Increased expression of the ectoenzyme CD38 in peripheral blood plasmablasts and plasma cells of patients with systemic sclerosis

Objective

CD38 is a type II glycoprotein highly expressed on plasmablasts and on short- and long-lived plasma cells, but weakly expressed by lymphoid, myeloid, and non-hematopoietic cells. CD38 is a target for therapies aimed at depleting antibody-producing plasma cells. Systemic sclerosis (SSc) is an immune-mediated disease with a well-documented pathogenic role of B cells. We therefore analyzed CD38 expression in different subsets of peripheral blood mononuclear cells (PBMCs) from a cohort of SSc patients.

Methods

Cell surface expression of CD38 was evaluated on PBMCs from SSc patients using eight-color flow cytometry analysis performed with a FacsCanto II (BD). Healthy individuals were used as controls (HC).

Results

Forty-six SSc patients (mean age 56, range 23-79 years; 38 females and 8 males), and thirty-two age- and sex-matched HC were studied. Twenty-eight patients had the limited cutaneous form and eighteen the diffuse cutaneous form of SSc. The mean disease duration was 7 years. Fourteen patients were on immunosuppressive therapy (14 MMF, 5 RTX). The total percentages of T, B and NK cells were not different between SSc and HC. Compared to HC, SSc patients had higher levels of CD3+CD38+ T cells (p<0.05), higher percentage (p<0.001) of CD3+CD4+CD25+FOXP3+ regulatory T cells, lower percentage (p<0.05) of CD3+CD56+ NK T cells. Moreover, SSc patients had higher levels of CD24^highCD19+CD38^high regulatory B cells than HC (p<0.01), while the amount of CD24+CD19+CD38+CD27+ memory B cells was lower (p<0.001). Finally, the percentages of circulating CD38^highCD27+ plasmablasts and CD138+CD38^high plasma cells were both higher in the SSc group than in HC (p<0.001). We did not observe any correlations between these immunophenotypes and disease subsets or duration, and ongoing immunosuppressive treatment.

Conclusions

The increased expression of CD38 in peripheral blood plasmablasts and plasma cells of SSc patients may suggest this ectoenzyme as a candidate therapeutic target, under the hypothesis that depletion of these cells may beneficially downregulate the chronic immune response in SSc patients. Validation of this data in multicenter cohorts shall be obtained prior to clinical trials with existing anti-CD38 drugs.

Speckle-tracking global longitudinal strain predicts clinical outcomes in patients with systemic sclerosis

Introduction

Systemic-sclerosis related cardiomyopathy is frequent and, albeit often asymptomatic, is likely secondary to the underlying pathophysiology of SSc itself and represents a negative prognostic factor. Speckle-tracking derived global longitudinal strain (GLS) has been proven to be a cost-effective tool in the detection of LV and RV dysfunction in patients with SSc and no overt cardiac disease.

Purpose

The aim of our study was to assess whether baseline GLS could predict clinical outcomes in patients with SSc in terms of death, heart failure, hospitalizations, and development of pulmonary hypertension.

Methods

We conducted a prospective observational study on all consecutive patients referred to our clinic between June 2016 and January 2022 with a confirmed diagnosis of SSc and no overt cardiac disease, pulmonary hypertension, or atrial fibrillation at the time of enrollment.

We performed baseline echocardiogram and GLS calculations for all patients as well as collected clinical and ECG data at baseline and at each follow up.

Results

Out of 164 patients (148 female, 58±14 years), 19 (11.6%) patients died during a median follow-up of 3.2 years for mainly non-cardiovascular deaths (7.3%) while cardiovascular deaths were lower (3% non-sudden, 1.3% sudden).

Left GLS at first visit was associated with all-cause death, with a 1% left GLS worsening associated with a 19% increased risk of death after adjusting for age, gender, and LVEF (adjusted HR 1.19; 95% CI 1.05–1.35; p=0.007).

Similarly, right GLS at first visit was associated with all-cause death, with a 1% right GLS worsening associated with a 12% increased risk of death after adjusting for age, gender, and TAPSE (adjusted HR 1.12; 95% CI 1.03–1.21; p=0.005).

Patients with a left GLS worse (i.e. higher) than −20% had a 3.5-fold increased risk of death when compared to patients with better left GLS (HR 3.55; 95% CI 1.28–9.88; p=0.015; Figure 1a). Similarly, patients with a right GLS worse than −20% had a 4.5-fold increased risk of death when compared to patients with better left GLS (HR 4.47; 95% CI 1.4–13.74; p=0.009; Figure 1b).

Conclusions

Baseline GLS measured is an effective tool to recognize patients with SSc and negative prognosis. It may help us identify early those who need to be followed more closely and start appropriate treatment in order to prevent major cardiovascular and non-cardiovascular events. The close relationship between left and right GLS as risk predictors underlines the role of SSc in promoting overt cardiac disease, not limited to pulmonary hypertension.

Funding Acknowledgement

Type of funding sources: None.

POS0890 NINTEDANIB REAL-LIFE EFFICACY AND SAFETY IN SYSTEMIC SCLEROSIS (SSc)-INTERTISTIAL LUNG DISEASE (ILD): AN ITALIAN MULTICENTRE PRELIMINARY STUDY

Background

Nintedanib (NTD) has been approved for Systemic Sclerosis (SSc)-Interstitial Lung Disease (ILD) following the positive results of the SENSCIS trial.

Objectives

to describe the efficacy and safety of NTD in SSc-ILD in a real-life setting.

Methods

The clinical data of SSc-ILD patients treated with NTD from 10 Italian SSc centres were retrospectively evaluated at baseline, 6 and 12 months: SSc clinical features, NTD tolerability, pulmonary function tests (PFTs) and modified Rodnan skin score (mRSS) were recorded.

Results

69 SSc-ILD patients (22 males [32%], mean age 60±12 years, disease onset 50±13 years, 4 [6%] anti-centromere, 53 [77%] anti-topoisomerase I, 3 [4%] anti-RNA-polimerase III) were identified. The vast majority (84%) was previously treated with immunosuppressants: 27 (39%) cyclophosphamide, 45 (65%) mycophenolate mofetil, 6 (9%) methotrexate, 9 (13%) azathioprine, 6 (9%) tocilizumab and 22 (32%) rituximab. In 11 (16%) patients, NTD was the first treatment for SSc-ILD. At baseline, 57 patients (83%) were on corticosteroids (mean daily prednisone dose 6±5 mg), 58 (84%) on immunosuppressants, 47 (68%) on mycophenolate mofetil, 14 (20%) on rituximab, 3 (4%) on tocilizumab, 2 on methotrexate (3%) and 1 (1%) on azathioprine. At baseline HRCT showed UIP pattern in 27 (39%) and NSIP pattern in 42 (61%) patients. The modifications of PFTs and mRSS over time are shown in Table 1. Since NTD introduction, gastro-intestinal (GI) side effects were recorded in 34 (49%) patients, with diarrhoea being the most common complaint (35%), followed by nausea/vomiting (23%) and weight loss (16%). In 21 (30%) patients, after a mean time of 2.6±3.4 months, NTD was maintained after dose adjustment. In 5 (7%) patients NTD was stopped after a median time of 5 (1-6) months due to subocclusion and persistent diarrhoea in 3 patients, untreatable nausea and vomiting in one patient and liver toxicity in 1 patient. During the follow-up after a median time of 10 (6 – 33) months, 4 patients died.

Table 1.

Pulmonary function tests and mRSS at baseline, 6 and 12 months in SSc-ILD on NTD.

Baseline6 monthsP valueBaseline12 monthsP valueFVC (% predicted)64 ± 1865 ± 18 (33 pts)0.63870 ± 1969 ± 18 (20 pts)0.586TLC (% predicted)64 ± 1561 ± 14 (27 pts)0.15464 ± 1465 ± 18 (16 pts)0.944DLCO (% predicted)40 ± 1741 ± 18 (29 pts)0.66040 ± 1838 ± 18 (20 pts)0.304mRSS9 ± 68 ± 6 (26 pts)0.0027 ± 48 ± 6 (15 pts)0.334

pts= patients

Conclusion

Our preliminary data confirm that in a real-life clinical scenario NTD, in combination with immunosuppressants, may stabilize PFT. However, despite the fact that GI side effects are frequent, they may be controlled with NTD dose adjustment thus retaining the drug in SSc-ILD patients. The NTD efficacy on skin involvement needs to be thoroughly evaluated on a larger SSc population.

Disclosure of Interests

Corrado Campochiaro Speakers bureau: Boeboehringer ingelheim, Giacomo De Luca Speakers bureau: boehringer ingelheim, Maria Grazia Lazzaroni Grant/research support from: boehringer ingelheim, Giuseppe Armentaro: None declared, Amelia Spinella: None declared, Barbara Vigone: None declared, Barbara Ruaro: None declared, Anna Stanziola: None declared, Devis Benfaremo: None declared, Enrico De Lorenzis: None declared, Francesco Benvenuti: None declared, Silvia Laura Bosello Speakers bureau: boehringer ingelheim, Gianluca Moroncini: None declared, Giovanna Cuomo: None declared, Marco Confalonieri: None declared, Lorenzo Beretta: None declared, Elisabetta Zanatta: None declared, Dilia Giuggioli: None declared, Nicoletta Del Papa: None declared, Paolo Airò: None declared, Lorenzo Dagna: None declared, Marco Matucci-Cerinic Speakers bureau: boehringer ingelheim

Incidence and predictors of cardiac arrhythmias in patients with systemic sclerosis

Funding Acknowledgements

Type of funding sources: None.

Introduction

Heart involvement in systemic sclerosis patients is frequent and represents a negative prognostic factor with around 25% of SSc patients dying from cardiovascular related causes. Cardiac arrhythmias represent 6% of the overall causes of death in SSc patients. Not only a plethora of conditions typical of the disease seem to favour the presence of an arrhythmic substrate such as microvascular disease or fibrosis but autoimmunity itself has been recognized as a pathogenic mechanism for cardiac arrhythmias.

Purpose

The aim of our study was to investigate the incidence of arrhythmias in patients with systemic sclerosis and identify potential predictors.

Methods

Prospective longitudinal study enrolling all consecutive patients with a diagnosis of SSc and no overt cardiac disease nor pulmonary hypertension. Echocardiographic parameters and GLS were obtained at baseline and at each follow up as well as 12 lead ECG. Presence of atrial fibrillation (AF), atrial tachycardia (AT), ventricular ectopic beats &gt;1000/24 h (VEB), supraventricular ectopic beats (SVEB), bundle branch block (BBB) and atrioventricular block (AVB) was registered.

Results

160 patients (144 females, 90%, mean age 59±14 years) were enrolled from June 2016 to December 2021. At enrolment, 11.3% of patients with SSc presented a previous history of supraventricular arrhythmia (5.6% supraventricular ectopic beats, 3.1% atrial fibrillation, 2.5% atrial flutter) and 5.6% a history of ventricular arrhythmia (5.0% ventricular ectopic beats, 0.6% ventricular tachycardia). After a median follow-up of 3.1 years (95% CI 1.4-4.8 years), five patients (3.1%) died of cardiovascular causes, of which three (1.8%) experienced a sudden cardiac death. During the same period, 16 patients (10%) presented a new diagnosis of supraventricular arrythmia (8.7% atrial fibrillation, 1.3% atrial flutter) and two patients (1.2%) a new diagnosis of ventricular tachycardia.

PR interval significantly increased during the 3.1-year follow-up (154±27 vs. 178±32 ms; p=0.013), as well as corrected QT interval (420±23 vs. 436±19 ms; p=0.001). New diagnosis of complete right and left bundle branch block was made in 18 (11.2%) and two (1.2%) of all SSc patients.

Diagnosis of pulmonary arterial hypertension was associated with a 4-fold and a 10-fold increased risk of supraventricular and ventricular arrhythmias, respectively (Figure 1). A diffuse SSc variant (p=0.049), indexed right (p=0.020) and left atrial volumes (p=0.035), and E/E’ ratios (p=0.016) were all associated with an increased risk of supraventricular arrhythmias. TAPSE (p=0.040), as well as right (p=0.030) global longitudinal strain were associated with an increased risk of ventricular arrhythmias.

Conclusions

Ssc patients are often by an arrhythmic profile with an increased risk of supraventricular and ventricular events as well as sudden cardiac death. A comprehensive cardiological work up may help in lowering the risk of arrhythmic complications.

Long term prognosis and cardiovascular complications of patients with systemic sclerosis-related cardiomiopathy

Background

Both primary (SSc related cardiomyopathy) and secondary cardiac involvement in systemic sclerosis (SSc) is frequent albeit mostly asymptomatic. It represents a negative prognostic factor as almost 25% of SSc patients die from either heart failure or arrhythmia complications. Speckle tracking global longitudinal strain has been proven to be an effective tool both to identify and detect the progress of subclinical heart disease in SSc. The aim of our study was to assess the association between SSc diagnosis and the development of heart failure, pulmonary hypertension, death and need for hospitalization.

Materials and methods

We conducted an observational prospective study enrolling all patients with a diagnosis of SSc and no overt cardiac disease. We excluded all patients with a known diagnosis of pulmonary hypertension and atrial fibrillation. For each patient standard echocardiogram and GLS variables were collected.

Results

We enrolled 70 patients (61 females, age 56.2±15.4 years) who were followed for a median of 3 years. 68% of the patients had a limited variant of the disease.

All-cause mortality was 10% in a 5-year follow-up. During the same period, PH was reached in 13% of all patients, HF in 7% and 18% required at least one hospital admission for cardiovascular causes. A diagnosis of PH was associated with an increased risk of death (ARR 34%; p&lt;0.001) and hospitalization for CV causes (ARR 73%; p&lt;0.001). Moreover, a diagnosis of HF was associated with an increased risk of death (ARR 50%; p&lt;0.001) and hospitalization for CV causes (ARR 61%; p&lt;0.001). A 1% worsening of GLS was associated with an increased risk to develop PH in the following 5 years, both for the left ventricle (OR 1.2; 95% CI: 1.1–1.4; p=0.043) and for the right ventricle (OR 1.1; 95% CI: 1.1–1.3; p=0.045).

Conclusions

Pulmonary hypertension and heart failure often occur in patients with cardiac involvement. Both proved themselves to be associated with an increased risk of death and hospitalization for CV causes. Moreover, GLS worsening of both the left and right ventricles may allow us to predict the diagnosis of PH and therefore preemptively start appropriate management.

Funding Acknowledgement

Type of funding sources: None.

Speckle tracking assessment of the atrial function in patients with systemic sclerosis

Background

Systemic sclerosis (SSc) is a chronic autoimmune disease characterized by small vessel vasculopathy, autoantibodies production and exaggerated extracellular matrix deposition, leading to extensive tissue fibrosis. Cardiac involvement in SSc, albeit often asymptomatic, is frequent and represents a negative prognostic factor. Speckle tracking global longitudinal strain (GLS) has proved itself to be an effective tool to identify the presence and the progression of subclinical SSc-related cardiomyopathy.

The aim of our study was to assess whether SSc-related cardiomyopathy affects not only the ventricles but also the right (RA) and left atria (LA) in patients with SSc and no overt cardiac disease nor pulmonary hypertension.

Materials and methods

Observational prospective study enrolling all consecutive patients with SSc age- and gender-matched 1:1 to healthy controls. Patients with structural heart disease, heart failure, atrial fibrillation and pulmonary hypertension were excluded.

For every patient, standard echocardiographic parameters and speckle-tracking derived variables were registered. The reservoir function (from the end of ventricular contraction to mitral valve opening), conduit function (from mitral valve opening through the onset of atrium contraction) and contraction function (from the onset of atrium contraction to the end of ventricular diastole) were assessed via GLS. Zero strain reference was set at left ventricular end diastole.

Results

Fifty-two SSc patients and 52 matched controls were consecutively enrolled. Left ventricular ejection fraction (66.5%±7.4% vs. 66.1%±5.9%; p=ns) right fractional area change (49.4%±9.6% vs. 49.2%±9.2%; p=ns) and mean sPAP (29.0%±5.3% vs. 24.4%±4.1%; p=ns) were well within the normal range and similar between SSc patients and controls. Right atrial reservoir function (35.0%±7.3% vs. 42.3%±8.5%; p=.024) and contraction function (14.8%±4.3% vs. 18.5%±4.1%; p=.034) were significantly lower in SSc patients when compared to matched controls. No difference was seen in right atrial conduit function or left atrial strain.

In patients with SSc, RA reservoir (r=.194; p=.033) and conduit function (r=.174; p=.036) were directly associated to right ventricular GLS. LA reservoir (r=.260; p=.008) and conduit function (r=.271; p=.006) were directly associated with left ventricular GLS. No association was observed between contraction function and GLS in both left and right chambers. Moreover, RA and LA reservoir (r=.358; p=.02), conduit (r=.525; p=.004) and contraction functions (r=.30; p=.0.18) were directly correlated.

Conclusions

While no significant difference was seen between cases and controls in terms of common echocardiographic parameters, RA reservoir and contraction function assessed through GLS were significantly impaired in patients with SSc. The correlation between impaired atrial and ventricular GLS in SSc may represent another indirect evidence of SSc-related heart global involvement.

Funding Acknowledgement

Type of funding sources: None.

AB0551 CLINICAL SIGNIFICANCE OF COGNITIVE IMPAIRMENT AND MALNUTRITION IN PATIENTS WITH SYSTEMIC SCLEROSIS

Background:

Previous studies reported a high prevalence of cognitive dysfunction in systemic sclerosis (SSc). Cognitive impairment was estimated to involve 60% to 80% of SSC patients and to be correlated with older age, disease severity, diffuse cutaneous subset and poor quality of life.

Objectives:

The aim of our study was to evaluate the association between cognitive impairment, nutritional status and the quality of life of SSc patients.

Methods:

Sixty-eight consecutive SSc patients followed at our Institution were evaluated for cognitive impairment using the validated Italian version of the Montreal Cognitive Assessment (MoCA). Scores <26 were considered abnormal. We also assessed other domains and quality of life measures such as UCLA SCTC GIT 2.0 for gastrointestinal involvement, BDI-II and PHQ-9 for anxiety and depression, EAT-10 for dysphagia symptoms, SHAQ and SF-36 for function and quality of life (QoL). The risk and the presence of overt malnutrition were assessed using the MUST questionnaire and the GLIM criteria, respectively. Clinical and demographic parameters such as age, sex, BMI, disease subset, organ involvement, autoantibody profile and modified Rodnan Skin Score were also recorded for each patient. Data were analysed by Student t-test or chi-square test and regression analyses were used to assess the association between variables.

Results:

A total of 68 SSc patients [47 (69.1%) limited SSc (lSSc) and 21 (30.9%) with diffuse SSc (dSSc), 59 female; mean age 60.2 (±13.4) years; mean disease duration 9 (±8.2) years; mean mRSS 8.1 (±7.6)] were included in the study.

Cognitive impairment was identified in 30 (44.1%) SSc patients; the mean MoCA score was 24.7 (±4.3). According to GLIM criteria, 16 (23.5%) patients were malnourished. Compared to patients with a MoCA≥26, patients with cognitive impairment were older (p<0.001), had more comorbidities (p<0.0001) and a worse QoL as assessed by the physical and general health domains of the Sf-36 (p<0.05). Malnourished patients were significantly more dysphagic (p<0.01) and had a worse HAQ (p<0.01) compared to well-fed patients. On regression analyses, cognitive impairment was related to increasing age (OR 1.08, 95%CI 1.03 to 1.14, p=0.001), but not to malnutrition, disease subset or symptoms. Malnutrition was associated with dysphagia (OR 1.10, 95%CI 1.01 to 1.20, p=0.01) and HAQ score (OR 2.69, 95%CI 1.24 to 5.82, p=0.01), but was not predicted by cognitive impairment.

Conclusion:

Cognitive dysfunction is frequently observed in SSc patients and mostly associated with increasing age and number of comorbidities. Malnutrition and cognitive impairment are both associated to QoL but seem to be unrelated.

Disclosure of Interests:

None declared

FRI0320 MULTICENTER VALIDATION OF THE DETECTION OF ARTHRITIS IN INFLAMMATORY BOWEL DISEASES (DETAIL) QUESTIONNAIRE FOR THE SCREENING OF SPONDYLOARTHRITIS IN PATIENTS WITH INFLAMMATORY BOWEL DISEASES

Background:

Spondyloarthritis (SpA) is the most frequent extra-intestinal manifestation in inflammatory bowel diseases (IBD), since it may occur in up to 25% of patients. The early referral to a Rheumatology Unit may lead to proper treatment and better outcomes for patients with suspect SpA. Recently, we have developed and preliminarily validated a self-administered screening questionnaire, called DETection of Arthritis in Inflammatory boweL diseases (DETAIL)1.

Objectives:

To validate the DETAIL questionnaire in a multicenter cohort of IBD patients enrolled at ten Gastroenterology and Rheumatology Units in Italy.

Methods:

The DETAIL instrument is a 6-item questionnaire developed through a Delphi method1. From October 2018 to March 2019, consecutive adult patients with IBD, Crohn’s disease (CD) or ulcerative colitis (UC), filled out independently the DETAIL in the outpatient waiting room. Thereafter, within 2 weeks a blinded rheumatologist assessed all the patients, irrespectively of the DETAIL results, and classified them to be affected or not by SpA according to ASAS criteria. The performance of the DETAIL was evaluated trough Bayesian analysis, defining for each item of the questionnaire the sensitivity, specificity, positive (LR+) and negative (LR-) likelihood ratios.

Results:

Overall, 418 IBD patients filled out the DETAIL questionnaire. Upon rheumatological evaluation, 102 (24.4%) patients received a diagnosis of SpA. Of the six questions, the best performances were found in item 6 (LR+ 3.77), reporting inflammatory back pain at night, and in item 3 (LR+ 3.31), exploring Achilles enthesitis. The presence of back pain lasting more than three months (LR+ 2.91), of back pain with inflammatory features (LR+ 2.55) and a history of dactylitis (LR+ 2.55), showed also a fairly good performance, whereas a history of peripheral synovitis was slightly worse (LR+ 2.16). The combination of at least three items answered affirmatively yielded a post-test probability of SpA of 75% or more. The presence of alternative diagnoses, such as osteoarthritis and fibromyalgia, represented a minor confounder.

Conclusion:

The DETAIL questionnaire is the first screening tool for the early detection of SpA/IBD that has been validated by a multicenter study group.

References:

[1]Di Carlo M, Luchetti MM, Benfaremo D, Di Donato E, Mosca P, Maltoni S, Benedetti A, Gabrielli A, Grassi W, Salaffi F. The DETection of Arthritis in Inflammatory boweL diseases (DETAIL) questionnaire: development and preliminary testing of a new tool to screen patients with inflammatory bowel disease for the presence of spondyloarthritis. Clin Rheumatol. 2018 Apr;37(4):1037-1044.

Acknowledgments:

We are grateful to all the members of the GRADES-IBD study group for their outstanding help in the enrollment of patients.

We also would like to acknowledge the “Società Italiana di Gastro-Reumatologia” (SIGR) for its help and assistance in the constitution of the multidisciplinary network.

Disclosure of Interests:

None declared

AB1211 IMMUNE-RELATED ADVERSE EVENTS IN PATIENTS RECEIVING PD-1/PD-L1 INHIBITORS: PRELIMINARY RESULTS FROM A PROSPECTIVE COHORT STUDY

Background:

Recent introduction of immune checkpoint inhibitors (ICIs) revolutionized oncological guidelines. Immune-related adverse events (IrAEs) may occur in as many as 85% of patients (10% with toxicity grade 3/4), but detailed epidemiology of irAEs is still lacking, mostly because of data collection and analysis vary widely.

Objectives:

The purpose of our study is to establish a prospective cohort of patients treated with PD-1/PD-L1 inhibitors in order to determine incidence, risk factors and characteristics of irAEs in a real-world setting.

Methods:

We conducted a prospective cohort study enrolling patients receiving anti-PD-1/PD-L1 agents for the treatment of metastatic or locally advanced non-small cell lung cancer, renal cell carcinoma, squamous cell carcinoma of the head and neck, Hodgkin lymphoma. Detailed recommendations have been implemented for cases fulfilling criteria for suspected irAEs, including procedures for evaluation and diagnosis, specific treatments and rules for drug discontinuation. IrAEs have been defined and graded according to Common Terminology Criteria for Adverse Events vs 5.0. Management strategies have been adapted by a multidisciplinary panel, basing on the oncological guidelines, which represent the current best clinical practice. AEs screening, physical examination, ECG and clinical laboratory evaluation have been performed at baseline visit and follow up (4, 8, 12 weeks).

Results:

Fifty-two patients have been enrolled from Jan 2019 to Dec 2020. Characteristics are reported in the Table below. Twelve patients developed irAEs (23%), 6 treated with nivolumab, 4 with pembrolizumab, 1 with atezolizumab and 1 with durvalumab. Mild-to-moderate (G1-G2) irAEs were hepatitis, hypothyroidism, III-V-VII cranial nerve palsy, polymyalgia-like syndrome, skin psoriasis and type-1 diabetes mellitus. Severe cases (G3) of bullous dermatitis, Lichen Planus, interstitial pneumonia and myositis occurred. One patient developed three different irAEs. Median time of onset was 4.5 weeks. IrAEs were successfully treated according to established guideline, but 4 patients stopped anti-neoplastic therapy due to irAEs and 11 for disease progression. Five patients died.

Conclusion:

Cancer patients receiving PD-1/PD-L1 agents are being prospectively followed. Preliminary results confirm that 1/4 patients may develop irAEs. Innovative tools are required in order to manage irAEs, prevent potential relapse and avoid useless interruption of therapy. Further research needs to get insights into pathophysiological mechanisms and risk factors.

References:

[1]Arnaud-Coffin P. A systematic review of adverse events in randomized trials assessing immune checkpoint inhibitors. Int J Cancer. 2019; Champiat S, Lambotte O, Barreau E, et al. Management of immune checkpoint blockade dysimmune toxicities: a collaborative position paper. Annals of Oncology 27, 2016.

CharacteristicsN = 52Age[years, median (range)]67 (31-92)Gender(F/M)17/35Cancer typeMelanoma12Renal cell carcinoma9Non-small-cell lung carcinoma Hodgkin29lymphoma1Head-neck cancer1AgentsNivolumab24Pembrolizumab16Atezolizumab8Durvalumab4irAEs12 pts (23%)*G14G26G34G40Drug discontinuation20 (39%)due to irAEs4due to disease progression11death5

*one patient had more than one event

Disclosure of Interests:

None declared

THU0518 ACCURACY OF DUAL-ENERGY COMPUTED TOMOGRAPHY FOR THE DETECTION OF BONE MARROW EDEMA IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS

Background:

An important applications of the Dual energy computed tomography DECT in the field of musculoskeletal radiology is the detection of bone marrow edema (BME), using a post-processing software to remove calcium in trabecular bone by using a “virtual non-calcium (VNCa)” subtraction process DECT have been successfully employed in the evaluation of the extent of BME in patients with sacroiliitis (1)

Objectives:

The aims of this study were i)to evaluate the discriminating capacity of DECT versus MRI in the detection of BME of the sacroiliac joints in patients with axial-SpA and to define the optimal cutoff; ii) to define of inter-observer agreement between radiologists

Methods:

All patients underwent a pelvic DECT examination, within 30 days of the MRI imaging, (Somatom Force; Siemens Healthineers, Enlangen, Germany). Each exam was evaluated by two operators: an experienced radiologist and a radiologist in training. The dedicated software also allows the precise calculation of the attenuation values in the region of interest (ROI). On the reformatted color-coded dual-energy virtual non-calcium images bone marrow signal is depicted in green and corresponding to high signal intensity on T2-weighted fat suppression MR images (Fig. 1). With the consent of the two operators, three ROIs were manually positioned for each side of the sacroiliac joints in the subchondral region of the proximal, middle and distal thirds of each joint head, respectively. The interobserver agreement analysis was carried out in the semi-quantitative evaluation of the scores assigned in CT. The accuracy of DECT for the detection of BME compared to MRI was analyzed using the Receiver Operating Characteristics (ROC) curve method

Figure 1.

Patient with SpA A. Short tau inversion recovery MR image demonstrating extensive BME in both iliac and sacral subchondral bone, indicating active sacroiliitis. B. CT Semicoronal multiplanar reformatted grayscale image shows signs of structural change. C. Semicoronal multiplanar reformatted color-coded dual-energyVNCaimage reveals bone marrow signal involving both sacroliliac joints, corresponds toBMEon the MR image

Results:

56 axial-SpA patients have been evaluated, 30 males and 26 females, a mean age of 48.6 ± 12.3 years, a mean disease duration of 5.5 ± 2.9 years, a mean C-reactive protein level of 3.0 ± 2.5 mg/dl. The inter-rater agreement of readers showed a high statistical significance greater than 0.80, in particular the weighted kappa is 0.815, with a standard error of 0.04 and a 95% variability coefficient between 0.73 and 0.89. Sensitivity, specificity, and positive likelihood ratio in the identification of BME at DECT were 95.8%, 83.3% and 6.67, respectively. The differences in mean CT number (HU) among the four levels of edema category were significant (p<0.0001). The AUC was 0.905 in the differentiation of the presence of BME from no edema (Fig. 2). A cutoff value of –14.8 HU yielded overall sensitivity of 82.86% and specificity of 90.48%, with an LR+ of 8.70, in the detection of BME

Figure 2.

Graph shows ROC curves from CT numbers (in Hounsfield units) derived from DECT images in the detection of sacroiliitis with and without BME. AUC was 0.905

Conclusion:

We confirm the potential of DECT for the detection of BME of the sacroiliac joints in patients affected by SpA. This new method appears to be very useful, not only in the diagnostic phase, but also for the monitoring of patients.

References:

[1]Carotti M, Salaffi F, Beci G, Giovagnoni A. The application of dual-energy computed tomography in the diagnosis of musculoskeletal disorders: a review of current concepts and applications. Radiol Med. 2019;124(11):1175-1183.

Disclosure of Interests:

None declared

SAT0307 PROGRESSION OF SUBCLINICAL MYOCARDIAL INVOLVEMENT IN PATIENTS WITH SYSTEMIC SCLEROSIS

Background:

Systemic sclerosis (SSc) is a progressive autoimmune disease affecting the skin as well as internal organs, including the heart. A few studies have identified a subclinical heart involvement in patients with no pulmonary hypertension. Changes in myocardial deformation are consistent with the idea of SSc-related cardiomyopathy as a primary condition affecting the heart globally through microvascular dysfunction and subsequent myocardial fibrosis.

Objectives:

The aim of the present study is to describe the progression of myocardial deformation in patients with SSc and no overt cardiac disease.

Methods:

Prospective longitudinal study enrolling consecutive SSc patients referred to the Clinica Medica, University Hospital ‘Ospedali Riuniti’, Ancona, Italy, from February 2016 to December 2018. All patients fulfilled the 2013 ACR/EULAR classification criteria for SSc. Patients with structural heart disease, heart failure, atrial fibrillation or pulmonary hypertension were excluded. Disease subset, antibodies pattern, cardiovascular risk factors and involvement of other organ systems were recorded for each patient. An echocardiographic exam was performed for all patients at baseline and during their follow-up evaluation. Standard and speckle-tracking derived variables for the systolic and diastolic function of the left ventricle (LV) and right ventricle (RV) were acquired. Speckle tracking analysis software (EchoPAC 13.0; GE Medical Systems, Milwaukee, USA) was used to assess the GLS of the left and right ventricle, excluding the ventricular septum from right ventricular GLS calculations.

Results:

Seventy-two patients (68 females, age 56.6±15.4 years) were enrolled. Common echocardiographic parameters of left and right systolic function were within normal range at baseline and did not change during follow-up. Mean GLS, however, worsened for both left (from -19.8±3.5% to -18.7±3.5%, p=.034) and right ventricle (from -20.9±6.1% to -18.7±5.4%, p=.013) during a median follow-up of 20 months (1st-3rd quartile 12-24 months). The increased impairment registered in SSc patients was homogenous across endocardial layers (LV from -22.5±-3.9 to -21.4±3.9, p=.041; RV from -24.2±6.2 to -20.6±5.9, p=.001), mesocardial layers (LV -19.7±3.6 to -18.7±3.5, p=.043; RV from -21.3±5.9 to -18.8±5.7, p=.012) and epicardial layers (LV from -17.1±3.0 to -16.4±3.1, p=.112, RV -18.8±6.3 to -16.0±8.4, p=.035), as well as myocardial segments. No difference in progression rate was observed stratifying patients according to disease subset or other clinical parameters.

Conclusion:

GLS impairment progressed over a 20-month follow-up period in a cohort of SSc patients without clinically overt cardiac involvement. Further studies are needed to assess the significance of subclinical heart involvement and its progression in patients with SSc.

Disclosure of Interests:

None declared