Liver disease in germline mutations of telomere-related genes: Prevalence, clinical, radiological, pathological features, outcome, and risk factors

BACKGROUND AND AIM

Germline mutations of telomere-related genes (TRG) induce multiorgan dysfunction, and liver-specific manifestations have not been clearly outlined. We aimed to describe TRG mutations-associated liver diseases.

APPROACH AND RESULTS

Retrospective multicenter analysis of liver disease (transaminases > 30 IU/L and/or abnormal liver imaging) in patients with TRG mutations. Main measurements were characteristics, outcomes, and risk factors of liver disease in a TRG mutations cohort. The prevalence of liver disease was compared to a community-based control group (n = 1190) stratified for age and matched 1:3 for known risk factors of liver disease. Among 132 patients with TRG mutations, 95 (72%) had liver disease, with associated lung, blood, skin, rheumatological, and ophthalmological TRG diseases in 82%, 77%, 55%, 39%, and 30% of cases, respectively. Liver biopsy was performed in 52/95 patients, identifying porto-sinusoidal vascular disease in 48% and advanced fibrosis/cirrhosis in 15%. After a follow-up of 21 months (12-54), ascites, hepato-pulmonary syndrome, variceal bleeding, and HCC occurred in 14%, 13%, 13%, and 2% of cases, respectively. Five-year liver transplantation-free survival was 69%. A FIB-4 score ≥ 3·25 and ≥1 risk factor for cirrhosis were associated with poor liver transplantation-free survival. Liver disease was more frequent in patients with TRG mutations than in the paired control group [80/396, (20%)], OR 12.9 (CI 95%: 7.8-21.3, p < 0.001).

CONCLUSIONS

TRG mutations significantly increase the risk of developing liver disease. Although symptoms may be mild, they may be associated with severe disease. Porto-sinusoidal vascular disease and cirrhosis were the most frequent lesions, suggesting that the mechanism of action is multifactorial.

High risk of lung cancer in surfactant-related gene variant carriers

BACKGROUND

Several rare surfactant-related gene (SRG) variants associated with interstitial lung disease are suspected to be associated with lung cancer, but data are missing. We aimed to study the epidemiology and phenotype of lung cancer in an international cohort of SRG variant carriers.

METHODS

We conducted a cross-sectional study of all adults with SRG variants in the OrphaLung network and compared lung cancer risk with telomere-related gene (TRG) variant carriers.

RESULTS

We identified 99 SRG adult variant carriers (SFTPA1 (n=18), SFTPA2 (n=31), SFTPC (n=24), ABCA3 (n=14) and NKX2-1 (n=12)), including 20 (20.2%) with lung cancer (SFTPA1 (n=7), SFTPA2 (n=8), SFTPC (n=3), NKX2-1 (n=2) and ABCA3 (n=0)). Among SRG variant carriers, the odds of lung cancer was associated with age (OR 1.04, 95% CI 1.01-1.08), smoking (OR 20.7, 95% CI 6.60-76.2) and SFTPA1/SFTPA2 variants (OR 3.97, 95% CI 1.39-13.2). Adenocarcinoma was the only histological type reported, with programmed death ligand-1 expression ≥1% in tumour cells in three samples. Cancer staging was localised (I/II) in eight (40%) individuals, locally advanced (III) in two (10%) and metastatic (IV) in 10 (50%). We found no somatic variant eligible for targeted therapy. Seven cancers were surgically removed, 10 received systemic therapy, and three received the best supportive care according to their stage and performance status. The median overall survival was 24 months, with stage I/II cancers showing better survival. We identified 233 TRG variant carriers. The comparative risk (subdistribution hazard ratio) for lung cancer in SRG patients versus TRG patients was 18.1 (95% CI 7.1-44.7).

CONCLUSIONS

The high risk of lung cancer among SRG variant carriers suggests specific screening and diagnostic and therapeutic challenges. The benefit of regular computed tomography scan follow-up should be evaluated.

Benralizumab for eosinophilic granulomatosis with polyangiitis

BACKGROUND

Benralizumab is effective in the treatment of eosinophilic asthma and is being investigated for the treatment of other eosinophil-associated diseases. Reports on the use of benralizumab for the treatment of eosinophilic granulomatosis with polyangiitis (EGPA) are limited to case reports and small case series.

METHODS

We conducted a multicentre, retrospective study including EGPA patients treated with off-label benralizumab. The primary endpoint was the rate of complete response defined as no disease activity (Birmingham Vasculitis Activity Score=0) and a prednisone dose ≤4 mg/day. Partial response was defined as no disease activity and a prednisone dose ≥4 mg/day.

RESULTS

Sixty-eight patients were included, including 31 (46%) who had previously received mepolizumab. The use of benralizumab was warranted by uncontrolled asthma in 54 (81%), persistent ear, nose and throat (ENT) manifestations in 27 (40%) and persistent glucocorticoids (GCs) use in 48 (74%) patients. Median (IQR) follow-up after starting benralizumab was 23 (9-34) months. Thirty-three patients (49%) achieved a complete response, 24 (36%) achieved a partial response and 10 (15%) did not respond. Among the 57 patients who initially responded, 10 (18%) eventually required further line treatments. GCs were discontinued in 23 patients (38%). Prior mepolizumab use was associated with a higher rate of primary failure (26.7% vs 5.4%, p=0.034) and less frequent GCs discontinuation (14.8% vs 55.9%, p=0.001). Vasculitis flares occurred in 7 patients (11%) and were associated with histological evidence of vasculitis and/or antineutrophil cytoplasmic antibodies positivity at benralizumab initiation (p=0.004).

CONCLUSIONS

Benralizumab appears to be an effective treatment for refractory asthma or ENT manifestations in EGPA and allows GC-sparing. However, its efficacy was lower after prior failure of mepolizumab.

Spirometry practice by French general practitioners between 2010 and 2018 in adults aged 40 to 75 years

In France, most spirometries are performed by pneumologists. Spirometry is difficult to access due to the distance to medical office and long delays for appointments. This lack of accessibility contributes to the underdiagnosis of chronic obstructive pulmonary disease (COPD) among patients aged between 40 and 75 years. In recent years, general practitioners (GPs) have been performing spirometry in private practice. However, the extent of this practice is unknown. A French retrospective, repetitive transversal study analysed data from the "Système National des Données de Santé" (SNDS) database. The targeted population was GPs in primary care that performed spirometries between 2010 and 2018, in patients aged between 40 and 75 years. Between 2010 and 2018, 302,674 (7.2%) spirometries were performed in France by GPs in private practices, in patients 40 to 75 years old. 5.4% by "expert GPs" (>60 spirometries/year) and 1.8% by "non-expert GPs". In "non-expert GPs" (2.8% of French GPs in 2018), the annual number of spirometries increased by 701 each year (p < 2.104), the annual number of GPs performing spirometries increased by 114 each year (p < 2.10-5). Overall, 24.9% of the spirometries performed by GPs were referrals from other GPs. The number of spirometries performed by GPs and the number of GPs performing spirometries has gradually increased over time. However, this increase is inadequate considering the need to early detect and follow up respiratory disorders.

Recommandations formalisées d’experts pour la prise en charge des pneumothorax spontanés primaires

Introduction : Le pneumothorax spontané primaire (PSP) est un épanchement gazeux dans la cavité pleurale, survenant hors traumatisme et pathologie respiratoire connue. Des recommandations formalisées d'experts sur le sujet sont justifiées par les pluralités de moyens diagnostiques, stratégies thérapeutiques et disciplines médicochirurgicales intervenant dans leur prise en charge.

Méthodes : Revue bibliographique, analyse de la littérature selon méthodologie GRADE (Grading of Recommendation Assessment, Development and Evaluation) ; propositions de recommandations cotées par experts, patients et organisateurs pour obtenir un consensus. Seuls les avis d'experts avec accord fort ont été retenus.

Résultats : Un décollement sur toute la hauteur de la ligne axillaire et supérieur ou égal à 2 cm au niveau du hile à la radiographie thoracique de face définit la grande abondance. La stratégie thérapeutique dépend de la présentation clinique : exsufflation en urgence pour PSP suffocant ; en l'absence de signe de gravité : prise en charge conservatrice (faible abondance), exsufflation ou drainage (grande abondance). Le traitement ambulatoire est possible si organisation en amont de la filière. Les indications, procédures chirurgicales et l'analgésie périopératoire sont détaillées. Les mesures associées, notamment le sevrage tabagique, sont décrites.

Conclusion : Ces recommandations sont une étape de l'optimisation des stratégies de traitement et de suivi des PSP en France.

[French practical guidelines for the diagnosis and management of IPF - 2021 update, full version]

BACKGROUND

Since the previous French guidelines were published in 2017, substantial additional knowledge about idiopathic pulmonary fibrosis has accumulated.

METHODS

Under the auspices of the French-speaking Learned Society of Pulmonology and at the initiative of the coordinating reference center, practical guidelines for treatment of rare pulmonary diseases have been established. They were elaborated by groups of writers, reviewers and coordinators with the help of the OrphaLung network, as well as pulmonologists with varying practice modalities, radiologists, pathologists, a general practitioner, a head nurse, and a patients' association. The method was developed according to rules entitled "Good clinical practice" in the overall framework of the "Guidelines for clinical practice" of the official French health authority (HAS), taking into account the results of an online vote using a Likert scale.

RESULTS

After analysis of the literature, 54 recommendations were formulated, improved, and validated by the working groups. The recommendations covered a wide-ranging aspects of the disease and its treatment: epidemiology, diagnostic modalities, quality criteria and interpretation of chest CT, indication and modalities of lung biopsy, etiologic workup, approach to familial disease entailing indications and modalities of genetic testing, evaluation of possible functional impairments and prognosis, indications for and use of antifibrotic therapy, lung transplantation, symptom management, comorbidities and complications, treatment of chronic respiratory failure, diagnosis and management of acute exacerbations of fibrosis.

CONCLUSION

These evidence-based guidelines are aimed at guiding the diagnosis and the management in clinical practice of idiopathic pulmonary fibrosis.

AB0657 Severity and impact of gastrointestinal symptoms in patients with SSc-ILD treated with nintedanib: data from SENSCIS-ON

Background

Gastrointestinal (GI) involvement is a common manifestation of systemic sclerosis (SSc) and a frequent side-effect of drugs used to treat SSc. In the SENSCIS trial, nintedanib reduced the rate of decline in forced vital capacity (FVC) in patients with SSc-associated interstitial lung disease (SSc-ILD), with an adverse event profile characterised predominantly by GI events.

Objectives

To assess the severity and impact of GI symptoms on quality of life in patients treated with nintedanib in the open-label extension trial, SENSCIS-ON.

Methods

Patients with SSc-ILD who completed the SENSCIS trial or a drug–drug interaction (DDI) study of nintedanib and oral contraceptive were eligible to enter SENSCIS-ON. Patients who received nintedanib in SENSCIS (up to 100 weeks) and continued nintedanib in SENSCIS-ON comprised the “continued nintedanib” group. Patients who received placebo in SENSCIS and initiated nintedanib in SENSCIS-ON, or who received nintedanib for a short time in the DDI study, comprised the “initiated nintedanib” group. We assessed changes in scores on the UCLA Scleroderma Clinical Trial Consortium Gastrointestinal Tract (UCLA SCTC GIT) questionnaire v2.0 from baseline to week 52. This questionnaire comprises 7 scales measuring the severity and impact of GI symptoms: reflux, distension or bloating, faecal soilage, diarrhoea, constipation, emotional well-being, social functioning. Each scale is scored from 0 to 3 except for the diarrhoea scale (0 to 2) and constipation scale (0 to 2.5). The total score, the mean of the scores for the scales except constipation, ranges from 0 to 2.83, with higher scores indicating worse symptoms.

Results

The “continued nintedanib” group comprised 197 patients and the “initiated nintedanib” group comprised 247 patients (231 from SENSCIS). Of these, 178 and 218 patients, respectively, provided a total UCLA SCTC GIT score at baseline. At baseline, mean (SD) total scores were 0.33 (0.33) and 0.33 (0.34) in the continued nintedanib and initiated nintedanib groups, respectively. Mean (SD) scores on the 7 scales ranged from 0.16 (0.52) to 0.70 (0.73) in the continued nintedanib group and from 0.13 (0.43) to 0.64 (0.68) in the initiated nintedanib group. Increases (worsening) in scores were observed in both groups from baseline to week 52, except for on the constipation scale (Figure 1). Based on the total score, between baseline and week 52, the proportion of patients with moderate or severe or very severe GI symptoms increased, but 45.7% and 39.7% of patients in the continued nintedanib and initiated nintedanib groups, respectively, had no or mild GI symptoms at week 52 (Table 1).

Table 1.

Changes in severity and impact of gastrointestinal symptoms based on UCLA SCTC GIT total score between baseline and week 52 of SENSCIS-ON

BaselineWeek 52None or mildModerateSevere or very severeMissingTotalContinued nintedanibNone or mild81 (41.1)5 (2.5)04 (2.0)90 (45.7)Moderate38 (19.3)10 (5.1)01 (0.5)49 (24.9)Severe or very severe13 (6.6)14 (7.1)7 (3.6)1 (0.5)35 (17.8)Missing6 (3.0)3 (1.5)1 (0.5)13 (6.6)23 (11.7)Total138 (70.1)32 (16.2)8 (4.1)19 (9.6)197 (100)Initiated nintedanibNone or mild87 (35.2)6 (2.4)1 (0.4)4 (1.6)98 (39.7)Moderate35 (14.2)12 (4.9)2 (0.8)3 (1.2)52 (21.1)Severe or very severe8 (3.2)7 (2.8)4 (1.6)1 (0.4)20 (8.1)Missing37 (15.0)15 (6.1)4 (1.6)21 (8.5)77 (31.2)Total167 (67.6)40 (16.2)11 (4.5)29 (11.7)247 (100)

Data are n (%) of patients. None or mild=scores of 0 to 0.49; moderate=scores of 0.5 to 1; severe or very severe=scores of 1.01 to 3.

Figure 1.

Changes in UCLA SCTC GIT scores from baseline to week 52 of SENSCIS-ON

Conclusion

In the SENSCIS-ON trial, the majority of patients with SSc-ILD treated with nintedanib had no or mild GI symptoms at baseline. A small worsening in GI symptoms was observed over 52 weeks. Diarrhoea had the greatest impact, reflecting the adverse event profile of nintedanib. Recommendations for the management of diarrhoea in patients treated with nintedanib should be implemented in clinical practice.

Acknowledgements

The SENSCIS-ON trial was funded by Boehringer Ingelheim.

Disclosure of Interests

Dinesh Khanna Shareholder of: Eicos Sciences, Inc - stocks, Consultant of: AbbVie, Acceleron, Actelion, Amgen, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, Galapagos NV, Genentech/Roche, Gilead, GlaxoSmithKline, Horizon Therapeutics, Merck Sharp & Dohme, Mitsubishi Tanabe Pharma, Sanofi-Aventis, United Therapeutics, Prometheus, Theraly, AstraZeneca, Grant/research support from: Bayer, Bristol-Myers Squibb, Horizon Therapeutics, Immune Tolerance Network, National Institutes of Health, Pfizer, Employee of: CiviBioPharma/Eicos Sciences, Inc - Leadership/Equity position – Chief Medical Officer, Elizabeth Volkmann Speakers bureau: Boehringer Ingelheim, Consultant of: Boehringer Ingelheim, Grant/research support from: Boehringer Ingelheim, Corbus, Forbius, Horizon, Kadmon, Kristin Highland Speakers bureau: Actelion Pharmaceuticals (Jansen), Bayer Healthcare, Boehringer Ingelheim, United Therapeutics, Paid instructor for: Acceleron Pharmaceuticals, Actelion Pharmaceuticals, Bayer Healthcare, Boehringer Ingelheim, Gilead Sciences, United Therapeutics, Consultant of: Boehringer Ingelheim, United Therapeutics, Genentech, Forsee Pharmaceuticals, Grant/research support from: Acceleron Pharmaceuticals, Actelion Pharmaceuticals, Bayer Healthcare, Boehringer Ingelheim, Genentech, Gossamer Bio, Eiger Pharmaceuticlas, Lilly Pharmaceuticals, Reata Pharmaceuticals, United Therapeutics, Viela Bio (Horizon Pharmaceuticals), Yannick Allanore Consultant of: Abbvie, AstraZeneca, Bayer, Boehringer Ingelheim, Janssen, Medsenic, Mylan, Prometheus, Roche, Sanofi, Grant/research support from: Alpine Immunosciences, Medsenic, OSE Immunotherapeutics, Stéphane Jouneau Paid instructor for: Cours, formations - Actelion, AIRB, AstraZeneca, Bristol-Myers Squibb, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, LVL, Mundipharma, Novartis, Pfizer, Roche, Consultant of: Advisory Boards, consultancy - AIRB, Boehringer Ingelheim, Roche, Grant/research support from: Recherche Clinique - AIRB, Biogen, Bristol-Myers Squibb, Boehringer Ingelheim, Galactic, Gilead, LVL, Roche, Savara

Aides pour des recherches - AIRB, Boehringer Ingelheim, LVL, Novartis, Roche, James Seibold Shareholder of: Prometheus Biosciences, Speakers bureau: Boehringer Ingelheim, Consultant of: Alexion, Blade, Camurus AB, GlaxoSmithKline, Prometheus Biosciences, Sironax, Sojournix, Xenikos, Employee of: Prometheus Biosciences, Alexandra James Employee of: Alexandra James is an employee of Elderbrook solutions GmbH that is contracted by Boehringer Ingelheim, Margarida Alves Employee of: Margarida Alves is an employee of Boehringer Ingelheim, Oliver Distler Speakers bureau: OD has/had relationships with the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three calendar years:

Speaker fee: Bayer, Boehringer Ingelheim, Janssen, Medscape

, Consultant of: OD has/had relationships with the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three calendar years:

Consultancy fee: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, 4P Science, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur

OD has/had relationships with the following companies in the area of potential treatments for arthritides in the last three calendar years:

Consultancy fee: Abbvie

, Grant/research support from: OD has/had relationships with the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three calendar years:

Research Grants: Boehringer Ingelheim, Kymera, Mitsubishi Tanabe

[French practical guidelines for the diagnosis and management of IPF - 2021 update, short version]

BACKGROUND

Since the previous French guidelines were published in 2017, substantial additional knowledge about idiopathic pulmonary fibrosis has accumulated.

METHODS

Under the auspices of the French-speaking Learned Society of Pulmonology and at the initiative of the coordinating reference center, practical guidelines for treatment of rare pulmonary diseases have been established. They were elaborated by groups of writers, reviewers and coordinators with the help of the OrphaLung network, as well as pulmonologists with varying practice modalities, radiologists, pathologists, a general practitioner, a head nurse, and a patients' association. The method was developed according to rules entitled "Good clinical practice" in the overall framework of the "Guidelines for clinical practice" of the official French health authority (HAS), taking into account the results of an online vote using a Likert scale.

RESULTS

After analysis of the literature, 54 recommendations were formulated, improved, and validated by the working groups. The recommendations covered a wide-ranging aspects of the disease and its treatment: epidemiology, diagnostic modalities, quality criteria and interpretation of chest CT, indication and modalities of lung biopsy, etiologic workup, approach to familial disease entailing indications and modalities of genetic testing, evaluation of possible functional impairments and prognosis, indications for and use of antifibrotic therapy, lung transplantation, symptom management, comorbidities and complications, treatment of chronic respiratory failure, diagnosis and management of acute exacerbations of fibrosis.

CONCLUSION

These evidence-based guidelines are aimed at guiding the diagnosis and the management in clinical practice of idiopathic pulmonary fibrosis.

Predictors of mortality in subjects with progressive fibrosing interstitial lung diseases

Background and objective

Demographic and clinical variables, measured at baseline or over time, have been associated with mortality in subjects with progressive fibrosing interstitial lung diseases (ILDs). We used data from the INPULSIS trials in subjects with idiopathic pulmonary fibrosis (IPF) and the INBUILD trial in subjects with other progressive fibrosing ILDs to assess relationships between demographic/clinical variables and mortality.

Methods

The relationships between baseline variables and time‐varying covariates and time to death over 52 weeks were analysed using pooled data from the INPULSIS trials and, separately, the INBUILD trial using a Cox proportional hazards model.

Results

Over 52 weeks, 68/1061 (6.4%) and 33/663 (5.0%) subjects died in the INPULSIS and INBUILD trials, respectively. In the INPULSIS trials, a relative decline in forced vital capacity (FVC) >10% predicted within 12 months (hazard ratio [HR] 3.77) and age (HR 1.03 per 1‐year increase) were associated with increased risk of mortality, while baseline FVC % predicted (HR 0.97 per 1‐unit increase) and diffusing capacity of the lungs for carbon monoxide (DLCO) % predicted (HR 0.77 per 1‐unit increase) were associated with lower risk. In the INBUILD trial, a relative decline in FVC >10% predicted within 12 months (HR 2.60) and a usual interstitial pneumonia‐like fibrotic pattern on HRCT (HR 2.98) were associated with increased risk of mortality, while baseline DLCO % predicted (HR 0.95 per 1‐unit increase) was associated with lower risk.

Conclusion

These data support similarity in the course of lung injury between IPF and other progressive fibrosing ILDs and the value of FVC decline as a predictor of mortality.

We assessed relationships between baseline and time‐varying factors and mortality over 52 weeks in 1061 subjects with idiopathic pulmonary fibrosis (IPF) and 663 subjects with other progressive fibrosing interstitial lung diseases (ILDs). Our findings support similarity in the course of IPF and ILD and an association between decline in forced vital capacity and mortality.

Idiopathic pulmonary fibrosis diagnosed concomitantly with diffuse squamous cell lung cancer on surgical lung biopsy: a case report

Background

Idiopathic pulmonary fibrosis is a disease with a poor prognosis and has been associated with increased lung cancer incidence.

Case presentation

We report the case of a Caucasian 75-year-old woman, a former smoker, hospitalized for breathlessness with a chest computed tomography scan showing an interstitial lung disease. A surgical lung biopsy was performed, confirming a pattern of usual interstitial pneumonia but also numerous disseminated foci of well-differentiated focally invasive squamous cell carcinoma without hypermetabolic lung nodule, mass, or enlarged lymph node visualized on chest computed tomography or positron emission tomography scan. Nintedanib was started for its antifibrotic and antitumor properties, without any other antineoplastic treatment. Three years after initiation of nintedanib, clinical, functional, and computed tomography scan evaluations were stable, and there was no evidence for evolution of the squamous cell carcinoma.

Conclusions

Data are scarce regarding the benefit of nintedanib in patients with idiopathic pulmonary fibrosis-associated lung cancer, and it is unclear whether nintedanib could have a preventive role in lung carcinogenesis in idiopathic pulmonary fibrosis patients. This experience could help the scientific community in case of similar incidental findings.

Home spirometry in patients with idiopathic pulmonary fibrosis: data from the INMARK trial

Background

Data from the INMARK trial were used to investigate the feasibility and validity of home spirometry as a measure of lung function decline in patients with idiopathic pulmonary fibrosis (IPF).

Methods

Subjects with IPF and preserved forced vital capacity (FVC) were randomised to receive nintedanib or placebo for 12 weeks followed by open-label nintedanib for 40 weeks. Clinic spirometry was conducted at baseline and weeks 4, 8, 12, 16, 20, 24, 36 and 52. Subjects were asked to perform home spirometry at least once a week and ideally daily. Correlations between home- and clinic-measured FVC and rates of change in FVC were assessed using Pearson correlation coefficients.

Results

In total, 346 subjects were treated. Mean adherence to weekly home spirometry decreased over time but remained above 75% in every 4-week period. Over 52 weeks, mean adherence was 86%. Variability in change from baseline in FVC was greater when measured by home rather than clinic spirometry. Strong correlations were observed between home- and clinic-measured FVC at all time-points (r=0.72–0.84), but correlations between home- and clinic-measured rates of change in FVC were weak (r=0.26 for rate of decline in FVC over 52 weeks).

Conclusion

Home spirometry was a feasible and valid measure of lung function in patients with IPF and preserved FVC, but estimates of the rate of FVC decline obtained using home spirometry were poorly correlated with those based on clinic spirometry.

In a 52-week study in 346 subjects with idiopathic pulmonary fibrosis, mean adherence to weekly home spirometry was 86%. Estimates of the rate of decline in forced vital capacity obtained using home and clinic spirometry were poorly correlated.https://bit.ly/2WjIQ4b

Pneumocystis in metastatic lung cancer, a pragmatic approach in support of prophylaxis

Lung cancer prognosis has improved in the last decade, including in patients with brain metastasis. However, few of these patients who receive corticosteroids have a primary prophylaxis for Pneumocystis jirovecii pneumonia (PJP). We report the case of an 80-year-old man diagnosed with non-small cell lung cancer and concomitant symptomatic brain metastases, treated with 50 mg/day of prednisolone without any prophylaxis, who presented an acute PJP. After 72 hours of unsuccessful treatment of PJP, the patient died. In our review of this case and the existing literature, we emphasise the importance of a wide use of prophylaxis for PJP, especially in advanced lung cancer treated with corticosteroid therapy. We discuss this issue and report current evidence for primary prophylaxis by trimethoprim–sulfamethoxazole.

POS0840 RISK OF MALNUTRITION IN PATIENTS WITH SYSTEMIC SCLEROSIS-ASSOCIATED INTERSTITIAL LUNG DISEASE (SSC-ILD): FURTHER ANALYSES OF THE SENSCIS TRIAL

Background:

Gastrointestinal (GI) involvement is common in patients with SSc and may lead to weight loss and malnutrition. In the SENSCIS trial in patients with SSc-ILD, nintedanib reduced the rate of decline in forced vital capacity (FVC) (mL/year) over 52 weeks, with mainly GI adverse events. The Malnutrition Universal Screening Tool (MUST) was developed to identify adults who are at risk of malnutrition and has been used in studies of patients with SSc.

Objectives:

To evaluate nutritional status over 52 weeks in the SENSCIS trial based on a modified MUST score.

Methods:

The SENSCIS trial enrolled patients with SSc-ILD with first non-Raynaud symptom ≤7 years before screening, extent of fibrotic ILD ≥10% on HRCT and FVC ≥40% predicted. Patients who had taken a stable dose of mycophenolate for ≥6 months were eligible to participate. Patients were randomised to receive nintedanib 150 mg bid or placebo. Dose reductions to 100 mg bid and treatment interruptions were allowed to manage adverse events and specific recommendations were provided for the management of diarrhoea. We calculated a modified MUST score at baseline and weeks 12, 24, 36 and 52 based on (A) BMI, (B) weight loss (week 12 vs baseline; week 24 vs week 12; week 36 vs week 24; week 52 vs week 36), and (C) a surrogate for acute disease effect (if the patient had any serious adverse event that led to hospitalisation between weight assessments and received ≥1 medication from the WHO classification code for “solutions for parenteral nutrition” for ≥5 days). MUST score at baseline was based solely on BMI. With scores ranging from 0 to 6, the risk of malnutrition is defined as low (score = 0), medium (score = 1) or high (score ≥2).

Results:

Among 576 patients who received nintedanib (n=288) or placebo (n=288), mean (SD) age at baseline was 54.0 (12.2) years, weight was 69.7 (15.9) kg and BMI was 25.9 (5.0) kg/m2; median time since onset of first non-Raynaud symptom was 3.4 years; and 75.2% of patients were female. In the nintedanib and placebo groups, respectively, MUST scores suggested that 74.0% and 78.1% of patients were at low risk of malnutrition at baseline and remained at low risk at their last measurement (Table 1). At weeks 12 and 52, respectively, mean (SD) MUST scores were 0.3 (0.6) and 0.4 (0.7) in the nintedanib group and 0.2 (0.5) and 0.2 (0.6) in the placebo group. At weeks 12, 24, 36 and 52, respectively, the proportions of patients at low risk of malnutrition were 81.8%, 80.9%, 72.9% and 76.5% in the nintedanib group and 86.6%, 86.4%, 88.3% and 80.8% in the placebo group; the proportions at medium risk were 12.1%, 13.1%, 18.0% and 13.5% in the nintedanib group and 8.5%, 8.6%, 5.8% and 13.1% in the placebo group; and the proportions of patients at high risk were 6.1%, 5.6%, 8.3% and 9.6% in the nintedanib group and 4.9%, 4.3%, 4.7% and 5.4% in the placebo group.

Table 1.

Risk of malnutrition at baseline and at last assessment over 52 weeks in the SENSCIS trial.

Last assessment of riskNintedanib (n=288)Placebo (n=288)Baseline riskBaseline riskLowMediumHighTotalLowMediumHighTotalLow213 (74.0)1 (0.3)0214 (74.3)225 (78.1)7 (2.4)0232 (80.6)Medium31 (10.8)8 (2.8)039 (13.5)20 (6.9)14 (4.9)4 (1.4)38 (13.2)High13 (4.5)8 (2.8)7 (2.4)28 (9.7)3 (1.0)2 (0.7)10 (3.5)15 (5.2)Missing7 (2.4)007 (2.4)3 (1.0)003 (1.0)Total264 (91.7)17 (5.9)7 (2.4)288 (100)251 (87.2)23 (8.0)14 (4.9)288 (100)

MUST score ranges from 0 to 6. Score of 0 = low risk: score of 1 = medium risk; score of ≥2 = high risk. Baseline MUST score was based solely on BMI.

Conclusion:

In the SENSCIS trial, scores based on a modified MUST indicated that most patients treated with nintedanib were at low risk of malnutrition at baseline and remained at low risk over 52 weeks. The proportions of patients at high risk of malnutrition were low but were numerically greater in patients who received nintedanib than placebo. Management of disease manifestations and gastrointestinal adverse events that may be associated with weight loss is important to reduce the risk of malnutrition in patients with SSc-ILD treated with nintedanib.

Acknowledgements:

The SENSCIS trial was funded by Boehringer Ingelheim. Medical writing support was provided by FleishmanHillard Fishburn, London, UK. The authors meet criteria for authorship as recommended by the International Committee of Medical Journal Editors (ICMJE).

Disclosure of Interests:

Elizabeth Volkmann Consultant of: Boehringer Ingelheim, Grant/research support from: Corbus and Forbius, Zsuzsanna McMahan: None declared, Sindhu Johnson Consultant of: Boehringer Ingelheim, CSL Behring and Ikaria, Grant/research support from: Bayer, Boehringer Ingelheim, Corbus, GlaxoSmithKline, Merck and Roche, Vanessa Smith Speakers bureau: Boehringer Ingelheim and Janssen, Consultant of: Boehringer Ingelheim, Grant/research support from: Belgian Fund for Scientific Research in Rheumatic diseases (FWRO), Boehringer Ingelheim, Research Foundation - Flanders (FWO) and Janssen, Stéphane Jouneau Speakers bureau: Actelion, AIRB, AstraZeneca, Bristol-Myers Squibb, Boehringer Ingelheim, Chiesi, Genzyme, GlaxoSmithKline, LVL Mediphar, Mundipharma, Novartis, Pfizer, Roche and Sanofi, Consultant of: AIRB, Boehringer Ingelheim, Novartis and Roche, Grant/research support from: AIRB, Boehringer Ingelheim, LVL Mediphar, Novartis and Roche, Corinna Miede Employee of: Currently an employee of mainanalytics GmbH, contracted by Boehringer Ingelheim, Margarida Alves Employee of: Currently an employee of Boehringer Ingelheim, Ariane Herrick Speakers bureau: Janssen, Consultant of: Boehringer Ingelheim, Camurus, CSL Behring and Gesynta Pharma, Grant/research support from: Actelion and Gesynta Pharma

POS0403 RISK FACTORS FOR PROGRESSION OF RHEUMATOID ARTHRITIS-ASSOCIATED INTERSTITIAL LUNG DISEASE: REASSURING IMPACT OF METHOTREXATE

Background:

Factors associated with rheumatoid arthritis-associated interstitial lung disease (RA-ILD) progression and prognosis are not well identified, especially the impact of methotrexate.

Objectives:

Identify risk factors of ILD progression in RA-ILD patients in a longitudinal study.

Methods:

RA patients with ILD confirmed in 2 high resolution computed tomography (HRCT) chest scans spaced at least 6 months apart (T0: date of the first HRCT chest scan describing ILD; Tx: date of the last HRCT chest scan available) were consecutively included in this retrospective multi-centric study from 2010 to 2020. HRCT chest scans were analyzed for each patient at T0 and Tx by 2 independent radiologists to determinate ILD pattern (definite UIP, probable UIP, indeterminate UIP, non-UIP) and progression during the follow-up including variation of the fibrosis score (aggravated or non-aggravated). Characteristics of patients (demographic-clinical-biological findings, respiratory function tests, and treatments exposure) at ILD diagnosis and during the follow-up (T0-Tx) were analyzed as potential determinants of ILD progression through multivariable logistic regression analysis. Overall survival was analyzed using Kaplan-Meier method.

Results:

74 RA-ILD patients were included. During a mean duration between T0-Tx of 2.8 years ± 2.4, 26 patients (35%) had ILD progression. Thirty-three patients (45%) were treated by methotrexate at ILD diagnosis (T0) and 29 of them (39%) continued methotrexate during T0-Tx. Logistic regression in multivariate analysis revealed that a treatment by methotrexate at ILD diagnosis was protective against ILD progression (OR=0.14 [0.04-0.52]; p=0.0031). Non-UIP pattern at ILD diagnosis was also protective against ILD progression (OR=0.09 [0.02-0.36]; p=0.0005). The follow-up for survival analysis was 5.1 years ± 2.9. Thirty-three patients (31%) died, and the 3-year survival rate was 80%. Survival was better for non-aggravated ILD patients (HR=3.5 [1.46-8.4]; p=0.004) and for patients treated by methotrexate during T0-Tx (HR= 0.36 [0.15-0.84]; p=0.018) and worse for definite UIP patterns (HR=2.570 [1.078-6.128]; p=0.0332).

Conclusion:

In RA-ILD patients, non-UIP pattern and methotrexate treatment are associated with better ILD evolution and prognosis.

Disclosure of Interests:

None declared

[Ambulatory management of bilateral secondary spontaneous pneumothorax in palliative care]

INTRODUCTION

Secondary spontaneous pneumothoraces account for 35% of all pneumothoraces after the age of 50. Their management is still debated and can be challenging due to the underlying respiratory condition. In our observation, the use of small-bore chest tubes allowed prolonged ambulatory care in a palliative setting.

CASE REPORT

We report the case of a 54-year-old woman suffering from a leiomyosarcoma with multiple pulmonary metastases who had repeated episodes of pneumothorax, one of which was bilateral. Treatment involved the bilateral insertion of 8.5F pigtail catheters connected to Heimlich valves that allowed management as an outpatient. Recurrences were treated similarly, in association with oncological management, providing great additional benefits for patient comfort in this palliative context.

CONCLUSION

Altogether, this case report confirms the applicability of outpatient management for drained spontaneous secondary pneumothoraces, even bilateral, especially in a palliative-care setting.

Chest CT in COVID-19 pneumonia: A review of current knowledge

•

Unenhanced chest CT is indicated for patients with suspected COVID-19 presenting with dyspnea, polypnea or arterial blood oxygen desaturation.

•

Most typical CT features of COVID-19 pneumonia include bilateral and multifocal ground-glass opacities predominating in the peripheral, posterior and basal parts of the lungs.

•

Between 15 and 30% of hospitalized patients with COVID-19 progress to acute respiratory distress syndrome, which is the main cause of mortality.

The current COVID-19 pandemic has highlighted the essential role of chest computed tomography (CT) examination in patient triage in the emergency departments, allowing them to be referred to “COVID” or “non-COVID” wards. Initial chest CT examination must be performed without intravenous administration of iodinated contrast material, but contrast material administration is required when pulmonary embolism is suspected, which seems to be frequent in severe forms of the disease. Typical CT features consist of bilateral ground-glass opacities with peripheral, posterior and basal predominance. Lung disease extent on CT correlates with clinical severity. Artificial intelligence could assist radiologists for diagnosis and prognosis evaluation.

SAT0329 IS THE RATE OF LUNG FUNCTION DECLINE THE SAME IN PATIENTS WITH SYSTEMIC SCLEROSIS-ASSOCIATED ILD (SSC-ILD) WHO EXPERIENCE WEIGHT LOSS? DATA FROM THE SENSCIS TRIAL

Background:

In the SENSCIS trial, nintedanib reduced the progression of SSc-ILD vs placebo, as shown by a lower rate of decline in forced vital capacity (FVC). The adverse event (AE) profile of nintedanib was characterised mainly by gastrointestinal (GI) events, including weight loss.

Objectives:

Assess FVC decline and AEs in subgroups by weight loss ≤5% vs >5% over 52 weeks in the SENSCIS trial.

Methods:

Patients with SSc-ILD with first non-Raynaud symptom <7 years before screening and ≥10% fibrosis of the lungs on an HRCT scan were randomised to nintedanib or placebo. In a non-randomised comparison, we analysed the rate of decline in FVC (mL/year) and AEs over 52 weeks in subgroups by weight loss (≤5% vs >5%) over 52 weeks.

Results:

In the nintedanib (n=288) and placebo (n=288) groups, respectively, 112 (38.9%) and 43 (14.9%) patients had weight loss >5% over 52 weeks. At baseline, patients with weight loss >5% over 52 weeks had a higher mean age (57.0 vs 52.9 years), greater proportion of females (81.3% vs 72.9%), and similar mean BMI (26.5 vs 25.7 kg/m2, respectively) and FVC % predicted (71.0% vs 73.1%, respectively) vs patients with weight loss ≤5%. In the placebo group, the mean (SE) annual rate of decline in FVC was similar between patients who had weight loss ≤5% and >5% over 52 weeks (-92.7 [14.7] mL/year and -96.4 [34.9] mL/year, respectively). The estimated annual rate of decline in FVC was lower in patients treated with nintedanib than placebo, with between-group differences in patients who had weight loss ≤5% and >5% of 49.9 mL/year [95% CI 4.2, 95.6]) and 30.2 mL/year [95% CI -50.5, 110.9]), respectively, with no evidence of heterogeneity between subgroups by weight loss (p=0.68 for interaction). Standardised differences in baseline values of potential confounders were <0.2 (indicating negligible differences). The most frequent AEs in patients treated with nintedanib were diarrhoea (74.4% and 77.7% of patients with weight loss ≤5% and >5%, respectively), nausea (30.1% and 33.9%, respectively) and vomiting (19.3% and 33.3%, respectively). In the nintedanib and placebo groups, respectively, AEs leading to discontinuation of study drug occurred in 17.0% and 8.6% of patients with weight loss ≤5%, and 14.3% and 9.3% of patients with weight loss >5% over 52 weeks.

Conclusion:

In the SENSCIS trial in patients with SSc-ILD, a greater proportion of patients treated with nintedanib than placebo had weight loss >5% over 52 weeks. The rate of decline in FVC was numerically lower in the nintedanib group than in the placebo group both in patients with weight loss ≤5% and >5% over 52 weeks. AEs leading to discontinuation of nintedanib were not more frequent in patients with weight loss >5% vs ≤5%.

References:

Disclosure of Interests: :

Alain LESCOAT: None declared, Stéphane Jouneau Grant/research support from: AIRB, Boehringer Ingelheim, LVL Medical, Novartis, Roche, Bellorophon Therapeutics, Biogen, Fibrogen, Galecto Biotech, Gilead Sciences, Pharm-Olam, Pliant Therapeutics, Savara Pharmaceuticals/Serendex Pharmaceuticals, Consultant of: Actelion, AIRB, AstraZeneca, Bristol-Myers Squibb, Boehringer Ingelheim, Chiesi, Genzyme, GlazoSmithKline, LVL Medical, Mundipharma, Novartis, Pfizer, Roche, Sanofi, Bruno Crestani Grant/research support from: AstraZeneca, Bristol-Myers Squibb, Boehringer Ingelheim, Novartis, Roche, Sanofi, Consultant of: AstraZeneca, Bristol-Myers Squibb, Boehringer Ingelheim, Roche, Sanofi, Speakers bureau: AstraZeneca, Boehringer Ingelheim, Roche, Sanofi, Gabriela Riemekasten Consultant of: Cell Trend GmbH, Janssen, Actelion, Boehringer Ingelheim, Speakers bureau: Actelion, Novartis, Janssen, Roche, GlaxoSmithKline, Boehringer Ingelheim, Pfizer, Yasuhiro Kondoh Consultant of: Boehringer Ingelheim, Asahi Kasei Pharma, Janssen, Shionogi, Speakers bureau: Boehringer Ingelheim, Asahi Kasei Pharma, Janssen, Eisai, KYORIN, Mitsubishi Tanabe Pharma, Novartis, Shionogi, Vanessa Smith Grant/research support from: The affiliated company received grants from Research Foundation - Flanders (FWO), Belgian Fund for Scientific Research in Rheumatic diseases (FWRO), Boehringer Ingelheim Pharma GmbH & Co and Janssen-Cilag NV, Consultant of: Boehringer-Ingelheim Pharma GmbH & Co, Speakers bureau: Actelion Pharmaceuticals Ltd, Boehringer-Ingelheim Pharma GmbH & Co and UCB Biopharma Sprl, Nina Patel Grant/research support from: Boehringer Ingelheim, Consultant of: Boehringer Ingelheim, Speakers bureau: Genentech, John Huggins Consultant of: I was a site PI for the SENSCIS trial for Boehringer Ingelheim, Christian Stock Employee of: Employee of Boehringer Ingelheim, Martina Gahlemann Employee of: Employee of Boehringer Ingelheim, Margarida Alves Employee of: Employee of Boehringer Ingelheim, Christopher Denton Grant/research support from: GlaxoSmithKline, CSL Behring, and Inventiva, Consultant of: Medscape, Roche-Genentech, Actelion, GlaxoSmithKline, Sanofi Aventis, Inventiva, CSL Behring, Boehringer Ingelheim, Corbus Pharmaceuticals, Acceleron, Curzion and Bayer

AB0158 IMPACT OF JAK INHIBITORS ON MACROPHAGE POLARISATION: PERSPECTIVES FOR SYSTEMIC SCLEROSIS

Background:

Macrophage can adopt various phenotypes and activation states according to their surrounding microenvironment. M1 or inflammatory macrophages are generated under IFNɣ/LPS signaling and express the membrane marker CD86. Different subtypes of M2 macrophages are also described: M2a macrophages (generated under IL4/IL13 signaling) and characterized by a high expression of CD206 and pro-fibrotic properties and, M2c macrophages (generated under IL10 and/or glucorticoid signaling), considered as anti-inflammatory resolving macrophages. There is growing interest in the role of macrophages in the pathogenesis of Systemic Sclerosis (SSc). Recent studies highlight that macrophages from fibrotic tissues such as lung or skin from SSc patients have a M2 phenotype whereas, in blood-monocytes derived macrophages (MDM), SSc MDM have a mixed signature associating M1 and M2 characteristics. Jak inhibitors are treatments used in rheumatoid arthritis and that can variously target signals that could be involved both in M1 and in M2 polarisation.

Objectives:

This study evaluates the impact of three Jak inhibitors on the polarisation state of human MDM in vitro.

Methods:

Blood monocytes form healthy donors (HD) were differentiated with M-CSF (for 7 days) in MDM and pre-treated by ruxolitinib (Jak2-Jak1 inhibitor), tofacitinib (Jak3 inhibitor) or itacitinib (Jak1 inhibitor) (1µM for all). They were then polarised into M1i (IFNɣ, 20µg/mL), M1Li (IFNɣ+LPS, 20µg/mL), M2a (IL4+IL13; 20µg/ML), M2c (IL10, 20µg/mL) and M2c(dex) (IL10+dexamethasone, 10 nM). The impact of each Jak inhibitor on phenotype (flow cytometry), gene expression (qPCR) and cytokine secretion (ELISA) was evaluated in each polarisation state.

Results:

Concerning phenotypes, all Jak inhibitors reduced the expression of the M1i and M1Li marker CD86, but ruxolitinib had a higher effect. Only ruxolitinib reduced the expression of the M1i marker MHCII. All Jak inhibitors reduced the expression of CD206 in M2a. They had no impact on the expression of CD163, CD204 in any M2 conditions. Key M1 genes were repressed by all Jak inhibitors, such as CXCL10, IL6 or TNFα with a more significant effect of ruxolitinib. All Jak inhibitors reduced the gene expression of CXCL13 and SOCS3 in M2c. Secretion levels of IL6 and CCL18 were also repressed, with a more significant effect of ruxolitinib.

Conclusion:

Jak inhibitors can limit M1 and M2 polarisation state in vitro, with a more significant effect of the Jak2-Jak1 inhibitor ruxolitinib. The relevance of these results in MDM from SSc patients and in vivo models of SSc is still to be determined.

Disclosure of Interests:

Alain LESCOAT: None declared, Alice Ballerie: None declared, Marie Lelong: None declared, Claudie Morzadec: None declared, Stéphane Jouneau Grant/research support from: AIRB, Boehringer Ingelheim, LVL Medical, Novartis, Roche, Bellorophon Therapeutics, Biogen, Fibrogen, Galecto Biotech, Gilead Sciences, Pharm-Olam, Pliant Therapeutics, Savara Pharmaceuticals/Serendex Pharmaceuticals, Consultant of: Actelion, AIRB, AstraZeneca, Bristol-Myers Squibb, Boehringer Ingelheim, Chiesi, Genzyme, GlazoSmithKline, LVL Medical, Mundipharma, Novartis, Pfizer, Roche, Sanofi, Patrick Jégo: None declared, Laurent Vernhet: None declared, Olivier Fardel: None declared, Valérie Lecureur: None declared

Nintedanib in patients with progressive fibrosing interstitial lung diseases-subgroup analyses by interstitial lung disease diagnosis in the INBUILD trial: a randomised, double-blind, placebo-controlled, parallel-group trial

BACKGROUND

The INBUILD trial investigated the efficacy and safety of nintedanib versus placebo in patients with progressive fibrosing interstitial lung diseases (ILDs) other than idiopathic pulmonary fibrosis (IPF). We aimed to establish the effects of nintedanib in subgroups based on ILD diagnosis.

METHODS

The INBUILD trial was a randomised, double-blind, placebo-controlled, parallel group trial done at 153 sites in 15 countries. Participants had an investigator-diagnosed fibrosing ILD other than IPF, with chest imaging features of fibrosis of more than 10% extent on high resolution CT (HRCT), forced vital capacity (FVC) of 45% or more predicted, and diffusing capacity of the lung for carbon monoxide (DLco) of at least 30% and less than 80% predicted. Participants fulfilled protocol-defined criteria for ILD progression in the 24 months before screening, despite management considered appropriate in clinical practice for the individual ILD. Participants were randomly assigned 1:1 by means of a pseudo-random number generator to receive nintedanib 150 mg twice daily or placebo for at least 52 weeks. Participants, investigators, and other personnel involved in the trial and analysis were masked to treatment assignment until after database lock. In this subgroup analysis, we assessed the rate of decline in FVC (mL/year) over 52 weeks in patients who received at least one dose of nintedanib or placebo in five prespecified subgroups based on the ILD diagnoses documented by the investigators: hypersensitivity pneumonitis, autoimmune ILDs, idiopathic non-specific interstitial pneumonia, unclassifiable idiopathic interstitial pneumonia, and other ILDs. The trial has been completed and is registered with ClinicalTrials.gov, number NCT02999178.

FINDINGS

Participants were recruited between Feb 23, 2017, and April 27, 2018. Of 663 participants who received at least one dose of nintedanib or placebo, 173 (26%) had chronic hypersensitivity pneumonitis, 170 (26%) an autoimmune ILD, 125 (19%) idiopathic non-specific interstitial pneumonia, 114 (17%) unclassifiable idiopathic interstitial pneumonia, and 81 (12%) other ILDs. The effect of nintedanib versus placebo on reducing the rate of FVC decline (mL/year) was consistent across the five subgroups by ILD diagnosis in the overall population (hypersensitivity pneumonitis 73·1 [95% CI -8·6 to 154·8]; autoimmune ILDs 104·0 [21·1 to 186·9]; idiopathic non-specific interstitial pneumonia 141·6 [46·0 to 237·2]; unclassifiable idiopathic interstitial pneumonia 68·3 [-31·4 to 168·1]; and other ILDs 197·1 [77·6 to 316·7]; p=0·41 for treatment by subgroup by time interaction). Adverse events reported in the subgroups were consistent with those reported in the overall population.

INTERPRETATION

The INBUILD trial was not designed or powered to provide evidence for a benefit of nintedanib in specific diagnostic subgroups. However, its results suggest that nintedanib reduces the rate of ILD progression, as measured by FVC decline, in patients who have a chronic fibrosing ILD and progressive phenotype, irrespective of the underlying ILD diagnosis.

FUNDING

Boehringer Ingelheim.

Idiopathic pulmonary fibrosis: Significance of the usual interstitial pneumonia (UIP) CT-scan patterns defined in new international guidelines

INTRODUCTION

The new 2018 international guidelines for diagnosing usual interstitial pneumonia (UIP)/idiopathic pulmonary fibrosis (IPF) by CT scan split the old pattern possible UIP (2011 IPF guidelines) into two new patterns: probable UIP and indeterminate for UIP. However, the proportions and prognoses of these new CT-scan patterns are not clear.

METHODS

We used a monocentric retrospective cohort of 322 patients suspected of having IPF (University Hospital of Rennes; Competence Center for Rare Lung Diseases; 1 January 2012-31 December 2017). All patients initially diagnosed by CT scan as possible UIP were included. The chest CT-scans were then reclassified according to the new 2018 international guidelines by 3 observers. These data were then subjected to survival analysis with multivariate Cox regression using a composite endpoint of death, lung transplantation, a decline of≥10% in forced vital capacity (FVC), or hospitalization.

RESULTS

Of the 89 possible UIP patients included, 74 (83%) were reclassified as probable UIP and 15 (17%) as indeterminate for UIP. Probable UIP patients were more likely to meet the composite endpoint (56/74 [75.7%] vs. 5/15 [33%] patients; HR [IC 95%] =3.12 [1.24; 7.83], P=0.015). Multivariate analysis indicated that the probable UIP pattern was associated with significantly increased risk of reaching the composite endpoint (HR [95% CI]=2.85[1.00; 8.10], P=0.049).

CONCLUSION

The majority of possible UIP diagnoses corresponded to probable UIP, which was associated with a significantly worse prognosis than indeterminate for UIP. This distinction between these two CT patterns emphasizes the relevance of the new international guidelines for the diagnosis of IPF.

[Lung metastases of pancreatic adenocarcinoma: Watch for the second train!]

Pulmonary metastases due to a pancreatic cancer are difficult to diagnose and demonstrate a wide range of radiological patterns. We report the case of a 37-year-old female patient, without past medical history, with multicystic lung disease in a context of chronic abdominal pain, fatigue and weight loss. After several months of diagnostic delay, pathological examination of surgical lung biopsies led to the diagnosis of secondary deposits of pancreatic cancer. The clinical and radiogical situation deteriorated quickly with the development of alveolar consolidation and Aspergillus superinfection was then diagnosed. This case illustrates the value of an early decision to undertake surgical lung biopsy in the work-up of multicystic lung disease when cancer is suspected. In addition, in the specific context of cancer, faced with clinical and/or radiological deterioration, it is essential to look for infection, particularly aspergillosis.

[Spontaneous lung volume reduction following pneumonia in a patient with emphysema]

INTRODUCTION

Lung volume reduction can be effective in appropriately selected patients with severe emphysema and is associated with reduced breathlessness and improved survival. Spontaneous resolution of emphysematous bullae can also sometimes occur.

CASE REPORT

We report a case of severe smoking-related emphysema in a 60-year-old patient, who presented in October 2013 with a right upper lobe acute community-acquired pneumonia on the background of previously undocumented emphysema. The patient improved following treatment with co-amoxiclav and serial radiology showed progressive cicatricial retraction. Nine months later there had been a major functional improvement characterized by a complete normalization of the patient's ventilatory parameters, specifically a 45% improvement in FEV₁. In the literature, the average FEV1 improvement obtained by surgical or endoscopic lung volume reduction techniques does not exceed 28%.

CONCLUSION

Rarely, emphysematous bullae resolve following infections. Further studies of the mechanisms involved in these natural regressions may be of interest in the development of new therapeutics.

[Targeted screening of COPD in primary care: Feasibility and effectiveness]

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is a common but under-diagnosed pathology in primary care. The objective was to study the feasibility of a randomized controlled trial in general practice to detect new cases of COPD at an earlier stage.

METHODS

A cluster randomized, controlled, multicenter intervention study comparing, according to a 2×2 factorial plan, two case finding strategies: a systematic GOLD-HAS hetero-questionnaire and coordination of the patient's path to facilitate access to spirometry. The PIL-DISCO pilot study took place in 2017. Patients between 40 and 80 years old, with no previous history of COPD, consulting their GP on a given day regardless of the reason, were included.

RESULTS

176 patients were included in 1.5 days. Spirometry was performed in none of the control arm, in 13 (29.5%) of the questionnaire arm, in 22 (50%) in the coordination arm and in 32 (72.7%) with the combination of the two strategies. Two cases of stage 2 COPD and thirteen other respiratory diseases were diagnosed.

CONCLUSIONS

This study confirms the feasibility of the protocol in primary care in terms of speed of inclusion and acceptability. An extension phase aiming to include 3200 patients will assess the diagnostic value of the two strategies tested in general practice.