Nailfold videocapillaroscopy patterns in systemic sclerosis: implications for cutaneous subsets, disease features and prognostic value for survival

OBJECTIVES

To assess the associations and prognostic value of scleroderma patterns by nailfold videocapillaroscopy (NVC) in patients with systemic sclerosis (SSc) and cutaneous subsets.

METHODS

At baseline, 1356 SSc patients from the RESCLE registry were compared according to the scleroderma pattern as Late pattern and non-Late pattern, which included Early and Active patterns. Patient characteristics, disease features, survival time and causes of death were analysed.

RESULTS

Late pattern was identified in 540 (39.8%), and non-Late pattern in 816 (60.2%) patients (88% women; 987 lcSSc/251 dcSSc). Late pattern was associated to dcSSc (OR=1.96; p<0.001), interstitial lung disease (ILD) (OR=1.29; p=0.031), and scleroderma renal crisis (OR=3.46; p<0.001). Once the cutaneous subset was disregarded in an alternative analysis, both digital ulcers (DU) (OR=1.29; p<0.037) and anti-topoisomerase I antibodies (OR=1.39; p< 0.036) emerged associated with the Late pattern. By cutaneous subsets, associations with Late pattern were: (1) in dcSSc, acro-osteolysis (OR=2.13; p=0.022), and systolic pulmonary artery pressure >40 mmHg by Doppler echocardiogram (OR=2.24; p<0.001); and (2) in lcSSc, ILD (OR=1.38; p=0.028). Survival was reduced in dcSSc with Late pattern compared to non-Late pattern (p=0.049). Risk factors for SSc mortality in multivariate regression Cox analysis were age at diagnosis (HR=1.03; p<0.001), dcSSc (HR=2.48; p<0.001), DU (HR=1.38; p=0.046), ILD (HR=2.81; p<0.001), and pulmonary arterial hypertension (HR=1.99; p<0.001).

CONCLUSIONS

SSc patients with Late pattern more frequently present dcSSc and develop more fibrotic and vascular manifestations. Advanced microangiopathy by NVC identifies dcSSc patients at risk of reduced survival due to SSc-related causes.

Anti-U11/U12 Antibodies as a Rare but Important Biomarker in Patients with Systemic Sclerosis: A Narrative Review

Anti-nuclear (ANA) are present in approximately 90% of systemic sclerosis (SSc) patients and are key biomarkers in supporting the diagnosis and determining the prognosis of this disease. In addition to the classification criteria autoantibodies for SSc [i.e., anti-centromere, anti-topoisomerase I (Scl-70), anti-RNA polymerase III], other autoantibodies have been associated with important SSc phenotypes. Among them, anti-U11/U12 ribonucleoprotein (RNP) antibodies, also known as anti-RNPC-3, were first reported in a patient with SSc, but very little is known about their association and clinical utility. The U11/U12 RNP macromolecular complex consists of several proteins involved in alternative mRNA splicing. More recent studies demonstrated associations of anti-anti-U11/U12 antibodies with SSc and severe pulmonary fibrosis as well as with moderate to severe gastrointestinal dysmotility. Lastly, anti-U11/U12 autoantibodies have been strongly associated with malignancy in SSc patients. Here, we aimed to summarize the knowledge of anti-U11/U12/RNPC-3 antibodies in SSc, including their seroclinical associations in a narrative literature review.

Standardized incidence ratios and risk factors for cancer in patients with systemic sclerosis: Data from the Spanish Scleroderma Registry (RESCLE)

AIM

Patients with systemic sclerosis (SSc) are at increased risk of cancer, a growing cause of non-SSc-related death among these patients. We analyzed the increased cancer risk among Spanish patients with SSc using standardized incidence ratios (SIRs) and identified independent cancer risk factors in this population.

MATERIAL AND METHODS

Spanish Scleroderma Registry data were analyzed to determine the demographic characteristics of patients with SSc, and logistic regression was used to identify cancer risk factors. SIRs with 95% confidence intervals (CIs) relative to the general Spanish population were calculated.

RESULTS

Of 1930 patients with SSc, 206 had cancer, most commonly breast, lung, hematological, and colorectal cancers. Patients with SSc had increased risks of overall cancer (SIR 1.48, 95% CI 1.36-1.60; P < 0.001), and of lung (SIR 2.22, 95% CI 1.77-2.73; P < 0.001), breast (SIR 1.31, 95% CI 1.10-1.54; P = 0.003), and hematological (SIR 2.03, 95% CI 1.52-2.62; P < 0.001) cancers. Cancer was associated with older age at SSc onset (odds ratio [OR] 1.22, 95% CI 1.01-1.03; P < 0.001), the presence of primary biliary cholangitis (OR 2.35, 95% CI 1.18-4.68; P = 0.015) and forced vital capacity <70% (OR 1.8, 95% CI 1.24-2.70; P = 0.002). The presence of anticentromere antibodies lowered the risk of cancer (OR 0.66, 95% CI 0.45-0.97; P = 0.036).

CONCLUSIONS

Spanish patients with SSc had an increased cancer risk compared with the general population. Some characteristics, including specific autoantibodies, may be related to this increased risk.

Anti-Polymyositis/Scl Antibodies in Systemic Sclerosis: Clinical Associations in a Multicentric Spanish Cohort and Review of the Literature

OBJECTIVES

To assess the clinical profile of patients with anti-polymyositis/Scl (PM/Scl) antibodies in a cohort of Spanish patients with systemic sclerosis.

METHODS

From the Spanish Scleroderma Study Group database, we selected patients in whom PM/Scl antibodies had been tested. We compared demographic, clinical, laboratory, and survival data between patients with and without PM/Scl antibodies.

RESULTS

Seventy-two of 947 patients (7.6%) tested positive for PM/Scl antibodies. Patients with PM/Scl antibodies presented initially with more puffy fingers and arthralgias but less Raynaud phenomenon. Regarding cumulative manifestations, myositis and arthritis were more prevalent in patients with PM/Scl antibodies, as well as pulmonary fibrosis. On the contrary, patients with PM/Scl antibodies had less pulmonary hypertension. No difference in terms of survival at 5 and 10 years was noticed between the 2 groups.

CONCLUSIONS

In systemic sclerosis patients from Spain, PM/Scl antibodies are associated with a distinct clinical profile. However, PM/Scl antibodies did not influence survival.

POS0427 CLINICAL CHARACTERISTICS OF PATIENTS WITH SYSTEMIC SCLEROSIS AND GASTRIC ANTRAL VASCULAR ECTASIA (GAVE)

Background:

Gastric antral vascular ectasia (GAVE) is one of the gastrointestinal (GI) manifestations related to systemic sclerosis (SSc). It can be presented as iron deficiency anemia or even upper gastrointestinal bleeding. GAVE is diagnosed by endoscopy observing an image of confluent vascular ectasias that is oriented longitudinally on the folds of the antrum in the appearance of “watermelon”. The definitive treatment for this manifestation consists in endoscopy guided fulguration when the clinical situation allows it.

Objectives:

The objective was to study a cohort of SSc patients at their first endoscopy. The clinical characteristics, laboratory tests and treatments received from SSc patients with GAVE were compared to those without this GI manifestation.

Methods:

From the cohort of patients with SSc in Hospital Universitari Vall d’Hebron, a total of 269 patients who had undergone at least one endoscopy during follow-up were selected. Twenty seven were diagnosed with GAVE. We compared the clinical, analytical and treatment characteristics of these patients with the remaining 242 who did not present GAVE. The statistical study was carried out using the SPSS 20.0 package (Chicago, IL), a p <0.05 was considered as statistical significance.

Results:

The prevalence of GAVE in SSc patients was 10.0%. Patients with GAVE had a higher median age SSc onset taking into account the first non-Raynaud’s phenomenon (RP) symptom attributable to the disease (56.6 vs 48.0 years, p = 0.001). The median age at first endoscopy was 56.5 years in GAVE group compared with 61.7 in the group without GAVE.

Compared with SSc patients without GAVE, patients with GAVE had a higher prevalence of Barrett’s esophagus (14.8% vs. 3.7%, p = 0.011), intestinal involvement (37% vs. 18.6%, p = 0.024) and a trend towards a lower prevalence of interstitial lung disease (25.9% vs 45.0%, p = 0.057).

No difference was identified in the prevalence of scleroderma renal crisis. Patients with GAVE presented a higher frequency of early or active Cutolo capillaroscopy pattern with a predominance of enlarged capillaries or megacapillaries (84.6% vs 62.4%, p = 0.025), greater frequency of anti-centromere antibodies (63.0% vs. 42.1%, p = 0.039) and a trend towards a lower proportion of anti-topoisomerase I (3.7% vs. 18.6%, p = 0.052). No difference was found in prevalence of anti-RNA polymerase III antibodies between groups. Patients with GAVE were treated less frequently with non-glucocorticoid immunosuppressants prior to diagnostic endoscopy (0% vs 20.2%, p = 0.010). The 33.3% of patients with GAVE were treated with endoscopic fulguration, and 66.7% of them received supplementary treatment with oral iron.

Conclusion:

SSc patients with GAVE had higher age at SSc onset, more frequency of Barrett’s esophagus and intestinal involvement, prevalence of anti-centromere antibodies, early or active Cutolo scleroderma pattern and lower prior non-glucocorticoids treatment.

References:

[1]Ghrénassia E, Avouac J, Khanna D, T.Derk C, Distler O, Suliman Y, et al. Prevalence, Correlates and Outcomes of Gastric Antral Vascular Ectasia in Systemic Sclerosis: A EUSTAR Case-control Study. The Journal of Rheumatology. 2014; 41:1.

Disclosure of Interests:

None declared

The incidence rate of pulmonary arterial hypertension and scleroderma renal crisis in systemic sclerosis patients with digital ulcers on endothelin antagonist receptors (ERAs) and phosphodiesterase-5 inhibitors (PDE5i)

INTRODUCTION

Endothelin antagonist receptors (ERAs) and phosphodiesterase-5 inhibitors (PDE5i) are beneficial in pulmonary arterial hypertension (PAH) and digital ulcers (DU) and prevent from DU recurrences. Our study aimed to determine the difference in the incidence rate of PAH and scleroderma renal crisis (SRC) in patients with SSc and DU (SSc-DU) under ERAs/PDE5i or without treatment.

METHODS

We conducted a retrospective cohort study including SSc-DU patients from the Spanish Scleroderma Registry (RESCLE). The primary outcome was the incidence rate of PAH and SRC in patients under ERAs/PDE5i or not.

RESULTS

Some 544 patients out of 1817 (29.9%) in the RESCLE database had DU, 221 (40.6%) under ERAs/PDE5i and 323 (59.4%) not. The incidence rate (95% CI) difference between patients under treatment or not under did not reach statistical significance in PAH [-0.1 (-4.8, 4.69), P = 0.988] or in SRC [0.7 (-2.2, 3.7), P = 0.620]. However, the time from the first DU to the diagnosis of SRC was delayed in treated patients [mean (s.d.) 7.6 (5.8) years vs 2.9  (5.3); P = 0.021]. The dcSSc subset was more prevalent in the treatment group (36 vs 26%; P = 0.018), along with anti-topoisomerase I antibodies (34 vs 18%; P < 0.001) and tendon friction rubs (12 vs 6%; P = 0.038), whereas the lcSSc subset was more prevalent in the no-treatment group (57 vs 66%; P = 0.031) along with ACA (37 vs 46%; P = 0.031).

CONCLUSION

There was no difference in the incidence rate of PAH and SRC between groups. However, treatment with ERAs and/or PDE5i appeared to delay the occurrence of SRC.

AB0558 RISK FACTORS FOR THE DEVELOPMENT OF BREAST CANCER IN SYSTEMIC SCLEROSIS

Background:

Prior literature shows a global increase of cancer risk among patients with systemic sclerosis (SSc). Although breast cancer (BC) is one of the most frequent malignancies in SSc patients, the characteristics of this neoplasm among SSc patients is not well established and it is uncertain whether SSc significantly increases the risk of this cancer.

Objectives:

Describe the characteristics and risk factors for BC among Spanish patients with SSc.

Methods:

Ambispective and multicenter study of patients with a diagnosis of SSc according to ACR/EULAR criteria and/or LeRoy classification included in the Spanish Scleroderma Registry (RESCLE) from 2006 to 2018. Characteristics of patients with BC were described and incidence was compared with that of the general population.

Results:

Among 1930 patients with SSc, 206 (10.7%) had cancer. BC was the most frequent tumor location (47 patients of 206 with cancer [22.8%]), followed by lung cancer (29, 14.1%). The risk of BC was increased in patients with SSc compared to the general population (standardized incidence ratio [SIR] 1.31; 95% CI 1.10-1.54;P= 0.003).

The comparison of patients with BC and those without cancer showed that patients with BC had older age at diagnosis of SSc (50.9 vs 45.9 years, respectively;P=0.004), were more frequently diagnosed of interstitial lung disease (ILD) (30/47 [63.8%] vs 694/1714 [40.5];P= 0.002) and pulmonary hypertension (12/24 [50.0%] vs 262/917 [28.6%];P= 0.037), had higher frequency of puffy hands as the first manifestation of SSc (4/45 [8.9%] vs 38/1664 [2.3 %];P= 0.023) and had more frequently primary biliary colangitis (PBC) (7 /46 [15.2%] vs 72 /1708 [4.2%];P= 0.004). Regarding autoimmunity profile, patients with SSc and BC had a significantly higher presence of anti-Ro (11/44 [25.0%] vs 214/1528 [14.0%];P= 0.049) and anti-mitochondrial antibodies (7/28 [25.0%] vs 96/837 [11.5%];P= 0.039). Multivariable regression analysis showed an independent association between the puffy hands (OR = 6.40; 95% CI 1.73-23.60;P= 0.005), diagnosis of PBC (OR = 5.70; 95% CI 2.16-15.07;P= 0.001), presence of ILD (OR = 3.29, 95% CI 1.69-6.39;P<0.001) and the presence of the anti-Ro antibody (OR 2.14; 95% CI 1.01-4.56;P= 0.048) with the presence of BC.

Conclusion:

BC risk was increased in patients with SSc. The development of ILD, PBC, the presence of anti Ro and puffy hands as the first clinical manifestation of SSc were identified as independent factors associated with the development of BC in our cohort.

References:

Colaci M et al. Breast cancer in systemic sclerosis: results of a cross-linkage of an Italian Rheumatologic Center and a population-based Cancer Registry and review of the literaure. Autoimmun Rev. 2014;13(2):132-7.

Zhang JQ et al. The risk of cancer development in systemic sclerosis: a meta-analysis. Cancer Epidemiol. 2013;37(5):523-7.

Disclosure of Interests:

Cristina Carbonell: None declared, Antonio-J Chamorro: None declared, Miguel Marcos: None declared, Alfredo Guillén del Castillo: None declared, Dolores Colunga Argüelles Consultant of: Actelion pharmaceuticals, GSK, MSD., Manuel Rubio-Rivas: None declared, Ana Argibay: None declared, Begoña Marí-Alfonso: None declared, Adela Marín Ballvé: None declared, Antoni Castro Consultant of: Actelion pharmaceuticals, GSK, MSD., Ana Belén Madroñero-Vuelta: None declared, Eduardo L. Callejas-Moraga: None declared, Vicent Fonollosa-Pla Consultant of: Actelion pharmaceuticals, GSK, MSD., Carmen Pilar Simeón-Aznar Consultant of: Actelion pharmaceuticals, GSK, MSD., on behalf of RESCLE Investigators, Autoimmune Diseases Study Group (GEAS): None declared

SAT0322 PREVALENCE AND RISK FACTORS FOR LEFT VENTRICULAR DIASTOLIC DYSFUNCTION IN SYSTEMIC SCLEROSIS: RESULTS FROM RESCLE REGISTRY

Background:

Left ventricular diastolic dysfunction (LVDD) is a very common finding in heart involvement in Systemic Sclerosis (SSc).

Objectives:

To determine the prevalence, risk factors and mortality associated with LVDD in a cohort of patients with SSc.

Methods:

A retrospective study was conducted with data from the multicentre Spanish Scleroderma Registry (RESCLE). A case-control study was performed to identify factors associated with LVDD.

Results:

Out of 1517 cases of SSc, 319 (21%) developed LVDD. Basal characteristics are shown in Table 1. In multivariate analysis, LVDD was associated to older age at diagnosis of SSc [54 vs 44 years, OR 1.05 (1,04-1.06)], presence of telangiectasia [67 vs 59%, OR 1.42 (1,88-1.08)], and treatment with calcium channel blockers [50 vs. 45%, OR 1.55 (1.16-1.96)], and inversely correlated to treatment with ACE inhibitors [74 vs. 83%, OR 0.59 (0.44-0.8)]. Mortality was increased in patients with LVDD (24 vs 17%, OR 1.4, p = 0.01). Kaplan–Meier cumulative survival for the SSc cohort, according to the presence or absence of LVDD showed significant differences in 30 years from the first SSc symptom (59 vs. 70%, p = 0.04).

Table 1.Number of patients1517319 (21%)1198 (79%)PLimited SSc923 (61%)201 (63%)722 (60%)0.438Diffuse SSc304 (20%)51 (16%)253 (21%)0.041Sine Sclerodema SSc174 (11%)47 (15%)127 (11%)0.048Age at disease onset(years) med±SD46.4±16.554.1±15.944.5±16.1<0.001Arterial hypertensión491 (33%)148 (48%)343 (30%)<0.001Digital ulcers615 (41%)108 (34%)507 (42%)0.006Telangiectasia918 (61%)212 (67%)706 (59%)0.011Interstitial lung disease645 (43%)153 (48%)492 (41%)0.021Pulmonary hypertension139 (9.2%)34 (11%)105 (8.8%)0.325Capillaroscopy Slow pattern673 (51%)130 (46%)543 (53%)0.038Centromere Antibodies679 (49%)154 (55%)525 (48%)0.032

Conclusion:

In our cohort, LVDD is relative common in SSc patients, and it is associated with older age at diagnosis, treatment with calcium channel blockers and telangiectasia. ACE inhibitors could play a protective role against the development of LVDD. Mortality is higher in SSc patients with LVDD, and is more significative over time.

References:

[1]Tennøe AHet al. Left Ventricular Diastolic Dysfunction Predicts Mortality in Patients with Systemic Sclerosis. J Am Coll Cardiol. 2018;72:1804-13

Disclosure of Interests:

Andrés González: None declared, Jose Luis Patier: None declared, Mónica López-Rodríguez: None declared, Alfredo Guillén del Castillo: None declared, Manuel Rubio-Rivas: None declared, Ana Argibay: None declared, Begoña Marí-Alfonso: None declared, Antonio-J Chamorro: None declared, Ana Belén Madroñero-Vuelta: None declared, Eduardo L. Callejas-Moraga: None declared, Cristina González-Echávarri: None declared, Norberto Ortego: None declared, Vicent Fonollosa-Pla Consultant of: Actelion pharmaceuticals, GSK, MSD., Carmen Pilar Simeón-Aznar Consultant of: Actelion pharmaceuticals, GSK, MSD., on behalf of RESCLE Investigators, Autoimmune Diseases Study Group (GEAS): None declared

THU0361 EPIDEMIOLOGIC VARIATION ON SCLERODERMA RENAL CRISIS AND CLINICAL FEATURES VARIATION ON SYSTEMIC SCLEROSIS PATIENTS OVER TIME: DATA FROM RESCLE REGISTRY

Background:

Scleroderma renal crisis (SRC) prevalence is decreasing. However, no Systemic Sclerosis (SSc) patient’s registry has evaluated that decrease over time. No treatment have been able to prevent SRC development.

Objectives:

Primary objective: to identify SRC prevalence in 2 periods in the RESCLE(Registro deESCLErodermia) registry. Secondary objective: to idenfy which features could justify that change on SRC prevalence.

Methods:

Up to December 2018, 1937 SSc patients were included by 31 referral centers in RESCLE registry. SRC prevalence and incidence in diagnosed patients before and after 2003 was determined. Clinical characteristics of diagnosed patients in each period of time were analysed to identify differences between them.

Results:

Out of 1937 SSc, 43 (2.2%) developed SRC. Prevalence of SRC before and after 2003 was 3.5% and 1.08%. SRC Incidence: Graphic 1. Significant differences between Pre-2003 vs. Post-2003 SSc cohorts were found in univariate analysis: Table 1 and 2.

Table. 1.

Univariate analysis

Pre-2003(%)Post-2003(%)Demographic datalcSSc6359dcSSc2815ssSSc6.414Early SSc1.13.3Very early SSc1.99.6Age at SSc dx49.1(±15.2)y55.0(±15.6)yTime from SSc dx to SRC1.1(0.2-4.3)y0.6(0.1-1.5)yACR/EULAR 2013 criteria9986ComorbiditiesSmoked2037Arterial hypertension3529Diagnostic proceduresPAPs >40mmHg by Echocardiography3825Not-sclerodermal pattern at VCS8.919Lupus anticoagulant124.8Prognostic featuresOverall mortality2911ILD-related death101.6

Conclusion:

SRC Prevalence and Incidence has decreased. Prevalence is three-fold in diagnosed SSc cohort pre-2003 than in post-2003. The post-2003 cohort showed lesser prevalence of dcSSc subtype, earlier SSc diagnosis, less organic involvement and more intensive treatment than pre-2003 cohort. All these findings could explain the decline in the SRC prevalence.

Figure:

Table 2.

Univariate analysis

Pre-2003 (%)Post-2003 (%)Clinical dataSkin sclerosis (as 1stsymptom)7.24.1Digital ulcers4931Telangiectasia6652Acroosteolysis124.6Calcinosis2914Joint contractures2813ILD4937Cardiac conduction alteration2027Left diastolic dysfunction4132Peripheral neuropathy136.1Sicca syndrome3724Treatment featuresCalcium channel blockers2340Specific vasodilators2.114Prostaglandin0.993.4Angiotensin system inhibitors5.116Corticosteroids1120Immunosuppressant315

y: years old; lcSSc: limited cutaneous SSc; dcSSc: diffuse cutaneous SSc; ssSSc: sine scleroderma SSc; ILD: Interstitial lung disease; PAPs: systolic Pulmonary Arterial Pressure; VCS: Video-capillaroscopy; dx: diagnosis

Disclosure of Interests:

Xavier Pla Salas: None declared, Carles Tolosa Consultant of: Actelion pharmaceuticals, GSK, MSD., Alfredo Guillén del Castillo: None declared, María Esther Sánchez García: None declared, Jorge Sánchez-Redondo: None declared, Eduardo L. Callejas-Moraga: None declared, Luis Sáez-Comet: None declared, Jose Antonio Vargas-Hitos: None declared, Jose Antonio Todolí Parra: None declared, Luis Trapiella Martínez: None declared, Ignasi Rodriguez-Pubto: None declared, Mayka Freire: None declared, Isaac Pons Martin del Campo: None declared, Vicent Fonollosa-Pla Consultant of: Actelion pharmaceuticals, GSK, MSD., Carmen Pilar Simeón-Aznar Consultant of: Actelion pharmaceuticals, GSK, MSD., on behalf of RESCLE Investigators, Autoimmune Diseases Study Group (GEAS): None declared

FRI0242 IMPACT OF PULMONARY ARTERIAL HYPERTENSION WITH OR WITHOUT INTERSTITIAL LUNG DISEASE ON SCLERODERMA: A RETROSPECTIVE COHORT STUDY FROM THE NATIONWIDE SPANISH SCLERODERMA (RESCLE) AND PULMONARY ARTERIAL HYPERTENSION (REHAP) REGISTRIES

Background:

Pulmonary arterial hypertension (PAH) and interstitial lung disease (ILD) are the major life-threatening complications in systemic sclerosis (SSc). Data on the impact of PAH and/or ILD in SSc patients (pts) are limited by their low prevalence.

Objectives:

To assess differences in demographic/clinical characteristics of SSc pts according to presence of PAH and how these are affected by ILD. The impact on characteristics and survival of PAH + ILD was also assessed.

Methods:

We compared data on SSc pts without PAH from the Spanish registry of patients with SSc (RESCLE) (SSc pts) and SSc pts with PAH from the Spanish registry of pts with PAH (REHAP) (SSc-PAH pts). Only data common in both registries were analyzed. Sub analyses were performed according to the presence/absence of ILD. Transplant-free survival from diagnosis of PAH was estimated using the Kaplan-Meier method.

Results:

1,579 pts with SSc (RESCLE) and 364 pts with SSc-PAH (REHAP) were analyzed. Compared to SSc pts, SSc-PAH pts had worse functional status (NYHA FC III/IV: 70.6% vs. 8.2% in SSc pts) and pulmonary function (lower mean forced vital capacity [FVC, 81.2±20.6% vs. 93.6±20] and diffusing capacity for carbon monoxide [DLCO, 45.3±17.7% vs. 79.0±36.6%]). More patients had FVC/DLCO ≥1.4 (77.8% vs. 34.8%), tricuspid regurgitation (91.4% vs. 46.1%) or pericardial effusion (30.0% vs. 5.1%). Mean systolic pulmonary artery pressure (sPAP) was higher (70.0±21.3 vs. 27.5±9.1 mmHg) (all respectively; P<0.001 for all). Prevalence of ILD on high-resolution computerized tomography was similar (44.9% [n=92] vs. 41.8% [n=422] in SSc pts; P=0.408). These differences were also found when splitting both cohorts according to the presence / absence of ILD. Compared to SSc-PAH pts without ILD (n=128), pts with PAH + ILD (n=92) had worse functional status (NYHA FC III: 69.6% vs. 55.5% in SSc-PAH pts without ILD; P=0.036), lower mean FVC (70.9±21.9 vs. 86.2±18.6) and lower DLCO (39.4 ±17.0 vs. 49.1±17.9) both P<0.001. Five-year survival rate was 35% in SSc-PAH pts with ILD vs. 45% in SSc-PAH without ILD (P=0.444 [figure 1]).

Conclusion:

PAH has a profound impact on functional status, pulmonary function and right ventricle function of SSc patients, independently of presence of ILD. Despite the deleterious effect of functional status and pulmonary function, in pts with SSc and PAH, presence of concomitant ILD has no impact on 5-year survival.

Disclosure of Interests:

Alfredo Guillén-del-Castillo Consultant of: Actelion pharmaceuticals, GSK, MSD., Manuel López-Meseguer Consultant of: Actelion pharmaceuticals, GSK, MSD., Carles Tolosa Consultant of: Actelion pharmaceuticals, GSK, MSD., Antonio Romás Broto Consultant of: Actelion pharmaceuticals, GSK, MSD., Dolores Colunga Argüelles Consultant of: Actelion pharmaceuticals, GSK, MSD., Isabel Blanco Consultant of: Actelion pharmaceuticals, GSK, MSD., Antoni Castro Consultant of: Actelion pharmaceuticals, GSK, MSD., Raquel López Reyes Consultant of: Actelion pharmaceuticals, GSK, MSD., Adela Marín Ballvé: None declared, Isabel Otero González Consultant of: Actelion pharmaceuticals, GSK, MSD., Vicent Fonollosa-Pla Consultant of: Actelion pharmaceuticals, GSK, MSD., Ernest Sala LLinas Consultant of: Actelion pharmaceuticals, GSK, MSD., Pilar Escribano Subías Consultant of: Actelion pharmaceuticals, GSK, MSD., Carmen Pilar Simeón-Aznar Consultant of: Actelion pharmaceuticals, GSK, MSD.

Longterm Efficacy and Safety of Monotherapy versus Combination Therapy in Systemic Sclerosis–associated Pulmonary Arterial Hypertension: A Retrospective RESCLE Registry Study

Objective.

Monotherapy is an option as first-line therapy for pulmonary arterial hypertension (PAH). However, combination therapy is a beneficial alternative. Our objective was to evaluate the efficacy of monotherapy versus combination therapy in patients with systemic sclerosis (SSc)–associated PAH.

Methods.

All patients with SSc-associated PAH from the Spanish Scleroderma Registry (RESCLE) were reviewed. Patients were split into 3 groups: monotherapy versus sequential combination versus upfront combination therapy. The primary endpoint was death from any cause at 1, 3, and 5 years from PAH diagnosis.

Results.

Seventy-six patients (4.2%) out of 1817 had SSc-related PAH. Thirty-four patients (45%) were receiving monotherapy [endothelin receptor antagonist (n = 22; 29%) or phosphodiesterase-5 inhibitors (n = 12; 16%)], 25 (33%) sequential combination, and 17 (22%) upfront combination therapy. A lower forced vital capacity/DLCO in the sequential combination group was reported (2.9 ± 1.1 vs 1.8 ± 0.4 vs 2.3 ± 0.8; p = 0.085) and also a higher mean pulmonary arterial pressure in combination groups (37.2 ± 8.7 mmHg vs 40.8 ± 8.8 vs 46 ± 15.9; p = 0.026) at baseline. Treatment regimen (p = 0.017) and functional class (p = 0.007) were found to be independent predictors of mortality. Sequential combination therapy was found to be an independent protective factor (HR 0.11, 95% CI 0.03–0.51; p = 0.004), while upfront combination therapy showed a trend (HR 0.68, 95% CI 0.23–1.97; p = 0.476). Survival from PAH diagnosis among monotherapy, sequential, and upfront combination groups was 78% versus 95.8% versus 94.1% at 1 year, 40.7% versus 81.5% versus 51.8% at 3 years, and 31.6% versus 56.5% versus 34.5% at 5 years (p = 0.007), respectively. Side effects were not significantly different among groups.

Conclusion.

Combination sequential therapy improved survival in our cohort.

Pulmonary hypertension in Spanish patients with systemic sclerosis. Data from the RESCLE registry

INTRODUCTION

Our objective was to evaluate the pulmonary hypertension (PH) data for Spanish patients with systemic sclerosis (SSc), define the PH types and determine the associated factors.

METHOD

Descriptive study of PH-related data from the multicentre RESCLE registry. Estimated systolic pulmonary artery pressure (esPAP), measured via echocardiogram was considered elevated if ≥ 35 mmHg. Left heart disease (LHD) and interstitial lung disease (ILD) were identified. When performed, data from right heart catheterisation (RHC) were collected.

RESULTS

esPAP was elevated in 350 of 808 patients (43.3%). One hundred and forty-four patients (17.8%) were considered to have PH (88 via RHC and the rest due to elevated esPAP along with evidence of significant LHD or ILD): PAH 3.7%, secondary to ILD 8.3%, secondary to LHD 2.8% and unclassified 3%. Prevalence of elevated esPAP was greater in diffuse SSc (dSSc) than in limited scleroderma (lSSc) (50.5 vs. 42.2%, p 0.046). In the group with elevated esPAP, a lower prevalence of anti-centromere antibodies (41.9% vs. 52.3%, p 0.006) and a greater prevalence of anti-topoisomerase-1 antibodies (ATA) (25.1% vs. 18.6%, p 0.04) were observed compared to the group with normal esPAP. Patients with elevated esPAP had a lower rate of digital ulcers (50.6% vs. 60.2%, p 0.007) and esophageal involvement (83.6% vs. 88.7%, p 0.07) and higher rate of renal crisis (4.6% vs. 1.8%, p 0.066).

CONCLUSIONS

Prevalence of PAH was lower than expected (3.7%). Probability of having elevated esPAP was higher among patients with dSSc and among those with ATA.

First clinical symptom as a prognostic factor in systemic sclerosis: results of a retrospective nationwide cohort study

The objective of the study is to determine the importance of the mode of onset as prognostic factor in systemic sclerosis (SSc). Data were collected from the Spanish Scleroderma Registry (RESCLE), a nationwide retrospective multicenter database created in 2006. As first symptom, we included Raynaud's phenomenon (RP), cutaneous sclerosis, arthralgia/arthritis, puffy hands, interstitial lung disease (ILD), pulmonary arterial hypertension (PAH), and digestive hypomotility. A total of 1625 patients were recruited. One thousand three hundred forty-two patients (83%) presented with RP as first symptom and 283 patients (17%) did not. Survival from first symptom in those patients with RP mode of onset was higher at any time than those with onset as non-Raynaud's phenomenon: 97 vs. 90% at 5 years, 93 vs. 82% at 10 years, 83 vs. 62% at 20 years, and 71 vs. 50% at 30 years (p < 0.001). In multivariate analysis, factors related to mortality were older age at onset, male gender, dcSSc subset, ILD, PAH, scleroderma renal crisis (SRC), heart involvement, and the mode of onset with non-Raynaud's phenomenon, especially in the form of puffy hands or pulmonary involvement. The mode of onset should be considered an independent prognostic factor in systemic sclerosis and, in particular, patients who initially present with non-Raynaud's phenomenon may be considered of poor prognosis.

Changes in the pattern of death of 987 patients with systemic sclerosis from 1990 to 2009 from the nationwide Spanish Scleroderma Registry (RESCLE)

OBJECTIVES

To determine the changes in the pattern of death of patients with systemic sclerosis (SSc) throughout 20 years.

METHODS

Data were collected from the Spanish Scleroderma Registry (RESCLE), retrospective multicentre database from 1990 to 2009. SSc-related and SSc-non related causes of death were assessed.

RESULTS

987 patients were recruited. Overall standardised mortality ratio (SMR) was 2.34 (2.24-2.44). SSc-related causes of death were responsible of 72% of all deaths of those patients diagnosed within 1990-99 vs. 48% within 2000-09 (p=0.006). Relative pulmonary death rate was stable over time (68.1% within 1990-99 vs. 63.9% within 2000-09, p=0.815). Relative renal death rate was decreasing over time (17% within 1990-99 vs. 5.5% within 2000-09, p=0.175). Heart distribution tripled its ratio (12.8% within 1990-99 vs. 30.6% within 2000-09, p=0.058).

CONCLUSIONS

SSc-related causes of death were decreasing over time and, among them, pulmonary involvement was the leading cause of death in both decades. The ratio of renal causes decreased since 1990 at the time that the ratio of cardiac causes increased.

Novel risk factors related to cancer in scleroderma

OBJECTIVE

Emerging data have shown an increased risk of malignancy among patients diagnosed with systemic sclerosis (SSc) so identification of risk factors linking both disorders might have prognostic implications. The aim of this study was to assess the clinical and treatment-related risk factors for cancer in a single-center cohort of patients with SSc.

METHODS

Demographic, clinical, capillaroscopic, immunological and treatment-related data from 432 consecutive SSc patients were retrospectively analyzed. Variables that reached significant association in the univariate analysis were entered into a logistic regression in order to identify independent risk factors for cancer.

RESULTS

Malignancy was diagnosed in 53 patients (12.2%). Fifty-eight neoplasms were identified, among which breast (n=15), lung (n=10) and hematologic (n=9) malignancies were the most prevalent. In 19 patients the diagnosis of both scleroderma and tumour was made in <3years apart. Cancer significantly decreased the probability of survival (OR=2.61; 95%CI 1.46-4.69; p=0.001). No association with age, sex, smoking, cutaneous subset or RNA polymerase-III antibodies was found. However, risk of cancer was directly associated with the presence of anti-PM/Scl antibodies (OR=3.90; 95%CI 1.31-11.61; p=0.014), and inversely related to aspirin use (OR=0.33; 95%CI 0.12-0.90; p=0.031), which remained as independent risk factors for cancer on multivariate analysis.

CONCLUSIONS

PM/Scl antibodies seem to be associated with a higher risk of cancer in scleroderma. In contrast, the use of aspirin is related to a lower risk of cancer in our series. More studies are needed to ascertain the role of anti PM/Scl antibodies and aspirin in the development of malignancy among patients with SSc.

Applying the ACR/EULAR Systemic Sclerosis Classification Criteria to the Spanish Scleroderma Registry Cohort

OBJECTIVE

To compare American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) classification criteria for systemic sclerosis (SSc) with previous American Rheumatology Association (ARA) criteria.

METHODS

This was a cross-sectional multicenter study comparing sensitivity of both criteria in the cutaneous subsets in the Spanish scleroderma registry (RESCLE) cohort.

RESULTS

In 1222 patients with SSc, the most prevalent items were Raynaud phenomenon (95%), skin thickening (91%), and abnormal capillaroscopy (89%). ARA criteria classified as SSc 63.5% of all patients, and 63%, 100%, 11.2%, and 0% in the limited, diffuse, sine, and pre-SSc subsets, respectively. ACR/EULAR criteria classified 87.5% of all patients and 98.5%, 100%, 41.8%, and 15.9% in the same subsets, respectively.

CONCLUSION

ACR/EULAR criteria are more sensitive than ARA criteria, especially in limited, sine, and pre-SSc subsets.

Pleural irregularity, a new ultrasound sign for the study of interstitial lung disease in systemic sclerosis and antisynthetase syndrome

OBJECTIVES

To evaluate a new ultrasound sign, pleural irregularity (PI), for the study of interstitial lung disease (ILD) in patients with systemic sclerosis (SSc) and antisynthetase syndrome (ASS).

METHODS

The study included patients from our SSc and ASS cohorts with varying degrees of ILD, enrolled from 2011 to 2014. Chest high-resolution computed tomography (HRCT), pulmonary function tests (FVC and DLCO) and chest sonography were performed in each patient. Ultrasound PI and B-lines were quantified using a 72-sonographic point score and HRCT lung abnormalities were quantified using Warrick and Wells scores and categorised through Goh's algorithm. PI was correlated with HRCT and pulmonary function test parameters and its diagnostic performance to detect and classify the extent of ILD was evaluated and compared with B-lines.

RESULTS

Thirty-seven patients were studied, 21 with ASS and 16 with SSc (8 without ILD). PI correlated with the Warrick score both in SSc (r=0.6, p=0.01) and ASS patients (r=0.6, p=0.005), showing a higher performance to detect ILD than using B-lines (p=0.01). In SSc patients PI also correlated with Wells score (r=0.7, p<0.001) and with DLCO (r=-0.5, p=0.05), showing a high diagnostic value for detecting ILD (AUC=0.85, 95% CI 0.64-1) and classifying it into limited or extensive (AUC=0.81, 95% CI 0.57-1). A modification of the Goh algorithm including PI was developed as a screening tool to avoid the use of HRCT in SSc patients without ultrasound evidence of extensive ILD.

CONCLUSIONS

PI is useful for evaluation of ILD in SSc and ASS patients, and can be incorporated into a diagnostic algorithm in SSc patients to reducing the need for exposure to ionising radiation.

Good outcome of interstitial lung disease in patients with scleroderma associated to anti-PM/Scl antibody

OBJECTIVE

The objective of this article was to establish the clinical course of interstitial lung disease (ILD) in scleroderma related to the presence of anti-PM/Scl antibody compared with anti-Scl-70 in a Spanish cohort. Furthermore, no study has thoroughly investigated the outcome of pulmonary function test in the first group of patients.

METHODS

A total of 63 Spanish patients with scleroderma and ILD were selected in a retrospective observational study. Among them, 14 were positive for anti-PM/Scl antibodies and 49 for anti-Scl-70. Clinical assessments, including pulmonary function test, were collected. Variations equal or greater than 10% in forced vital capacity (FVC) were considered significant. Progression-free survival of disease was defined as the period of stable illness since pulmonary fibrosis diagnosis.

RESULTS

Anti-Scl-70 patients had a higher frequency of diffuse SSc subset, peripheral vasculopathy, and gastrointestinal involvement. Inflammatory myopathy was associated to anti-PM/Scl antibody. Anti-PM/Scl patients presented more improvement in FVC during follow-up, 30.8% compared to a 7.1% in Scl-70 group (P = 0.04), with less worsening of this parameter (15.4% vs 52.4% in Scl-70 patients, P = 0.01), and secondary less frequency of severe restrictive pattern (FVC < 50%) (7.7% compared to 42.9% in the other group, P = 0.02). Regarding treatment, more anticalcineurinics were used in anti-PM/Scl patients, while cyclophosphamide and mycophenolate were mainly used in anti-Scl-70 patients. The progression-free survival of disease was higher in anti-PM/Scl patients, with 76% at 10 years from diagnosis of ILD against a 29% in the Scl-70 group.

CONCLUSIONS

Several features and prognosis of ILD in SSc may be modified depending on the identified immunological profile.

Anti-PDGFR-alpha antibodies measured by non-bioactivity assays are not specific for systemic sclerosis

OBJECTIVE

To evaluate the presence of anti-PDGFR-alpha antibodies by immunological methods in patients with systemic sclerosis (SSc).

METHODS

Fifty-eight women diagnosed with SSc and 36 healthy women controls were included. IgG anti-PDGFR-alpha were measured by ELISA and immunoblot. Associations with clinical and immunological findings were also studied.

RESULTS

Non-significant differences were detected between patients with SSc and controls: median value 0.287 (range 0-2.06) versus median value 0.226 (range 0-2.94), respectively (p = 0.583). No correlation between the presence of anti-PDGFR-alpha antibodies and clinical and serological features was found. Serum samples from patients with SSc and healthy people who had high titres of anti-PDGFR-alpha antibodies by ELISA recognised the same band corresponding to PDGFR-alpha by immunoblot.

CONCLUSION

Although anti-PDGFR-alpha antibodies seem to be disease-specific when determined by bioactivity assays, these antibodies are also detected in normal subjects when immunological methods are used. Thus, anti-PDGFR-alpha antibodies may arise from natural autoantibodies. Possibly, SSc autoantibodies recognise a different epitope on the PDGFR-alpha molecule which triggers its stimulatory effect when analysed by functional assays. Alternatively, naturally occurring autoantibodies may even become pathogenic after affinity maturation and class switching in genetically susceptible subjects.

Lack of association of the PTPN22 gene polymorphism R620W with systemic sclerosis

OBJECTIVE

It has recently been reported that some autoimmune diseases seem to be associated with a functional polymorphism in PTPN22, a gene which encodes a phosphatase known to be important in T-cell signaling. The aim of our study was to check for the prevalence of the PTPN22 R620W polymorphism in patients with systemic sclerosis.

METHODS

DNA samples from 54 systemic sclerosis patients and 55 healthy controls were obtained from peripheral blood and genotyping was performed by means of a restriction fragment length polymorphism analysis of PCR products (RFLP-PCR).

RESULTS

Allele frequency for the T allele was slightly higher in the patients group (0.074 versus 0.055). Eight out of the 54 systemic sclerosis patients (14.8 %) were heterozygous for this single nucleotide polymorphism whereas the CT genotype was found in 6 out of the 55 controls (10.9%). Nevertheless, the difference did not reach statistical significance (p = 0.542). Neither certain antibodies linked to systemic sclerosis (anti-centromere and anti-topoisomerase I antibodies) nor any particular clinical involvement were associated with the polymorphism.

CONCLUSION

This particular single nucleotide polymorphism of PTPN22 does not seem to be associated with systemic sclerosis.

Lack of evidence of foetal microchimerism in female Spanish patients with systemic sclerosis

Our objective was to study the presence of microchimerism in a series of 47 female Spanish patients with scleroderma (SSc) and to compare with a control group. Polymerase chain reaction was used to identify Y-chromosome sequences in DNA extracted from peripheral blood cells. Y-chromosome sequences were found in DNA from peripheral blood cells in four out of 47 (8.5%) patients with scleroderma (two limited and two diffuse) and in two out of 40 (5%) healthy women (no statistical differences were found). When we compared SSc patients and healthy controls who had had at least one male child, four out of 29 (13.7%) and two out of 26 (7.6%) had microchimerism respectively (no statistically significant differences were found). Patients with both scleroderma and persistent microchimerism had had a male offspring. Foetal microchimerism does not seem to play a major role in most cases of female Spanish patients with SSc.

Comprehensive noninvasive assessment of cardiac involvement in limited systemic sclerosis

OBJECTIVE

To assess cardiovascular abnormalities in patients with limited systemic sclerosis (SSc), using noninvasive cardiac techniques.

METHODS

Sixty-three patients with limited SSc were prospectively evaluated with Doppler echocardiography and thallium-201 perfusion scintigraphy after a cold-stress test and radionuclide ventriculography.

RESULTS

In the patients with limited SSc, there was a significantly high prevalence of abnormal left- and right-diastolic function parameters (P = 0.001 and P = 0.0002, respectively), thickening of papillary muscles (46%; P = 0.003), and mild mitral regurgitation (49%; P < 0.0001), compared with controls. Systolic pulmonary arterial hypertension was detected in 9 patients (14%), and pericardial effusion in 11 patients (18%). In 64% of patients with limited SSc, an ischemic response was detected on the thallium cold-stress scan; similarly, an ischemic response was detected in 57% of patients with primary Raynaud's phenomenon (P < 0.0001 versus controls).

CONCLUSION

Although the frequency of cardiovascular symptoms was low in patients with limited SSc, a significant rate of cardiovascular abnormalities was found by noninvasive cardiac techniques.

Thrombotic thrombocytopenic purpura preceding systemic lupus erythematosus

The case of a patient admitted with thrombotic thrombocytopenic purpura nine years after developing systemic lupus erythematosus (SLE) is reported. Thrombotic thrombocytopenic purpura associated with SLE has been described on other occasions, but in most patients the diagnosis of SLE precedes that of thrombotic thrombocytopenic purpura. The unusual sequence and the chronological separation of the two diseases is emphasised.