Limited efficacy of nintedanib for idiopathic pleuroparenchymal fibroelastosis

Idiopathic pleuroparenchymal fibroelastosis: diagnosis and management

INTRODUCTION

Idiopathic pleuroparenchymal fibroelastosis (iPPFE) is a rare progressive interstitial lung disease characterized by upper-lobe fibrosis, severe restrictive impairment, and poor prognosis. Unlike idiopathic pulmonary fibrosis, in which acute exacerbations, chronic respiratory failure, and lung cancer are the major causes of death, iPPFE primarily leads to progressive respiratory failure, often complicated by malnutrition and recurrent pneumothorax. Despite growing recognition, its pathogenesis remains unclear and no effective treatments exist.

AREAS COVERED

This review summarizes the epidemiological, clinical, radiological, and pathological features of iPPFE, as well as diagnostic and prognostic advancements. Key prognostic factors include weight loss, reduced forced vital capacity, hypercapnia, and lower-lobe interstitial pneumonia. Serum biomarkers (e.g. latent transforming growth factor-beta binding protein-4) are being explored for early detection and prognostic purposes. Although antifibrotic agents show limited efficacy, supportive care - pulmonary rehabilitation, nutritional management, and pneumothorax prevention - remains essential. Research on the fibroelastotic pathways may inform the development of future therapies.

EXPERT OPINION

IPPFE remains a challenging disease. Therefore, early diagnosis and comprehensive management of this condition are crucial. Future research should refine prognostic models and explore novel therapeutic approaches for treating fibroelastosis. Lung transplantation may be an option for select patients. Further studies are required to optimize these outcomes.

Pleuroparenchymal Fibroelastosis: Update on CT and Histologic Findings

Pleuroparenchymal fibroelastosis (PPFE) is an interstitial lung disease (ILD) characterized at CT by upper lobe-predominant pleural thickening and subpleural fibrosis and histologically by visceral pleural fibrosis and subpleural fibroelastosis. Although initially classified as a rare idiopathic interstitial pneumonia, many cases are related to known risk factors, particularly hematopoietic stem cell and lung transplant, or observed in association with other ILDs. This review summarizes the diagnostic criteria for PPFE and illustrates the CT and histologic manifestations, aiming to familiarize the radiologist with the range of findings suggestive of the diagnosis. Keywords: Conventional Radiography, CT, Pulmonary, Thorax, Lung, Pleura, Complications, Transplantation, Fibrosis © RSNA, 2025.

Diagnostic and prognostic implications of a deep suprasternal notch in idiopathic pleuroparenchymal fibroelastosis

BACKGROUND

Idiopathic pleuroparenchymal fibroelastosis (iPPFE) is a distinctive chronic interstitial lung disease characterized by upper lobe-dominant elastofibrosis. Deepening of the suprasternal notch is a notable physical feature in patients with iPPFE. However, the anatomical explanation and clinical significance of iPPFE have not yet been studied in detail.

METHODS

We retrospectively examined 84 patients with iPPFE, 59 with idiopathic pulmonary fibrosis (IPF), 32 with chronic hypersensitivity pneumonitis (CHP), and 91 non-interstitial lung disease (ILD) controls. The depth of the suprasternal notch assessed on axial chest computed tomography and its association with clinical, radiological, and physiological parameters, and patient outcomes were investigated.

RESULTS

The depth of the suprasternal notch was anatomically correlated with the thickness of the pre-tracheal soft tissue and posterior or right deviation of the trachea in patients with iPPFE. The depth of the suprasternal notch effectively discriminated patients with iPPFE from those with IPF (sensitivity, 75 %; specificity, 86.4 %), CHP (sensitivity, 75 %; specificity, 84.4 %), and non-ILD controls (sensitivity, 75 %; specificity, 83.5 %), with a cutoff value of 9.5 mm. A log-rank test showed that patients with iPPFE with a deep suprasternal notch had significantly shorter survival than those without a deep suprasternal notch. In addition, a multivariate Cox regression analysis adjusted for age, sex, and %forced vital capacity showed that the depth of the suprasternal notch was an independent risk factor for mortality.

CONCLUSION

The suprasternal notch is a simple and useful indicator with diagnostic and prognostic implications for patients with iPPFE.

Idiopathic pleuroparenchymal fibroelastosis: A review of the previous literature and current knowledge

Idiopathic pleuroparenchymal fibroelastosis (iPPFE) is characterized by upper lobe-dominant fibrosis involving the pleura and subpleural lung parenchyma. Pathologically, it is characterized by parenchymal intra-alveolar fibrosis with marked deposition of elastic fibers and dense thickening of the visceral pleura. Since iPPFE was categorized as a rare idiopathic interstitial pneumonia (IIP) by the America Thoracic Society/European Respiratory Society, several studies have been conducted, revealing an overall picture of iPPFE in terms of epidemiology, clinical manifestations, and mortality, in addition to its radiological and histological characteristics. Subsequently, several clinical diagnostic criteria that were not necessary for pathological analyses were proposed. Further, the underlying diseases responsible for secondary PPFE and PPFE-like lesions and their clinical implications were delineated. Typically, patients with iPPFE exhibit lean body stature together with platythorax, as well as relatively severe impairment of pulmonary function. In addition to upper-lobe PPFE lesions, lower-lobe interstitial lung disease (ILD) is commonly observed in patients with iPPFE, with the usual interstitial pneumonia pattern being most frequent. These distinct features of iPPFE were mostly associated with mortality, resulting in a poor prognosis relative to fibrotic ILD. Despite increased knowledge regarding the clinical characteristics of iPPFE, no effective therapy has been established other than lung transplantation. The efficacy of antifibrotic therapy, nutrition intervention, and pulmonary rehabilitation has not been determined. This article reviews previous studies and discusses the etiology, clinical manifestations, mortality risk, and treatment of iPPFE.

A Case of Pleuroparenchymal Fibroelastosis

Pleuroparenchymal fibroelastosis (PPFE) is a rare fibrotic lung disease with a poor prognosis. Some patients with PPFE have prominent lesions in one upper lobe. Due to the unilateral nature of lesions, similarities between some patients of PPFE and unilateral upper field pulmonary fibrosis (unilateral upper-PF) have been indicated. A 55-year-old man was referred to our hospital with PPFE, which had developed dyspnea 9 months previously. He had undergone resection of renal cancer 64 months prior to the onset of PPFE. He was administered the antifibrotic drug nintedanib, but passed away due to respiratory failure 43 months after the onset. What were impressive points in the clinical course of this PPFE patient was the similarity to unilateral upper-PF, including his medical history, and the poor prognosis. Although very rare, we do believe that the information on medical history and progression in this patient might provide suggestion into the treatment of future patients with a similar trajectory.

Proposed Clinical Algorithm for Pleuroparenchymal Fibroelastosis (PPFE)

Pleuroparenchymal fibroelastosis (PPFE) is characterized by fibrosis involving the pleura and subpleural lung parenchyma, predominantly in the upper lobes. As PPFE appears to occur in patients with heterogeneous etiologies, the disease course is thus also heterogenous, with some patients showing rapid progression while others have slow progression. Therefore, it is very difficult to predict prognosis with PPFE. Needless to say, this problematic matter has influenced the treatment strategy of PPFE patients. In fact, until now no evidence has been shown for use in creating an appropriate management algorithm for PPFE. We speculate that "uncoordinated breathing" is the most important reason for dyspnea in PPFE patients. Because monitoring of physique and not just pulmonary function and radiological evaluation is also very important, particularly in PPFE patients, this review focused on the characteristics of PPFE through an overview of previous studies in this field, and we proposed an algorithm as precision medicine based on the current evidence. Multiple views by the pulmonologist are needed to standardize a clinical algorithm that is necessary to correctly assess PPFE patients under the premise of maintenance of physique by providing appropriate nutritional care and pulmonary rehabilitation.

Two cases of airway-centered fibroelastosis treated with an antifibrotic agent and corticosteroids

Airway-centered fibroelastosis is characterized by peribronchovascular fibroelastosis, predominantly in the upper lobes, with little-to-no pleural involvement. In this study, we describe two cases of airway-centered fibroelastosis diagnosed based on radiological and pathological findings. The first case comprised a 44-year-old man whose forced vital capacity improved over three months following treatment with nintedanib. The second case involved a 50-year-old woman who was treated with oral corticosteroids but yielded an unfavorable outcome. An effective treatment for airway-centered fibroelastosis has not yet been identified; therefore, this study may help contribute to a more thorough discussion regarding treatment strategies for this disease.

Real-world experience of nintedanib for progressive fibrosing interstitial lung disease in the UK

Background

Nintedanib slows progression of lung function decline in patients with progressive fibrosing (PF) interstitial lung disease (ILD) and was recommended for this indication within the United Kingdom (UK) National Health Service in Scotland in June 2021 and in England, Wales and Northern Ireland in November 2021. To date, there has been no national evaluation of the use of nintedanib for PF-ILD in a real-world setting.

Methods

26 UK centres were invited to take part in a national service evaluation between 17 November 2021 and 30 September 2022. Summary data regarding underlying diagnosis, pulmonary function tests, diagnostic criteria, radiological appearance, concurrent immunosuppressive therapy and drug tolerability were collected via electronic survey.

Results

24 UK prescribing centres responded to the service evaluation invitation. Between 17 November 2021 and 30 September 2022, 1120 patients received a multidisciplinary team recommendation to commence nintedanib for PF-ILD. The most common underlying diagnoses were hypersensitivity pneumonitis (298 out of 1120, 26.6%), connective tissue disease associated ILD (197 out of 1120, 17.6%), rheumatoid arthritis associated ILD (180 out of 1120, 16.0%), idiopathic nonspecific interstitial pneumonia (125 out of 1120, 11.1%) and unclassifiable ILD (100 out of 1120, 8.9%). Of these, 54.4% (609 out of 1120) were receiving concomitant corticosteroids, 355 (31.7%) out of 1120 were receiving concomitant mycophenolate mofetil and 340 (30.3%) out of 1120 were receiving another immunosuppressive/modulatory therapy. Radiological progression of ILD combined with worsening respiratory symptoms was the most common reason for the diagnosis of PF-ILD.

Conclusion

We have demonstrated the use of nintedanib for the treatment of PF-ILD across a broad range of underlying conditions. Nintedanib is frequently co-prescribed alongside immunosuppressive and immunomodulatory therapy. The use of nintedanib for the treatment of PF-ILD has demonstrated acceptable tolerability in a real-world setting.

Home high-flow nasal therapy in a patient with pleuroparenchymal fibroelastosis: A case report

A 62-year-old man with pleuroparenchymal fibroelastosis (PPFE), who had been under observation for 19 years, was admitted due to headache, fatigue, and dyspnea. Although no acute findings were detected, his symptoms were attributed to hypercapnia and exertional hypoxemia. He had a history of pneumothorax, but chose not to undergo positive airway pressure ventilation. Consequently, home high-flow nasal therapy (HFNT) was initiated, and 4 months later, he observed an improvement in his quality of life, body weight gain, and relief from hypercapnia. These outcomes suggested that home HFNT holds potential for improving the quality of life for patients with PPFE.

Overcoming the challenges of a misdiagnosed rare lung disease - idiopathic pleuroparenchymal fibroelastosis

Pleuroparenchymal fibroelastosis (PPFE) is a rare condition characterized by pleural and subpleural lung fibroelastosis with an upper lobe predominance. We present the third case of idiopathic PPFE from India, as well as the second ante-mortem diagnosis. A 27-year-old man presented with a 1-year history of modified Medical Research Council class II shortness of breath and dry cough. He described a 15-kg weight loss. After a clinico-radiological diagnosis, he was given anti-tubercular treatment and referred because he showed no improvement. A high-resolution computed tomography of the chest revealed bilateral upper lobe bullae, parenchymal and subpleural fibrosis, and irregular pleural thickening. PPFE was found in surgical lung and pleural biopsies. He was given systemic glucocorticoids but did not respond clinically or radiologically. Pirfenidone and a lung transplant were out of reach for him. He died 9 months after being diagnosed with his condition. Finally, idiopathic PPFE is an extremely rare entity, with only three cases reported from our subcontinent. As a result, it is easily underdiagnosed or misdiagnosed; clinician awareness of this condition is critical for better diagnosis and management.

Extracellular Targets to Reduce Excessive Scarring in Response to Tissue Injury

Excessive scar formation is a hallmark of localized and systemic fibrotic disorders. Despite extensive studies to define valid anti-fibrotic targets and develop effective therapeutics, progressive fibrosis remains a significant medical problem. Regardless of the injury type or location of wounded tissue, excessive production and accumulation of collagen-rich extracellular matrix is the common denominator of all fibrotic disorders. A long-standing dogma was that anti-fibrotic approaches should focus on overall intracellular processes that drive fibrotic scarring. Because of the poor outcomes of these approaches, scientific efforts now focus on regulating the extracellular components of fibrotic tissues. Crucial extracellular players include cellular receptors of matrix components, macromolecules that form the matrix architecture, auxiliary proteins that facilitate the formation of stiff scar tissue, matricellular proteins, and extracellular vesicles that modulate matrix homeostasis. This review summarizes studies targeting the extracellular aspects of fibrotic tissue synthesis, presents the rationale for these studies, and discusses the progress and limitations of current extracellular approaches to limit fibrotic healing.

The world of rare interstitial lung diseases

The world of rare interstitial lung diseases (ILDs) is diverse and complex. Diagnosis and therapy usually pose challenges. This review describes a selection of rare and ultrarare ILDs including pulmonary alveolar proteinosis, pulmonary alveolar microlithiasis and pleuroparenchymal fibroelastosis. In addition, monogenic ILDs or ILDs in congenital syndromes and various multiple cystic lung diseases will be discussed. All these conditions are part of the scope of the European Reference Network on rare respiratory diseases (ERN-LUNG). Epidemiology, pathogenesis, diagnostics and treatment of each disease are presented.

Clinical features of idiopathic pleuroparenchymal fibroelastosis with progressive phenotype showing a decline in forced vital capacity

BACKGROUND

Idiopathic pleuroparenchymal fibroelastosis (IPPFE) is heterogeneous, with some patients showing a progressive decline in forced vital capacity (FVC). However, the clinical features of these cases with progressive phenotypes remain unknown.

METHODS

This retrospective study included 48 patients diagnosed with IPPFE who underwent longitudinal pulmonary function tests at our institution from 2005 to 2021. The progressive phenotype was defined as a relative decline of ≥10% in %FVC within two years from diagnosis of IPPFE, and its clinical features were evaluated.

RESULTS

Of the 48 patients, 23 (47.9%) were classified as progressive IPPFE. They were significantly older with a higher rate of dyspnea, fine crackles on chest auscultation, lower-lobe usual interstitial pneumonia (UIP) pattern on high-resolution computed tomography, and lower %FVC at diagnosis than non-progressive IPPFE. Additionally, progressive IPPFE had a significantly higher rate of long-term oxygen therapy requirement, the incidence of pneumothorax, and weight loss after diagnosis, which showed worse survival than non-progressive IPPFE. The relative decline in %FVC and weight loss showed a significant positive correlation. Multivariate analysis revealed that lower body mass index tended to predict early progression, and the coexistence of lower-lobe UIP pattern was significantly associated with early progression. A decline in %FVC was an independent poor prognostic factor in IPPFE.

CONCLUSIONS

With a progressive decline in %FVC, IPPFE often has an advanced stage at diagnosis and lower-lobe UIP pattern and is associated with weight loss and worse survival.

Acute exacerbation of pleuroparenchymal fibroelastosis with lower lobe usual interstitial pneumonia: An autopsy case

An 87-year-old man presented with dyspnea. Computed tomography revealed progressive subpleural consolidation in the apex, reticular shadows in the lower lobes, and bilateral ground glass opacifications. He died of respiratory failure on day 3. The post-mortem examination showed exudative stage diffuse alveolar damage and pulmonary edema. Intraalveolar collagenous fibrosis and subpleural elastosis were observed in the upper lobes, accompanied by interlobular septal and pleural thickening and lung architecture remodeling in the lower lobes. He was diagnosed with acute exacerbation of pleuroparenchymal fibroelastosis with lower lobe usual interstitial pneumonia, which can be fatal.

Idiopathic pleuroparenchymal fibroelastosis

The term idiopathic pleuroparenchymal fibroelastosis refers to a rare interstitial lung disease that predominantly involves the upper lobes. It has been considered a rare subtype of interstitial lung disease since 2013, when it was included in the joint consensus statement on the diagnosis of interstitial lung diseases published by the American Thoracic Society (ATS) and the European Respiratory Society (ERS). Currently, two distinct types of pleuroparenchymal fibroelastosis are recognized: the idiopathic type for cases in which it has not been possible to establish a specific etiology and a secondary type associated with a variety of different causes. The diagnosis of pleuroparenchymal fibroelastosis must be managed from a combined clinical and radiological perspective. High-resolution computed tomography (HRCT) is the imaging method of choice for the evaluation and diagnosis of pleuroparenchymal fibroelastosis. In many cases, the diagnosis will be based exclusively on the HRCT findings and histologic confirmation will be unnecessary. This article describes the clinical, radiological, and histological characteristics of pleuroparenchymal fibroelastosis, discussing the different associations with this entity and its differential diagnosis.