of pregnant patients.

Objectives

The P-RHEUM.it study was designed as a nationwide, web-based longitudinal observational cohort study to collect data about pregnancy in ARD in 26 centers in Italy. The study started in May 2018 and has been supported by the Italian Society for Rheumatology.

Methods

Pregnant patients with a definite rheumatic disease according international criteria were enrolled up to gestational week (GW) 20. The course of maternal disease activity, the use of medications, fetal and maternal complications, and the quality of life (EuroQoL questionnaire) were collected for each trimester, as well as pregnancy outcome, mode of delivery, neonatal complications, and maternal and children’s follow-up to 6 months after delivery, including the screening for post-partum depression by means of EPDS (Edinburgh Postnatal Depression Scale).

Results

As of December 2021, 758 pregnancies had been enrolled, 205 (27%) ongoing and 553 (73%) with outcome. Pregnancy loss occurred in 54 (9.8%) cases (40 spontaneous miscarriages; 6 voluntary terminations). Live births were 495 (89.5%), perinatal death occurred in 4 (0.7%) cases. Table 1 reports on the group of 495 live births, along with subgroups of Rheumatoid Arthritis (RA) and Systemic Lupus Erythematosus (SLE), the two most represented diseases. Regarding treatments, 166 (30%) pregnancies were exposed to corticosteroids, 239 (43%) to hydroxychloroquine, 59 (10.7%) to csDMARDs, 84 (15.2%) to TNF inhibitors, 1 (0.2%) to non-TNFi bDMARDs, 299 (54%) to low dose acetylsalicylic acid, and 126 (22.8%) to heparin.

Table 1.PREGNANCIES WITH LIVE BIRTHS, EXCLUDING PERINATAL DEATHSTotal pregnancies (n=495)RA pregnancies (n=69)SLE pregnancies (n=93)Age at conception (years)34 (31 - 37)34.5 (32 - 38)34 (31 - 36)Disease duration (years)6.1 (2.2 - 11.1)7.1 (4.3 - 11.6)9.3 (5.9 - 15.9)Caucasian431 (87.8%)53 (79.1%)75 (80.6%)Never smokers358 (73.8%)53 (80.3%)66 (71.7%)Body Mass Index >3045 (9.5%)7 (10.3%)5 (5.6%)Arterial Hypertension6 (1.2%)0 (0%)2 (2.2%)Time to pregnancy (months)3 (1 - 6)3 (1 - 6)3 (0 - 10)Physician-reported flares in the 12 months prior to conception107 (23%)22 (34.4%)13 (14.8%)Physician global assessment at enrolment (VAS 0-100)5 (0 - 17)5 (0 - 20)4 (0 - 10)Patient global health at enrolment (VAS 0-100)18 (7 - 30)10 (5 - 29)10 (5 - 25)EuroQoL at enrolment (-1.6 – 1)1 (0.8 - 1)1 (0.8 - 1)1 (0.8 - 1)Flares during pregnancy35 (7.1%)6 (8.7%)7 (7.5%)Hypertensive disturbances*8 (1.7%)1 (1.6%)6 (6.6%)Delivery at term (≥37 GW)410 (85.1%)53 (77.9%)74 (80.4%)Spontaneous vaginal delivery173 (35.9%)23 (33.8%)23 (25.3%)Congenital malformations11 (2.4%)2 (3.1%)1 (1.1%)Small for gestational age (SGA) neonate24 (4.9%)1 (1.4%)9 (9.9%)Breastfeeding in the first 4 weeks after delivery341 (79.7%)45 (77.6%)59 (76.6%)EPDS score at risk for post-partum depression22 (14.1%)0 (0%)3 (10.3%)

Continuous variables are expressed as median (interquartile range); *gestational hypertension/preeclampsia/HELLP syndrome/eclampsia.

Conclusion

Multiple factors may have contributed to the high rate of live births, including good disease control before and during pregnancy thanks to the use of anti-rheumatic drugs and low frequency of general risk factors. SLE pregnancy was affected by a higher frequency of complications (hypertensive disturbances, SGA babies) as compared to RA pregnancy. Nearly 80% of patients breastfed in the first month after delivery. For the first time, data about the screening questionnaire for post-partum depression were collected, showing at least 1 out 10 patients can be at risk.

References

[1]Meissner Y et al. Arthritis Res Ther;21(1):241; Ann Rheum Dis. 2021;80(1):49-56.

Acknowledgements

P-RHEUM.it study is supported by the Italian Society for Rheumatology (SIR). All the Investigators are acknowledged for their contribution.

Disclosure of Interests

None declared

POS0737 LOW PRECONCEPTIONAL COMPLEMENT LEVEL IS RELATED WITH ADVERSE OBSTETRIC OUTCOME IN A MULTICENTRIC COHORT OF PREGNANCY IN PATIENTS WITH APS AND APL POSITIVITY

Background:

The role of complement in the antiphospholipid (aPL) related pathology has been widely studied in animal models. Antiphospholipid antibodies can induce fetal loss in experimental animals but mice deficient in specific complement components (C4, C3, C5) appear somehow protected. In addition, in pregnant mice injected with aPL, antibody deposition has been found at decidual level causing focal necrosis, apoptosis and neutrophil infiltrates and supporting aPL pathogenetic potential. On the other hand, human studies did find hypocomplementemia associated to pregnancy complications in patients with obstetric antiphospholipid syndrome (APS). These results, however, are not unanimously confirmed and, in addition, some studies only show increased levels of complement activation products (i.e. Bb) and not decreased levels of C3 and/or C4. A recently study focusing on complement level in early pregnancy and before pregnancy showed a significant correlation with pregnancy complications and loss in a large cohort of primary APS.

Objectives:

To investigate if the simple detection of low C3 and/or C4 could be considered a risk factor for adverse pregnancy outcome in APS and aPL carriers pregnancies.

Methods:

We performed a multicentric study including patients from 10 Italian and 1 Russian Centers. Data on pregnancies in women with primary APS (n=434) and asymptomatic carriers with persistently positive aPL but not fulfilling clinical criteria for APS (n=218) were retrospectively collected. Serum C3 and C4 levels were evaluated by nephelometry; hypocomplementemia was defined by local laboratory reference values. Statistical analysis was performed using GraphPad.

Results:

Preconceptional complement levels and gestational outcome were available for 107 (25%) pregnancies in APS out of 434 and for 196 (90%) pregnancies in aPL carriers women out of 218. In pregnancies with low preconceptional C3 and/or C4, a significantly higher prevalence of pregnancy losses was observed (p=0.019). A subgroup analysis focusing on triple aPL positive patients was also performed. Preconceptional low C3 and/or C4 levels were found to be associated with an increased rate of pregnancy loss (p = 0.027) in this subgroup also. Otherwise, adverse pregnancy outcomes in single or double aPL positive women were not related to preconception complement levels (p = 0.44) (Table 1). Of note, all the pregnancy losses in the triple positive group occurred in patients treated with low dose aspirin and low molecular weight heparin from the time of positive pregnancy test.

Conclusion:

Our findings confirm that decreased complement levels before pregnancy are associated with increased risk of adverse outcome. This has been seen only in in women with triple aPL positivity, indeed single or double positivity does not show this trend. Complement levels are cheap and easy to be measured therefore they could represent a useful aid to identify patients at increased risk of pregnancy loss. test positivity.

References:

[1]De Carolis S, et al. Complementemia and obstetric outcome in pregnancy with antiphospholipid syndrome. Lupus (2012) 21:776–8.

[2]Kim MY, et al. Complement activation predicts adverse pregnancy outcome in patients with systemic lupus erythematosus and/or antiphospholipid antibodies. Ann Rheum Dis (2018) 77:549–55.

[3]Fredi M, et al. Risk Factors for Adverse Maternal and Fetal Outcomes in Women With Confirmed aPL Positivity: Results From a Multicenter Study of 283 Pregnancies. Front Immunol. 2018 May 7;9:864.

Triple aPL positivitySingle or double aPL positivityGestational outcomeLow C3/C4 (n=49)Normal C3/C4(n=17)pLow C3/C4 (n=57)Normal C3/C4(n=165)pTerm live birth (>37w)15 (31%)6 (35%)ns34 (60%)110 (67%)nsPreterm live birth (≤37w)22 (45%)11 (65%)ns15 (26%)38 (23%)nsPregnancy losses (abortion and miscarriages)12 (24%)0 (0%)0.0278 (14%) 17 (10%)ns

Disclosure of Interests:

None declared

POS0693 EFFICACY AND SAFETY OF BELIMUMAB IN PATIENTS WITH LUPUS NEPHRITIS IN REAL-LIFE SETTING: RESULTS FROM A LARGE, NATIONWIDE, MULTICENTRIC, PROSPECTIVE COHORT

Background:

LN is still a severe manifestation of Systemic lupus erythematosus (SLE) and multitarget therapy is needed to control the disease especially in refractory cases.

Objectives:

To evaluate renal response in SLE patients with glomerulonephritis (GN) treated with Belimumab in real-life setting.

Methods:

Patients with proteinuria >0.5 g/24 h and/or active sediment at baseline enrolled in a multicentre Italian cohort of SLE patients (BeRLiSS study), treated with monthly iv Belimumab 10 mg/kg plus standard of care were considered in this study. Complete renal response (CRR) was defined as proteinuria <0.5 g/24 h, estimated glomerular filtration rate (eGFR)≥90ml/min/1.73m2 and no rescue therapy. Primary efficacy renal response (PERR) was defined as proteinuria ≤0.7 g/24 h, eGFR ≥60ml/min/1.73m2 and no rescue therapy. Prevalence and predictive factors of CRR and PERR at 12 and 24 months after Belimumab initiation were analyzed by multivariate logistic regression analysis.

Results:

A total of 91 patients were considered in this study, 79 female, mean age 40.51±9.03 years, mean disease duration 12.18±8.15 years, median follow-up time after Belimumab initiation 22 months. Twenty patients had baseline proteinuria ≥0.5 <1 g/day, 17 ≥1 <2 g/day, 13 ≥2 g/day. Belimumab was started at GN onset in 20 (22%) patients and at the time of a renal flare in all other cases. Seventy-five patients underwent a renal biopsy: 1 class I, 4 class II, 14 class III, 47 class IV and 9 class V. Baseline serum creatinine was 82.44±29.26 umol/L; 15 patients showed eGFR<60ml/min/1.73m2 at baseline. Immunosuppresants were taken by 70 (76.9%) patients: 47 micofenolate, 15 azathioprine and 5 ciclosporine. Sixty patients (65.9%) were on antimalarials. During follow-up 34 (37.4%) patients achieved CRR. Among them 5 (14.7%) patients relapsed and 29 (85.3%) patients maintained remission. Mean time to achieved CRR was 9.71±5.91 months.

High levels of baseline proteinuria were a negative independent predictor of CRR and PERR at 6 months (OR 0.044 CI95% 0.006-0.320 p=0.002 and OR 0.232 CI95% 0.091-0.596 p=0.002) and 12 months (OR 0.029 CI95% 0.002-0.556 p=0.019 and OR 0.056 CI95% 0.009-0.327 p=0.001). High levels of baseline creatinine were a negative independent predictor of renal response. Renal response at 6 months was a strong predictive factor of renal response at 12 and 24 months.

Conclusion:

Belimumab is an effective add-on therapy in the treatment of GN in real-life practice setting.

Disclosure of Interests:

None declared

POS0751 COMORBIDITY AND LONG-TERM OUTCOME IN PATIENTS WITH CONGENITAL HEART BLOCK: PRELIMINARY DATA OF THE ITALIAN REGISTRY ON THE IMMUNE-MEDIATED CONGENITAL HEART BLOCK

Background:

Congenital heart block (CHB) is due to placental transfer of maternal anti-Ro/SSA autoantibodies to the fetus. The prevalence of CHB has been estimated as 1-2% in anti-Ro/SSA women while the recurrence rate is 16-19% (1). This condition is associated with a high rate of fetal/neonatal mortality and most of the cases requires pacemaker (PM) pacing. Given the rarity of CHB, limited data are available regarding the long-term follow-up of the offspring other than the cardiovascular complications.

Objectives:

The results of the Italian Registry of the autoimmune congenital heart block were recently described (2). A peculiarity of this cohort was that most of the mothers had an established diagnosis of systemic autoimmune disease at CHB detection, in contrast with other registries where CHB was mostly incidentally detected in healthy women. Here we report an update, with the preliminary data regarding the long-term outcome of patients with CHB, their unaffected siblings and health controls born from mothers positive for Ro/SSA.

Methods:

Data regarding demography, treatment, maternal, neonatal outcome, and follow-up were collected through an online electronic datasheet. A dedicated questionnaire was created with the aim to investigate general health, cardiovascular follow-up, and frequency of autoimmune diseases.

Results:

One-hundred and five cases of CHB in 99 patients were included from 1969 to December 2020. CHB was mostly detected in utero (97 cases, 92.3%) with 8 neonatal cases. Third degree CHB occurred in 71 cases (67.6%). Child mortality was observed in 29 (27.6%) cases: 20 in utero, 7 during neonatal period and 2 during childhood. Overall, a PM was implanted in 54 out of the 85 live births (63.5%). Then, our cohort was divided into 2 subgroups: pregnancy that occurred before (N=61) and after 2010 (N=44) with the aim to evaluate possible differences among the subgroups. Whereas mortality, PM, CHB degree were similar, CHB more frequently occurred in the last 10 years among Ro/SSA asymptomatic carriers than in the group of pregnancies before 2010 (53.6% vs 32.8%, p=0.038). Questionnaires from 14 surviving CHB cases, 8 unaffected siblings 12 controls born from mothers Ro/SSA positive were collected. Among CHB cases, 6 were males and 8 females, median age 12 years (range 6-28). All presented a third degree CHB, 10 required a neonatal PM pacing and one had an implantable ECG recorder. PM was substituted at least once in 9 patients, the oldest patient had to change it four times. No dilated cardiomyopathy occurred and most of the patients maintain an annual follow-up. Two cases of autoimmune diseases were registered among CHB cases, one idiopathic juvenile arthritis and one Cogan’s vasculitis, both born from mothers with Sjogren Syndrome. Four cases of neurodevelopmental disorders occurred: three cases of learning disabilities (one in each group) and one case of speech disorder in the sibling group. In addition, a CHB case presented a stress disorder linked to frequent hospitalizations.

Conclusion:

This registry is an ongoing project aiming at collecting all Italian CHB. Moreover, here we reported the preliminary data concerning the evaluation of long-term follow-up of CHB patients. Our data, even if need to be confirmed in larger cohort, seems reassuring: no differences were reported comparing CHB patients with unaffected siblings or controls.

References:

[1]Brito-Zéron et al. Nat Rev Rheumatol 2015;11:301-312.

[2]Fredi M et al. Front Cardiovasc Med. 2019 Feb 28;6:11.

Disclosure of Interests:

None declared

OP0137 GENOME-WIDE WHOLE-BLOOD TRANSCRIPTOME PROFILING IN A LARGE EUROPEAN COHORT OF SYSTEMIC SCLEROSIS PATIENTS

Background:

The analysis of annotated transcripts from genome-wide expression studies data is of paramount importance to understand the molecular phenomena underlying the occurrence of complex diseases, such as systemic sclerosis (SSc).

Objectives:

To perform whole-blood transcriptome and pathway analysis on whole-blood (WB) RNA collected in two cohorts of European SSc patients. Via a discovery and validation strategy we aimed at characterizing the molecular pathways that differentiate SSc from controls and that are reproducible in geographically diverse populations.

Methods:

WB samples from 252 controls and 162 SSc patients were collected in RNA stabilizers. Patients were divided into a discovery (n=79; Southern Europe) and validation cohort (n=83; Central-Western Europe). RNA sequencing was performed by an Illumina assay. Functional annotations of Reactome pathways were performed with the FAIME algorithm. In parallel, a immunophenotyping analysis on 28 circulating cell populations was assessed. We then tested: the presence of differentially expressed genes or pathways and the correlation between absolute cell counts and RNA transcripts/FAIME scores in regression models. Results significant in both populations were considered as replicated.

Results:

A total of 15224 genes and 1277 related functional pathways were available for analysis. Among these, 99 genes and 225 pathways were significant in both sets. The heatmap in figure shows the relative expression of replicated pathways and the distribution of cases and controls (red and green bars). Among the significant pathways we found a deregulation in: type-I IFN, TLR-cascade and signalling, function of the tumor suppressor p53 protein, platelet degranulation and activation. Correlation analysis showed that the count of several cell subtypes is jointly associated with RNA transcripts or FAIME scores with strong differences in relation to the geographical origin of samples; neutrophils emerged as the major determinant of gene expression in SSc-whole-blood samples.

Conclusion:

We discovered a set of differentially expressed genes and pathways that could be validated in two independent sets of SSc patients highlighting a number of deregulated molecular processes that have relevance for the pathogenesis of autoimmunity and SSc.

Acknowledgments:

This work was supported by EU/EFPIA/Innovative Medicines Initiative Joint Undertaking PRECISESADS grant No. 115565.

Disclosure of Interests:

Lorenzo Beretta Grant/research support from: Pfizer, Guillermo Barturen: None declared, Barbara Vigone: None declared, Chiara Bellocchi: None declared, Nicolas Hunzelmann: None declared, Ellen Delanghe: None declared, László Kovács: None declared, Ricard Cervera: None declared, Maria Gerosa: None declared, Rafaela Ortega Castro: None declared, Isabel Almeida: None declared, Divi Cornec: None declared, Carlo Chizzolini Consultant of: Boehringer Ingelheim, Roche, Jacques-Olivier Pers: None declared, Zuzanna Makowska Employee of: Bayer AG, Anne buttgereit Employee of: Bayer AG, Ralf Lesche Employee of: Bayer, Martin Kerick: None declared, Marta Alarcon-Riquelme: None declared, Javier Martin Ibanez: None declared

FRI0183 DISTINCTIVE TRAITS OF MYOCARDIAL INFLAMMATION IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS: A MULTICENTRE STUDY

Background:

Myocarditis is an infrequent but potentially life-threatening inflammatory disorder and might be part of the spectrum of systemic lupus erythematosus (SLE). Little is known about the clinical and histologic features of myocarditis in SLE, especially compared to other forms of myocarditis.

Objectives:

to test for potential distinctive traits among myocarditis in SLE (MyoSLE), SLE without myocarditis (OnlySLE) and myocarditis without SLE (OnlyMyo)

Methods:

Patients with MyoSLE were identified from three centres and compared with 231 cross-sectionally enrolled patients with OnlySLE and 87 patients with OnlyMyo. MyoSLE patients were split into two groups based on myocarditis onset within (early onset) vs after (late onset) the first year from SLE diagnosis. OnlySLE patients were dichotomised in the same way based on disease duration at time of enrolment. Demographics and general clinical features were collected retrospectively. SLE disease activity index 2000 (SLEDAI-2K), SLE International Collaborating Clinics/American College of Rheumatology damage index (SDI), clinical and laboratory features were collected at time of myocarditis onset in MyoSLE and at enrolment in OnlySLE. Quantitative data are expressed as median [interquartile range].

Results:

Fourteen MyoSLE patients were identified, 50% with early onset. Women were equally frequent among MyoSLE (71%) and OnlySLE patients (87%) and less frequent in the OnlyMyo group (43%; p<0.001). Age was comparable among groups. Clinical features at presentation, including left ventricular ejection fraction, were similar between MyoSLE and OnlyMyo, although the former had higher levels of pro-brain natriuretic peptide (1.1 [0.4-1.8] vs 0.1 [0.1-0.5] ng/ml; p=0.004). Patients with MyoSLE also had a lower frequency of left ventricle lateral wall involvement (36 vs 68%; p=0.035) and of oedema (20 vs 71%; p=0.036) and necrosis (0 vs 64%; p=0.009) at biopsy. Antiphospholipid antibodies (aPL) were more frequent in MyoSLE (57%) compared to both OnlyMyo (16%; p=0.003) and OnlySLE (28%; p=0.031). Compared to OnlySLE, patients with MyoSLE also had a higher prevalence of aPL-syndrome (APS: 36 vs 7%; p=0.003), neuropsychiatric (NPSLE: 43 vs 19%; p=0.039) and gastrointestinal manifestations (21 vs 5%; p=0.045). Early and late onset patients had similar demographics and clinical features and did not differ from patients with OnlySLE with similar disease duration in terms of SLEDAI-2K and SDI. Late onset MyoSLE patients had a higher prevalence of NPSLE (57 vs 18%; p=0.026) and APS (57 vs 7%; p=0.001) and higher C-reactive protein levels (6 [2-12] vs 1[0-4] mg/l; p=0.024) compared to OnlySLE patients with the same disease duration.

Conclusion:

Demographics of patients with MyoSLE are more similar to patients with OnlySLE than to OnlyMyo patients. MyoSLE might have distinct histological and pathogenic features compared to OnlyMyo. Patients with MyoSLE show similar patterns of disease activity and accrued damage at time of myocarditis onset compared to patients with OnlySLE with the same disease duration but might diverge later on in SLE course. aPL are frequent in MyoSLE and might both contribute to the pathogenesis of myocardial inflammation and account for the high prevalence of NPSLE and APS, especially in late onset cases.

References:

[1]Gartshteyn Y et al., Lupus, 2020

[2]Thomas G et al., J Rheumatol, 2017

[3]Peretto G et al., Int J Cardiol, 2019

[4]McDonnell T et al., Blood Rev, 2019

Disclosure of Interests:

Giuseppe Alvise Ramirez: None declared, Maria Gerosa: None declared, Giacomo De Luca Speakers bureau: SOBI, Novartis, Celgene, Pfizer, MSD, Lorenzo Beretta Grant/research support from: Pfizer, Simone Sala: None declared, Giovanni Peretto: None declared, Luca Moroni: None declared, Francesca Mastropaolo: None declared, adriana cariddi: None declared, Silvia Sartorelli: None declared, Corrado Campochiaro Speakers bureau: Novartis, Pfizer, Roche, GSK, SOBI, Enrica Bozzolo: None declared, Roberto Caporali Consultant of: AbbVie; Gilead Sciences, Inc.; Lilly; Merck Sharp & Dohme; Celgene; Bristol-Myers Squibb; Pfizer; UCB, Speakers bureau: Abbvie; Bristol-Myers Squibb; Celgene; Lilly; Gilead Sciences, Inc; MSD; Pfizer; Roche; UCB, Lorenzo Dagna Grant/research support from: The Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR) received unresctricted research/educational grants from Abbvie, Bristol-Myers Squibb, Celgene, Janssen, Merk Sharp & Dohme, Mundipharma Pharmaceuticals, Novartis, Pfizer, Roche, Sanofi-Genzyme, and SOBI., Consultant of: Prof Lorenzo Dagna received consultation honoraria from Abbvie, Amgen, Biogen, Bristol-Myers Squibb, Celltrion, Novartis, Pfizer, Roche, Sanofi-Genzyme, and SOBI.

THU0221 EVIDENCE FOR A PATHOGENIC ROLE OF EXTRA-FOLLICULAR, IL-10 PRODUCING CCR6+B-HELPER T-CELLS IN SYSTEMIC LUPUS ERYTHEMATOSUS

Background:

IL-10 plays a key role in systemic lupus erythematosus (SLE) pathogenesis, promoting B-cell response. IL10 is mainly secreted by regulatory T-cells, but follicular helper T-cells (TFH), also produce it. We previously identified a subset of CCR6+IL-7R+T-cells in human tonsils providing IL-10-dependent B-cell help. These CCR6+T-cells were able to produce IL-10, inducing IgG production.

Objectives:

to investigate a possible role of CD4+CCR6+IL7R+T-cells in SLE pathogenesis.

Methods:

37 patients fulfilling the ACR criteria for SLE have been included. Disease activity was assessed by 2k-SLEDAI. PBMC were analyzed by flow cytometry, using specific lineage markers. CCR6+IL7R+T-cells purified from total PBMC of SLE patients or healthy donors (HD) were co-cultured with autologous CD20+B-cells. IL-10, Il-17, total IgG and anti-dsDNA antibodies titers in patients serum and culture supernatants were assessed by ELISA. Embedded sections of lymph nodes from 8 SLE patients were analyzed by immunofluorescence (IF).

Results:

IL10 levels were significantly higher in SLE patients (Fig 1A). CD4+CCR6+IL7R+T-cells were significantly increased in SLE, in particular in those with higher disease activity and higher IL10 levels. CD4+CCR6+IL7R+T-cells levels associated with anti-dsDNA positivity. CCR6+IL7R+T-cells of SLE patients induced production of IgG and anti-dsDNA IgG (in anti-dsDNA + patients) from autologous B-cells, providing spontaneous help for autoantibody productionex vivo(Fig 1B-C). The IF study of lymph nodes of SLE patients showed that IL-10-producing CCR6+T-cells were highly abundant and co-localized with B-cells at follicle margins.

Fig 1

Conclusion:

our study revealed a novel population of extra-follicular B-helper T-cells, which produce IL-10 and could play a prominent pathogenic role in SLE. Further studies will clarify if this potentially pathogenic cell population might represent a possible future therapeutic target.

References:

[1]Facciotti F. J Allergy Clin Immunol. 2016; Geginat J. Semin Immunol. 2019; Tsokos GC. Nat Rev Rheumatol. 2019

Tab 1:

SLE patients characteristics

(n=37)DemographicsFemale/Male, n37/5Age, years, median (IQR)44 (38-49)Disease duration, years, median (IQR)19 (11-26)Lab testsANA86%*anti-dsDNA (%)46% medium/high titre41%Disease activity and clinical manifestations SLEDAI-2K, median (min-max)3.5 (0-24) Moderate/high activity19%Ongoing therapyPrednisone dose mg/day, median (IQR)7,5 mg (2,5 – 20)hydroxychloroquine78%Immunosuppressants87%Fig 2

Disclosure of Interests: :

Maria Gerosa: None declared, Federica Facciotti: None declared, Paola Larghi: None declared, Roberto Bosotti: None declared, Chiara Vasco: None declared, Nicola Gagliani: None declared, Chiara Cordiglieri: None declared, Elsa Rottoli: None declared, Alessandra Emiliana Penatti: None declared, Lorenza Maria Argolini: None declared, Bhavna Karnani: None declared, Yasushi Kobayashi: None declared, Mauro Bombaci: None declared, Jan Piet Van Hamburg: None declared, Roberta Gualtierotti: None declared, Stefano Gatti: None declared, Sara Torretta: None declared, Lorenzo Pignataro: None declared, Sander W. Tas: None declared, Roberto Caporali Consultant of: AbbVie; Gilead Sciences, Inc.; Lilly; Merck Sharp & Dohme; Celgene; Bristol-Myers Squibb; Pfizer; UCB, Speakers bureau: Abbvie; Bristol-Myers Squibb; Celgene; Lilly; Gilead Sciences, Inc; MSD; Pfizer; Roche; UCB, Sergio Abrignani: None declared, Massimiliano Pagani: None declared, Fabio Grassi: None declared, Pier Luigi Meroni: None declared, Richard Flavell: None declared, Jens Geginat: None declared

SAT0207 ANTI-SSA/RO POSITIVITY AND CONGENITAL HEART BLOCK: OBSTETRIC AND FETAL OUTCOME IN A COHORT OF ANTI-SSA/RO POSITIVE PREGNANT WOMEN WITH AND WITHOUT AUTO-IMMUNE DISEASES FROM THREE ITALIAN TERTIARY REFERRAL CENTERS

Background:

neonatal lupus syndrome (NLS) is an acquired disease caused by the trasplacental passage of anti-SSA antibodies. Congenital heart block (CHB) represents the most serious manifestation of NLS. The rate of CHB in Anti-SSA positive pregnant women ranges from 1 to 5% in different studies

Objectives:

to retrospectively assess the prevalence of CHB in a cohort of anti-SSA positive pregnant women followed in 3 Italian tertiary centers

Methods:

pregnancies of anti-SSA positive women attending the pregnancy clinic of ASST Pini CTO/Policlinico Mangiagalli, Rheumatology Division of Spedali Civili, Brescia and Rheumatology Division of Ospedale S Matteo, Pavia from 2009 to 2019 were included. Patients underwent monthly clinical examination. Fetal heart rate was assessed weekly by Doppler ultrasound from 14thto 26thgestational week. On week 14 and 26, a fetal echocardiography was performed. A EKG was performed at birth

Results:

351 prospectively followed pregnancies in 292 anti-SSA/Ro positive women were included. Table 1 reports diagnosis. None of the prospectively followed pregnancies were complicated by complete CHB. Seven additional patients were referred to our clinics after diagnosis of CHB and were subsequently found to be anti-SSA positive, reporting no symptoms of diseases. Considering the 7 additional pregnancies, the incidence of CHB was 1.9%. We observed 3 neonates (0.8%) with cutaneous NLS and 1 case of transient increase of liver enzymes. In another neonate, a 1thdegree A-V block was found after birth. A complete analysis of maternal and fetal outcome was possible in 244 cases (Table 2) and compared with 3158 unselected healthy controls. Among these 244 cases, 65% were taking hydroxychloroquine

Table 1.

patients diagnosis

n%Sjogren’s Syndrome58`20Systemic lupus erythematosus7626UCTD7425Asymptomatic Ro carriers5619Other2810292100Table 2.

maternal and fetal outcome

healthy controls N=3158Anti-SSA/Ro ptsN=244P valuePrevious CHB n (%)2 (0.8)Anti-SSB pos n (%)46 (18.8)aPL pos n (%)49 (20)PregnancyLive births3158241Preeclampsia, n (%)43 (1.1)2 (0.8)nsDeliveryDelivery <37 wks, n (%) / < 34 wks n (%)401 (12.6) /201 (6)35 (15.6) / 14 (6)ns / nsCesarean Section, n (%)897 (29.3)115 (47.5)<0.001

Conclusion:

none of the patients prospectively followed in our centers before and during pregnancy developed complete CHB. If the 7 cases of anti-SSA positivity diagnosed after CHB detection were included in the analysis, the incidence of CHB was comparable to previous reports. Our data suggest that a strict follow up and proper treatment of anti-SSA positive patients with or without an autoimmune disease before and during pregnancy can reduce the risk of NLS. Further studies are warranted to confirm a possible protective role of anti-rheumatic treatments, including HCQ

References:

[1]Fredi M. Front Cardiovasc Med. 2019

Disclosure of Interests:

Maria Gerosa: None declared, Micaela Fredi: None declared, Laura Andreoli: None declared, Cecilia Chighizola: None declared, Lorenza Maria Argolini: None declared, Davide Donzelli: None declared, Tamara Vojinovic: None declared, Véronique Ramoni: None declared, Elisa Bellis: None declared, Laura Trespidi: None declared, Federica Gazzola: None declared, Enrico Ferrazzi: None declared, Sonia Zatti: None declared, Fausta Benvenuti: None declared, Pier Luigi Meroni: None declared, Franco Franceschini: None declared, Carlomaurizio Montecucco: None declared, Rolando Cimaz: None declared, Roberto Caporali Consultant of: AbbVie; Gilead Sciences, Inc.; Lilly; Merck Sharp & Dohme; Celgene; Bristol-Myers Squibb; Pfizer; UCB, Speakers bureau: Abbvie; Bristol-Myers Squibb; Celgene; Lilly; Gilead Sciences, Inc; MSD; Pfizer; Roche; UCB, Angela Tincani: None declared

FRI0167 LONG TERM CLINICAL OUTCOME IN SYSTEMIC LUPUS ERYTHEMATOSUS PATIENTS FOLLOWED FOR MORE THAN 20 YEARS IN THREE ITALIAN TERTIARY REFERRAL CENTERS: THE MILAN SYSTEMIC LUPUS ERYTHEMATOSUS CONSORTIUM (SMILE) COHORT

Background:

the prognosis of Systemic lupus Erythematosus (SLE) patients has significantly improved over time, raising the need for more data about disease activity and damage accrual in the long term.

Objectives:

to investigate the risk of long term disease activity and to identify viable prognostic markers for disease flares in SLE patients with long standing disease

Methods:

data on SLE patients regularly followed at ASST PINI-CTO, Fondazione Ca’ Granda Policlinico and Ospedale San Raffaele, Milan (Milan Systemic Lupus Erythematosus Consortium, SMiLE, cohort) with disease duration ≥ 20 years, were retrospectively analyzed. Organ involvement as per the British Isles Lupus Assessment Group (BILAG) definitions was recorded along with achievement of clinical and complete remission (CR and CCR: clinical SLEDAI =0, PGA <0.5 and no prednisone or immunosuppression ± negative serology) and lupus low disease activity state (LLDAS) at 15 (T15) and 20 (T20) years of follow up. Damage accrual was estimated according to the SLE International Collaborating Clinics/American College of Rheumatology damage index (SDI).

Results:

data from 168 patients (table 1) were available for analysis. Remission (CR+CCR) and LLDAS were achieved in 22% and 61% at T15 and 25% and 71% at T20. LLDAS was not associated with a history of involvement in any BILAG domain, but it was inversely associated with treatment with mycophenolate at any time (50 vs 23% treated vs not treated; p=0.02). SDI>0 was found in 49% patients at T15 and in 71% at T20. LLDAS at T15 was associated with lower flare rates in the following five years (HR= 0.395, 95%, CI=0.239-0.653; Figure, left panel; p<0.001). The risk of flaring for LLDAS was largely comparable to CCR and CR (Figure, middle panel). In the T15-T20 timeframe, 37% of patients had a flare. Patients with both low complement and anti-dsDNA positivity at T15 had an increased risk of flaring compared to serologically inactive patients (HR=2.86, 95%, CI=1.572-5.19; Figure right panel). Flaring patients were more likely to show an increase in SDI from T15 to T20 (37% vs 9% in patients with stable SDI; p<0.001)

Table 1.

Demographic, laboratory and clinical characteristics of patients with SLE

Characteristics(n=168)Demographic characteristicsFemale, n (%)150 (89.3)Age at diagnosis years, median (IQR)24 (18-32)Clinical and serological features during 15 years follow up, n (%)Musculoskeletal140 (83)Mucocutaneous135 (80)Constitutional114 (68)Haematological103 (61)Nephritis81 (48)Cardiopulmonary49 (29)NPSLE31 (18)Positive anti-dsDNA136 (81)Hypocomplementemia136 (81)Positive antiphospholipid73 (44)CR / CCR at T1513 (8) / 23 (14)CR / CCR at T2017 (10) / 25 (15)

Conclusion:

LLDAS is common in SLE patients with long disease duration although up to 37% of patients with 15-year disease duration may experience a flare during the following 5 years. The flare risk increases with failure to attain LLDAS at T15 and with active serology. Late flares associate with damage accrual.

References:

[1]Aringer M, Ann Rheum Dis. 2019; Franklin K, Ann Rheum Dis 2019

Table 2.

therapy during the 20 year follow up

Therapy (ever)%Prednisone83Hydroxychloroquine91Mycophenolate mofetil33Azathioprine50Methotrexate23Cyclophosphamide36Fig 1:

risk of flare according to disease activity

Disclosure of Interests:

Maria Gerosa: None declared, Giuseppe Alvise Ramirez: None declared, Chiara Bellocchi: None declared, Lorenza Maria Argolini: None declared, Luca Moroni: None declared, Martina Cornalba: None declared, Nicola Farina: None declared, Lorenzo Dagna Grant/research support from: Abbvie, BMS, Celgene, Janssen, MSD, Mundipharma Pharmaceuticals, Novartis, Pfizer, Roche, SG, SOBI, Consultant of: Abbvie, Amgen, Biogen, BMS, Celltrion, Novartis, Pfizer, Roche, SG, and SOBI, Roberto Caporali Consultant of: AbbVie; Gilead Sciences, Inc.; Lilly; Merck Sharp & Dohme; Celgene; Bristol-Myers Squibb; Pfizer; UCB, Speakers bureau: Abbvie; Bristol-Myers Squibb; Celgene; Lilly; Gilead Sciences, Inc; MSD; Pfizer; Roche; UCB, Enrica Bozzolo: None declared, Lorenzo Beretta Grant/research support from: Pfizer

Environmental electroactive consortia as reusable biosensing element for freshwater toxicity monitoring

The development of tools to monitor water quality is mandatory in a scenario where clean water resources are decreasing. Here, the biosensing capability of an electroactive river sediment consortium was tested towards three model contaminants (glutaraldehyde, nickel(II) and chromium(III)). The proposed biosensor is a small membrane-less single chamber Microbial Fuel Cell (MFC), fabricated by 3D printing. Its semi-continuous mode of operation resulted in long-term current profile stability and reproducibility. A linear trend of response was obtained for glutaraldehyde in a concentration range of 5-1000 ppm. After the recovery of the electroactive consortium activity, the MFC-based biosensors were shown to be sensitive towards Ni(II) and Cr(III), at concentrations above 2 mg L^-1. To effectively analyze biosensor response, a novel algorithm was proposed, offering advantages for the realization of energy-saving protocols for MFC-biosensor data transmission. Implementation of the device and method, from laboratory test to real environment, can offer a low cost in situ system for detection of water contaminants.

IL-10 producing regulatory and helper T-cells in systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a highly heterogeneous autoimmune disease characterised by the production of pathogenic autoantibodies against nuclear self-antigens. The anti-inflammatory and tolerogenic cytokine Interleukin-10 appears to play a paradoxical pathogenic role in SLE and is therefore currently therapeutically targeted in clinical trials. It is generally assumed that the pathogenic effect of IL-10 in SLE is due to its growth and differentiation factor activity on autoreactive B-cells, but effects on other cells might also play a role. To date, a unique cellular source of pathogenic IL-10 in SLE has not been identified. In this review, we focus on the contribution of different CD4⁺T-cell subsets to IL-10 and autoantibody production in SLE. In particular, we discuss that IL-10 produced by different subsets of adaptive regulatory T-cells, follicular helper T-cells and extra-follicular B-helper T-cells is likely to have different effects on autoreactive B-cell responses. A better understanding of the role of IL-10 in B-cell responses and lupus would allow to identify the most promising therapies for individual SLE patients in the future.

Accuracy of dielectric-dependent hybrid functionals in the prediction of optoelectronic properties of metal oxide semiconductors: a comprehensive comparison with many-body GW and experiments

Understanding the electronic structure of metal oxide semiconductors is crucial to their numerous technological applications, such as photoelectrochemical water splitting and solar cells. The needed experimental and theoretical knowledge goes beyond that of pristine bulk crystals, and must include the effects of surfaces and interfaces, as well as those due to the presence of intrinsic defects (e.g. oxygen vacancies), or dopants for band engineering. In this review, we present an account of the recent efforts in predicting and understanding the optoelectronic properties of oxides using ab initio theoretical methods. In particular, we discuss the performance of recently developed dielectric-dependent hybrid functionals, providing a comparison against the results of many-body GW calculations, including G ₀ W ₀ as well as more refined approaches, such as quasiparticle self-consistent GW. We summarize results in the recent literature for the band gap, the band level alignment at surfaces, and optical transition energies in defective oxides, including wide gap oxide semiconductors and transition metal oxides. Correlated transition metal oxides are also discussed. For each method, we describe successes and drawbacks, emphasizing the challenges faced by the development of improved theoretical approaches. The theoretical section is preceded by a critical overview of the main experimental techniques needed to characterize the optoelectronic properties of semiconductors, including absorption and reflection spectroscopy, photoemission, and scanning tunneling spectroscopy (STS).

Evaluation of phosphatidylserine-dependent antiprothrombin antibody testing for the diagnosis of antiphospholipid syndrome: results of an international multicentre study

Objective A task force of scientists at the International Congress on Antiphospholipid Antibodies recognized that phosphatidylserine-dependent antiprothrombin antibodies (aPS/PT) might contribute to a better identification of antiphospholipid syndrome (APS). Accordingly, initial and replication retrospective, cross-sectional multicentre studies were conducted to ascertain the value of aPS/PT for APS diagnosis. Methods In the initial study (eight centres, seven countries), clinical/laboratory data were retrospectively collected. Serum/plasma samples were tested for IgG aPS/PT at Inova Diagnostics (Inova) using two ELISA kits. A replication study (five centres, five countries) was carried out afterwards. Results In the initial study ( n = 247), a moderate agreement between the IgG aPS/PT Inova and MBL ELISA kits was observed ( k = 0.598). IgG aPS/PT were more prevalent in APS patients (51%) than in those without (9%), OR 10.8, 95% CI (4.0-29.3), p < 0.0001. Sensitivity, specificity, positive (LR+) and negative (LR-) likelihood ratio of IgG aPS/PT for APS diagnosis were 51%, 91%, 5.9 and 0.5, respectively. In the replication study ( n = 214), a moderate/substantial agreement between the IgG aPS/PT results obtained with both ELISA kits was observed ( k = 0.630). IgG aPS/PT were more prevalent in APS patients (47%) than in those without (12%), OR 6.4, 95% CI (2.6-16), p < 0.0001. Sensitivity, specificity, LR + and LR- for APS diagnosis were 47%, 88%, 3.9 and 0.6, respectively. Conclusions IgG aPS/PT detection is an easily performed laboratory parameter that might contribute to a better and more complete identification of patients with APS.

Immune function in children born to mothers with autoimmune diseases and exposed in utero to immunosuppressants

The administration of immunosuppressive drugs during pregnancy is often necessary in women with autoimmune diseases. Teratogenicity of immunosuppressives during pregnancy has been evaluated, only few data exist about the effects on immune systems. We therefore performed a pilot study on the influence of foetal exposure to immunosuppressives on immune function of babies born to mothers with autoimmune disorders. We investigated serological and cellular parameters as indicators of immune system status. We included in the study 14 babies (mean age 11 months, range 1—24) born to mothers with autoimmune diseases and exposed in utero to different immunosuppressants and, as controls, 14 babies whose mothers had autoimmune manifestations but did not receive immunosuppressive therapy. We evaluated: (i) complete blood count, (ii) immunoglobulin levels and IgG subclasses, (iii) antibody response to hepatitis B vaccine, (iv) leukocyte subpopulations and (v) interleukin-2 and interferon γ in vitro production by resting or activated peripheral blood mononuclear cells. We did not find statistically significant differences between exposed and not exposed babies or among treatments for the tested parameters. Immunosuppressive regimens currently in use for controlling maternal autoimmune disorders do not significantly affect the immune status of the offspring. Lupus (2007) 16, 651—656.

Measurement of Electrical Skin Impedance of Dermal-Visceral Zones as a Diagnostic Tool for Disorders of the Immune System

Among complementary medicine approaches, diagnostic screening tools based on neuroreflexology have been recently developed. Such techniques are based on the rationale that measurement of electrical impedance of specific dermal zones might reflect the occurrence of pathological states in the corresponding internal organs or systems. Our objective was to evaluate the reliability of a neuroreflexology-based diagnostic test in diagnosing immune-mediated diseases in a blinded single centre study. Seventy-eight patients with immune-mediated diseases (38 patients with autoimmune diseases (AD), and 40 allergic patients) were included in the study. Thirty age and sex matched healthy subjects were also evaluated as a control group. All the patients and subjects underwent conventional medical history and physical examination. We evaluated a device manufactured by Medex Screen Ltd (Arad, Israel). The Medex Test analysis was carried out by a second physician who was blinded to the previous diagnosis. A high correlation between the formal clinical diagnosis and the results of the measurement of electrical skin impedance was reported, with a specificity of 93.3% and a sensitivity of 81.2%. Both sensitivity and specificity dropped when analysing the autoimmune and the allergic group separately, but remained significant for the autoimmune diseases. Degree of activity of the allergic disorders, or specific treatment, did not affect the diagnostic properties of the described device. The Medex Test neurophysiology based technique has the potential to serve as a diagnostic tool for immune based pathologies. Future studies will define this tool place in routine evaluation and potential screening ability.

Operative classification of brain arteriovenous malformation. Part two: validation

SUMMARY

The most important issue when dealing with a patient with a brain AVM is the decision whether to treat or not. Only after this decision has been made, taking into consideration a number of factors depending on both the patient and the specific type of AVM, can the best option for treatment be chosen. An operative classification of brain AVMs, previously adopted in the Department of Neuroradiology and Neurosurgery of Verona (Italy) and published in this journal, was subjected to validation in a consecutive group of 104 patients clinically followed for at least three years after completion of treatment. This classification, slightly modified from the original version concerning the importance of some specific items, allowed us to assess the indication to treat in each case, whatever type of treatment was offered to the patient.

Pidotimod: a reappraisal

Pidotimod (Polimod ) is a synthetic dipeptide molecule with biological and immunological activity on both the adaptive and the innate immune responses. In vitro studies, both from animal and human specimens, have documented a good activity on innate and adaptive immune responses and have been confirmed by in vivo studies. These activities have been applied in clinical studies demonstrating the efficacy of pidotimod in reducing the rate of recurrent infections of the upper respiratory and urinary tracts in children. The same results were obtained in recurrent respiratory tract infections in adults. Interestingly, these effects are more evident in the setting of immune defects such as senescence, Downs syndrome, and cancer.

Software for hepatic vessel classification: feasibility study for virtual surgery

PURPOSE

The detection and classification of hepatic vessels in diagnostic images are essential for hepatic pre-surgery planning. Our team has developed a tool for classification, analysis, and 3D reconstruction of the hepatic and portal systems.

METHODS

Our software first extracts a graphic representation of a set of connected voxels, representing both systems. It then calculates two binary volumes representing the main part of the two venous systems. Finally, it combines these results to obtain the correct vessel classification.

RESULTS

Segmentation steps are semi-automatic and require about 40 min to complete. Schematization and classification steps are automatic and require about 17 min for results.

CONCLUSION

The software provides a correct and detailed reconstruction even where pathologies have caused morphological and geometrical variations in the vessels. The time required for the entire procedure is compatible with clinical requirements, providing an efficient tool for diagnosis and surgical planning.

Rheumatoid arthritis: a female challenge

Rheumatoid arthritis (RA) is two- to three-fold more frequent in women than in men and a strong association with sex hormones has been demonstrated. There is strong evidence that autoimmunity is under genetic control, and genes in sexual chromosomes can play a role in supporting the female prevalence. On the other hand, it is widely accepted that sex hormones--estrogens in particular--may regulate the immune response by favoring the survival of forbidden autoreactive clones and ultimately the prevalence of autoimmunity in women. Accordingly, estrogens have been suggested to be associated with the development of RA. Pregnancy in RA women is a common situation and most pregnant patients experience a remission. This has been closely related to a switch from Th1 to Th2 immune responses and to a decreased production of proinflammatory cytokines, at least in part supported by the changes of the hormonal profile in pregnancy. Pregnancy planning is required in RA in order to avoid unwanted complications. In particular, the need to control the disease requires safe use of antirheumatic drugs both during the pregnancy itself and in the breastfeeding period. Hormonal treatment for contraception is contraindicated in the case of positivity for antiphospholipid antibodies owing to the increased thrombophilic risk. Similarly, replacement hormonal treatment in postmenopausal women with RA to control osteoporosis is no longer recommended as a result of its ability to increase the cardiovascular risk closely associated with RA itself.

Diagnostic value of PRND gene expression profiles in astrocytomas: relationship to tumor grades of malignancy

Doppel (PRND) is a paralogue of the mammalian prion (PRNP) gene. It is abundant in testis and, unlike PRNP, it is expressed at low levels in the adult central nervous system (CNS). Besides, doppel overexpression correlates with some prion-disease pathological features, such as ataxia and death of cerebellar neurons. Recently, ectopic expression of doppel was found in two different tumor types, specifically in glial and haematological cancers. In order to address clinical important issues, PRND mRNA expression was investigated in a panel of 111 astrocytoma tissue samples, histologically classified according to the World Health Organization (WHO) criteria (6 grade I pilocytic astrocytomas, 15 grade II low-grade astrocytomas, 26 grade III anaplastic astrocytomas and 64 grade IV glioblastoma multiforme). Real-time PRND gene expression profiling, after normalisation with GAPDH, revealed large differences between low (WHO I and II) and high grade (III and IV) of malignancy (P<0.001). Extensive differences in PRND gene expression were also found within each grade of malignancy, suggesting that PRND mRNA quantitation might be useful to distinguish astrocytoma subtypes, and important in disease stratification and in the assessment of specific treatment strategies.

Electrocardiographic abnormalities in infants born from mothers with autoimmune diseases a multicentre prospective study

OBJECTIVES

To assess the prevalence of congenital heart block (CHB) and electrocardiographic (ECG) abnormalities in infants of anti-Ro/SSA-positive women.

METHODS

Sixty anti-Ro-positive and 36 anti-Ro-negative patients were prospectively followed before/during pregnancy and underwent weekly fetal echocardiography from 18th to 26th weeks of gestational age. Infants' ECG and/or ECG-Holter were performed at 1, 3, 6 and 12 months. ECG of 200 consecutive neonates were used as a healthy control group.

RESULTS

One of 61 fetuses of anti-Ro-positive mothers developed CHB (20th week); another anti-Ro-positive baby developed second degree atrioventricular (AV) block (30th week). The prevalence of transient first degree AV block detected post-natally was significantly higher in the anti-Ro-positive group, in comparison with healthy controls (P = 0.002). No differences in corrected QT (QTc) interval prolongation prevalence (>/=440 ms) was observed between the anti-Ro-positive and -negative groups, but both were significantly higher than that of the control population (P < 0.001). ECG-Holter showed QTc prolongation in 59% of infants of anti-Ro-positive and in 60% of infants of anti-Ro-negative mothers. Holter QTc was >/=470 ms in four infants of anti-Ro-positive group and two of anti-Ro-negative group. Known acquired causes of QTc prolongation were excluded.

CONCLUSIONS

This prospective study confirms the low occurrence of CHB in newborns from anti-Ro-positive mothers. ECG abnormalities (first degree AV block and QTc interval prolongation) are frequent in infants of mothers with autoimmune diseases, independently of maternal disease, autoantibody profile and treatment during pregnancy.

Statins and autoimmune diseases

Besides the well-known lipid-lowering effect, statins display nonlipid-lowering pharmacological activities. In vitro and in vivo studies suggest that statins have direct anti-inflammatory, anti-thrombotic and plaque-stabilizing effects via a number of mechanisms. A direct immunomodulatory effect has been also demonstrated in in vitro and in vivo experimental models. In addition to traditional risk factors, systemic inflammation, immune-mediated responses and thrombophilia have been suggested to play a major role in sustaining the premature atherosclerosis in autoimmune diseases such as rheumatoid arthritis and systemic lupus erythematosus. This review focuses on the anti-inflammatory and immunomodulating mechanisms of statins as demonstrated in in vitro and in vivo experimental models, providing new insights for the use of statins in treating systemic autoimmune diseases both for their anti-atherosclerotic activity and for their pleiotropic effects on inflammation, haemostasis and the immune responses.

Gamma knife radiosurgery in brain metastases from testicular tumors

To our knowledge, there are no published reports on the effectiveness of radiosurgery in the management of brain metastases from testicular nonseminomatous germ cell tumor. The authors evaluate the results of gamma knife (GK) treatment in three patients with these unusual intracranial lesions. Between April 1995 and July 2001, three patients with brain metastasis from testicular nonseminomatous germ cell tumor underwent adjuvant radiosurgery at our department. The primary tumor had been surgically removed in all cases. At diagnosis, one patient was stage IB and two were stage III poor risk. Chemotherapy and whole brain radiotherapy were administered before radiosurgery in all cases. Pre-GK radiotherapy was administered with a daily fraction dosage of 1.8-2.0 Gy. The indications for radiosurgery were tumor volume <20 cm3, microsurgery too risky, refusal of surgery. All the lesions were located in eloquent brain areas. Post-GK high-dose chemotherapy with autologous peripheral-blood stem-cell rescue was administered in two cases due to systemic recurrence of the disease. All patients are still alive with a median and mean follow-up period after radiosurgery of 63 and 68.3 mo, respectively. They had no neurological deficits at the latest examination. Neuroradiological follow-up invariably showed tumor growth control (complete response in two cases and partial response in one) with typically delayed post-radiosurgical imaging changes (transient in two cases and long-lasting in one). In conclusion, GK seems to be highly effective and safe in brain metastases from testicular nonseminomatous germ cell tumor. In cases with diffuse metastatic brain involvement, the whole brain radiotherapy preceding radiosurgery should be delivered with 1.8 Gy daily fraction to prevent the risk of long-lasting post-radiosurgical imaging changes.

Gamma knife radiosurgery in skull base meningiomas: a possible relationship between somatostatin receptor decrease and early neurological improvement without tumour shrinkage at short-term imaging follow-up

BACKGROUND

This study investigates a possible relationship between the effects of gamma knife (GK) on meningioma somatostatin receptors (SRs) and the high rate of early neurological improvement without tumour reduction at short-term imaging follow-up.

METHODS

From December 1997 to December 2002, somatostatin receptor scintigraphy (SRS) using an 111Indium-labelled somatostatin analogue, Octreotide, was performed both before and 7-12 months after radiosurgery in 20 patients with intracranial meningiomas. Semiquantitative data were calculated as an SRS index.

FINDINGS

The pre-GK SRS index was always > 1, averaging 4.44 +/- 3.20. There were no statistically significant differences between the pre-GK average values of primary (4.80 +/- 3.65) and residual (3.75 +/- 1.93) meningiomas. At the first clinical/MRI follow-up, the neurological examination had improved in 15/20 (75%) and had not changed in 5/20 patients. A corresponding slight tumour shrinkage on high-resolution MRI was documented in 3/20 cases only. The post-GK average SRS index was lower than pre-GK values both in primary (3.87 +/- 3.19) and in adjuvant (2.52 +/- 1.14) treatments, but the differences were not significant. However, the subgroup of patients with early neurological improvement showed a higher pre-GK average SRS index (5.21 +/- 3.33) and a more substantial post-GK average SRS index decrease (3.86 +/- 3.00) than the patients whose clinical condition remained stable (2.10 +/- 0.59 and 1.99 +/- 0.55, respectively). The difference between the two subgroups of patients proved to be statistically significant (P < 0.05).

CONCLUSIONS

Our preliminary findings suggest a possible relationship between a decrease in the concentration of SRs on meningioma cells at short-term functional imaging follow-up after radiosurgery and early neurological improvement.

Multimodality Stereotactic Approach to the Treatment of Cystic Craniopharyngiomas

OBJECTIVES

To present the therapeutic reliability of a multimodality stereotactic approach (MSA) to cystic craniopharyngiomas (CPs), combining neuroendoscopy, intracavitary bleomycin and gamma knife (GK) radiosurgery.

METHODS

8 patients with mono- or multicystic CP (7/8 regrowths/recurrence) underwent stereotactic neuroendoscopy and subsequently treatment with intracavitary bleomycin and GK. They were clinically characterized by hypopituitarism (7 cases), visual impairment (7), endocranial hypertension (7), cognitive and behavioral disturbances (3), and cranial nerve deficits or focal signs (3). Concomitant hydrocephalus was observed in 3/8 patients. According to Backlund's classification, the treated CPs were classified as type A (3 cases), type Cc (4 cases) and type Dc (1 case). In all 8 patients, neuroendoscopy allowed evacuation of the cyst and, in multi-cystic CPs, fenestration of the interposed septa so as to create a single communicating cavity. Thus, a single catheter and Ommaya reservoir system was sufficient both for subsequent aspirations and for bleomycin injection (doses of 1.5-3 mg, usually repeated every 7-8 days, with total doses ranging from 3-35 mg). GK radiosurgery was carried out at a later stage on the collapsed cyst in type A forms, while in types Cc and Dc, it was used on the solid nodule on the same day as the neuroendoscopy.

RESULTS

The median follow-up period was 42.5 months. Neurological improvement was observed in 8/8 patients. A complete response (reduction of the entire tumor volume > 90 %) was observed in 3/8 cases (type A), a subtotal response (reduction > 50 %) in 4/8 cases (types Cc and Dc), and a partial response (reduction < 50 %) in 1/8 cases (type Cc). Treatment of CP alone led to normalization of the ventricular morphology in the 3 patients with associated hydrocephalus. Transient GK-related visual worsening was recorded in one case only. One patient died because of ventriculitis after repeated shunt replacements.

CONCLUSIONS

This MSA seems to be an effective and safe treatment alternative to microsurgery, above all in patients with regrowing/recurrent cystic CPs.

Gamma knife radiosurgery in meningiomas of the posterior fossa. Experience with 62 treated lesions

OBJECTIVES

This study was undertaken to assess the role of the gamma knife (GK) in the treatment of meningiomas of the posterior cranial fossa (PCF) and to statistically analyze the predictability of arbitrarily-selected prognostic factors in such treatment.

METHODS

From February 1993 to November 1998, 57 patients underwent GK treatment for 62 meningiomas of the PCF (19 M/38 F; average age, 57.5 years, ranging from 25 - 82 years). Tumor sites included: foramen jugular-petrous bone (26/62), petroclival (23/62), cerebellar convexity (6/62), tentorium (6/62), and foramen magnum (1/62). Single lesions were treated in 44/62 cases while meningiomatosis was treated in the remaining 18. Post-operative residual or recurrent tumor was found in 27/62 patients and, in 7/27, histology documented characteristics of biological aggressiveness (GII/III). Indications for radiosurgery included: advanced age, high operative risk, tumor volume < 20 ml, inoperable or refused for additional surgery. The prognostic factors statistically analyzed included: meningiomatosis (yes/no), radiosurgery as primary or adjuvant treatment, GI vs. GII/III histology, and tumor volume (< or = 5 ml vs. > 5 ml).

RESULTS

The observation periods varied from 6 to 64.3 months (median 28.7 months). At the end of the study, 53/57 patients were alive and reported to be in stable or improved neurological condition. The cause of death for the remaining 4 patients included: 2 deaths associated with tumor progression, while 2 died due to causes unrelated to the disease. Neuroradiological evaluation documented the disappearance or reduction of the meningioma mass in 34/62 (55 %) cases, a stable imaging picture in 25/62 (40 %), and a progression only in 3/62 (5 %). To date, there have been no reported cases of post-GK permanent morbidity or mortality. Side effects observed were of a transient nature due to post-radiosurgical edema (6.5 %). With regard to statistical analysis, the only factor to appear to significantly influence efficacy of radiosurgery for tumor growth control (TGC) was the biological nature of the meningioma (chi(2) = 2.708). The presence of meningiomatosis, SR as a primary or adjuvant treatment nor tumor volume were shown to statistically influence tumor behavior after GK.

CONCLUSIONS

The excellent results obtained for TGC with minimal associated side effects suggest that GK is an effective therapeutic tool also for treatment of PCF meningiomas.

New dosimetric approach for multidimensional dose evaluation in gamma knife radiosurgery

✓ During the past two decades, the progress in computerized treatment planning systems has led to more accurate imaging and therapy by using the gamma knife, especially with the smallest collimators (4 mm). However, the ionization chambers that have been used to calibrate the gamma knife are not useful with the smallest collimators because the chambers are too big compared with the irradiated volume. Therefore, it is important to develop more suitable dosimeters. This study proposes a new dosimeter method.

The FriXyGel method proposed here is based on a phantom dosimeter, an acquisition chain, and dedicated software. This dosimeter uses an agarose gel into which a ferrous sulphate solution (Fricke solution) and a metal ion indicator (xylenol orange) are incorporated. The absorbed dose is detected through measurements of visible light transmission, imaged by means of a charge-coupled device camera provided with a suitable optical filter. Gel layers are imaged before and after irradiation, and the differences in light absorption are related to the absorbed dose. By choosing convenient thickness of gel layers and by building up a phantom with different gel slices, it is possible to obtain a three-dimensional (3D) representation of the absorbed dose.

The final 3D representation is reached after several mathematical processes have been applied to the images. The first step identifies and reduces all factors that could alter the original data, such as nonuniformity in illumination. Then, after calibration procedures, it is possible to obtain absorbed dose values and to discover their 3D representation. This goal has been reached by developing appropriate software that performs all the calculations necessary for spatial representation routines and prompt comparison with theoretical calculations.

Simian virus 40 footprints in normal human tissues, brain and bone tumours of different histotypes

SV40 footprints were investigated by PCR in normal human tissues and tumours of different histotypes, followed by Southern blot hybridization with a specific internal oligoprobe for SV40 DNA. Specific SV40 amplification products were detected at high prevalence in primary human brain tumours: 83% of choroid plexus papillomas, 75% ependymomas, 47% astrocytomas and 37% glioblastomas. SV40 footprints were also revealed in primary bone tumours: 35% osteosarcomas and Ewing's tumours. Positive normal tissue samples ranged from 45% of sperm fluids to 8% of brain tissue. Normal bone tissue specimens were SV40 negative. These results indicate that SV40 is associated with human brain and bone neoplasms, whereas normal bone and brain tissues were either SV40 negative or positive at low grade. SV40 footprints were found in other normal samples such as PBC, B- and T-lymphocytes and sperm fluids, indicating that SV40 is latent in these cells. Therefore, these cells may be vectors of SV40 in other host tissues and may spread SV40 infection by blood transfusion and sexual transmission in the human population.

Stereotactic radiosurgery for the treatment of arteriovenous malformations in childhood

BACKGROUND

The main techniques and results in stereotactic radiosurgical treatment of endocranial AVM's are described and compared. The authors also report their preliminary experience in the treatment of 6 consecutive pediatric patients with intracerebral vascular malformations using gamma knife (GK) radiosurgery.

METHODS

The various stereotactic radiosurgery methods currently used (charged-particle beam, modified linear accelerator, and GK) are described. At the Department of Neurosurgery in Verona, from February 1993 to February 1996, stereotactic GK radiosurgery was performed on 721 patients, including 20 of pediatric age (3%). Of the 78 AVMs, 7 (9%) were diagnosed in children. One patient was lost at follow-up. Among the remaining 6 children, there were 3 males and 3 females with a mean age of 12.3 years (range, 5-16 years). Treatment general anesthesia was needed only in 1 case. The AVM volume was always less than 10 cc. After completion of the procedure, children were discharged from the hospital the following day.

RESULTS

The follow-up period ranged from 4 months to 29 months (median 18.8 months). The angiographic confirmed total obliteration is used as the end point of an AVM treated radiosurgically, and usually requires 2 to 3 years. All the patients are alive; four of the treated children are neurologically normal and one patient has clinically improved to a normal neurological status. The sixth patient has fixed neurological deficits that existed prior to treatment. Among the three cases with a follow-up period of over 2 years, complete obliteration has been angiographically confirmed in 2 patients and subtotal in 1 patient. In the three remaining patients with follow-up periods less than 2 years, serial MR images suggest subtotal obliteration in 2 cases and no significant change in one patient who had undergone treatment within the current year. To date, neither persistent GK radiosurgery-related complications nor bleeding following stereotactic radiosurgery has been described.

CONCLUSIONS

The review of literature and our preliminary results suggest that also in children, as in adults, the use of stereotactically delivered irradiation represents a safe and effective technique obtaining complete obliteration of AVMs previously considered surgically inaccessible due to their location and poor response to resection and/or embolization.