Tumor-associated antigens are associated with primary Sjögren's syndrome-related interstitial lung disease and disease activity

OBJECTIVES

Tumor-associated antigens (TAAs) have been shown to be associated with a variety of connective tissue diseases. However, the role of TAAs in primary Sjögren's syndrome (pSS) patients is still unclear. This study aims to explore the correlation between TAA levels and systemic clinical manifestations and disease activity in pSS patients.

METHODS

Data were retrospectively collected from 108 patients with pSS (pSS group) and 100 healthy subjects (HCs group). Comparison of clinical characteristics and serological parameters between the TAA-positive group and the TAA-negative group. The independent risk factors of TAAs positivity were analyzed by univariate and multivariate regression, and the receiver operating characteristic curve was used to analyze the diagnostic performance of TAAs for pSS-associated interstitial lung disease (pSS-ILD).

RESULTS

Compared with the control group, the positivity rates of CEA, CA125, CA15-3, and CYFRA21-1 were higher, and the levels of serum CA125, CA15-3, and CYFRA21-1were higher in the pSS group. The incidence of ILD, pleural effusion, pericardial effusion, and ESSDAI ≥5 in the TAA-positive group was higher than in the TAA-positive group. Multivariate logistic regression analysis showed that the incidence of ILD was identified as an independent risk factor for TAA positivity. The AUC of CEA, CYFRA21-1, and NSE in the diagnosis of pSS-ILD were 0.690, 0.840, and 0.872, respectively, and the combined diagnosis could reach 0.952.

CONCLUSION

Certain TAA-positive rates and serum levels were increased in pSS patients. The TAA-positive group is correlated with the ESSDAI scores. ILD was an independent risk factor for TAA positivity, and CYFRA21-1 and NSE had the best diagnostic value in patients with pSS-ILD.

Prognostic role of serum CA-125 and CA19-9 in lung transplant candidates with interstitial lung disease: a retrospective cohort study

BACKGROUND

Advanced interstitial lung disease (ILD) often necessitates lung transplantation, and identifying accessible prognostic markers is essential for effective management. However, the link between serum tumour markers and survival in waitlisted lung transplant candidates with advanced ILD remains underexplored.

OBJECTIVE

To evaluate associations between serum tumour marker levels and long-term survival in lung transplant candidates with advanced ILD.

METHODS

This study included 282 patients with end-stage ILD who were waitlisted for lung transplantation from November 2012 to March 2021. Baseline data and serum tumour marker levels were assessed before listing. Vital status and transplant outcomes were retrospectively reviewed as of 31 May 2023. Associations between tumour markers, clinical variables and mortality were analysed using Cox proportional hazards models with competing risk regression.

RESULTS

During a median wait time of 17.8 months (IQR: 7.8-44.1), 107 patients received transplants, 38 survived on the list and 137 died while waiting. Multivariable analysis identified higher CA-125 levels (HR 1.03, 95% CI 1.01 to 1.06, p=0.001), older age (HR 1.03, 95% CI 1.01 to 1.06, p=0.001), female gender (HR 1.43, 95% CI 1.01 to 2.04, p<0.04), elevated C-reactive protein (HR 1.17, 95% CI 1.03 to 1.34, p=0.01) and cerebrovascular disease (HR 2.03, 95% CI 1.38 to 2.98, p=0.01) as significant predictors of mortality.

CONCLUSION

Among waitlisted lung transplant candidates with advanced ILD, elevated serum carbohydrate antigen (CA)-125 and CA19-9 levels are associated with higher mortality risk. Routine assessment of these markers may enhance risk stratification for this patient population.

Cancer in connective tissue disease

The association between cancer and autoimmunity is well-recognized, as represented by the increased incidence of cancer among patients with systemic autoimmune diseases; however, the underlying mechanisms remain only partially understood. On the one hand, malignancy may trigger a breakdown of immune tolerance in predisposed individuals, as autoimmune syndromes often emerge shortly after cancer diagnosis, suggesting that tumor antigens might initiate an autoimmune response. However, by involving persistent responses and the creation of a pro-inflammatory environment, the chronic immune activation characteristic of autoimmunity may promote oncogenesis. This scenario is further complicated by the use of immunosuppressive therapies for autoimmune conditions, which, as seen in transplant immunology, are associated with a higher risk of cancer, although data in rheumatology have not yielded definitive conclusions. Connective tissue diseases include systemic lupus erythematosus, primary Sjögren syndrome, idiopathic inflammatory myopathies, systemic sclerosis, mixed connective tissue disease, and undifferentiated forms. These conditions have been variably associated with an increased risk of cancer, both at the time of disease onset and in patients with long-standing autoimmune conditions, providing a paradigm for investigating this complex interplay. Despite recent progress, many unmet needs remain that warrant further research.

Elevated serum tumor-associated antigens in patients with interstitial lung disease: a retrospective study on clinical features and prognosis

BACKGROUND

Elevated serum tumor-associated antigens (TAAs) were reported to be common in patients with interstitial lung disease (ILD) and correlated with pulmonary involvement or malignancy development. However, there were no adequate longitudinal studies on the association between elevated TAAs and various types of ILDs in Chinese patients.

RESEARCH DESIGN AND METHODS

The treatment-naïve ILD patients were retrospectively enrolled. The clinical, laboratory, imaging characteristics, and prognosis were analyzed and compared among those with normal and different number of elevated TAAs.

RESULTS

An increase of at least one TAA was present in 169/308 (54.87%) of our patients. Both baseline alveolar and interstitial scores were much higher, and lung involvement tended to be worse during follow-up in patients with two and three or more elevated TAAs than in normal TAAs. Patients with three or more elevated TAAs had the highest interstitial scores and a higher all-cause mortality during follow-up than those with one elevated TAA or normal TAAs. The occurrence of malignancy was similar in all patients.

CONCLUSION

Elevated TAAs were present in 54.87% of ILD patients and associated with lung interstitial lesions, which might be a marker for lung involvement progression, while not for malignancy development in ILD.

Determinants for worsening in systemic autoimmune rheumatic disease-associated interstitial lung disease: a systematic review and meta-analysis of cohort studies

Background

To identify risk factors for progression, acute exacerbation (AE), and the development of rapidly progressive interstitial lung disease (RP-ILD) in Systemic autoimmune rheumatic disease-associated interstitial lung disease (SARD-ILD).

Methods

We systematically searched PubMed, EMBASE, Scopus, the Cochrane Library, and Web of Science databases to identify eligible cohort studies up until January 01, 2024. Two reviewers independently screened the literature and extracted data. We employed the Newcastle-Ottawa Scale (NOS) to assess study quality and performed meta-analyses using STATA software.

Results

This review included 50 studies. For progression, 28 studies were included, four significant risk factors were identified: male (OR = 1.97, 95% CI 1.26-3.08, p < 0.001), UIP patterns on HRCT (OR = 1.94, 95% CI 1.48-2.54, p < 0.001), extensive lung involvement (OR = 2.15, 95% CI 1.66-2.80, p < 0.001), and age (OR = 1.07, 95% CI 1.05-1.10, p < 0.001); and 11 potential risk factors. Seven studies were included in AE, and three potential risk factors were highlighted: FVC, UIP patterns on HRCT, and smoking history. In RP-ILD, 15 studies were included. Three risk factors were determined: High CRP (OR = 2.45, 95% CI 1.87-3.21, p < 0.001), Ro-52 positivity (OR = 5.35, 95% CI 3.46-8.29, p < 0.001), and MDA5 antibodies (OR = 2.09, 95% CI 1.47-2.95, p < 0.001); along with 10 potential risk factors.

Conclusion

Our meta-analysis identified male sex, UIP pattern on HRCT, extensive lung involvement, and advanced age as significant risk factors for the progression of SARD-ILD. High CRP, Ro-52 positivity, and MDA5 antibodies were significant risk factors for developing of RP-ILD in patients with IIM. We also discovered several potential risk factors that may be associated with the progression of SARD-ILD and acute exacerbation, as well as the occurrence of RP-ILD in IIM patients.

Systematic review registration

https://www.crd.york.ac.uk/prospero/.

Heterogeneity of determining disease severity, clinical course and outcomes in systemic sclerosis-associated interstitial lung disease: a systematic literature review

Objective The course of systemic sclerosis-associated interstitial lung disease (SSc-ILD) is highly variable and different from continuously progressive idiopathic pulmonary fibrosis (IPF). Most proposed definitions of progressive pulmonary fibrosis or SSc-ILD severity are based on the research data from patients with IPF and are not validated for patients with SSc-ILD. Our study aimed to gather the current evidence for severity, progression and outcomes of SSc-ILD.Methods A systematic literature review to search for definitions of severity, progression and outcomes recorded for SSc-ILD was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in Medline, Embase, Web of Science and Cochrane Library up to 1 August 2023.Results A total of 9054 papers were reviewed and 342 were finally included. The most frequent tools used for the definition of SSc-ILD progression and severity were combined changes of carbon monoxide diffusing capacity (DLCO) and forced vital capacity (FVC), isolated FVC or DLCO changes, high-resolution CT (HRCT) extension and composite algorithms including pulmonary function test, clinical signs and HRCT data. Mortality was the most frequently reported long-term event, both from all causes or ILD related.Conclusions The studies presenting definitions of SSc-ILD 'progression', 'severity' and 'outcome' show a large heterogeneity. These results emphasise the need for developing a standardised, consensus definition of severe SSc-ILD, to link a disease specific definition of progression as a surrogate outcome for clinical trials and clinical practice.PROSPERO registration number CRD42022379254.Cite Now.

Treatable Traits in Systemic Sclerosis

Systemic sclerosis (SSc) is a chronic systemic disease within the spectrum of connective tissue diseases, specifically characterized by vascular abnormalities and inflammatory and fibrotic involvement of the skin and internal organs resulting in high morbidity and mortality. The clinical phenotype of SSc is heterogeneous, and serum autoantibodies together with the extent of skin involvement have a predictive value in the risk stratification. Current recommendations include an organ-based management according to the predominant involvement with only limited individual factors included in the treatment algorithm. Similar to what has been proposed for other chronic diseases, we hypothesize that a "treatable trait" approach based on relevant phenotypes and endotypes could address the unmet needs in SSc stratification and treatment to maximize the outcomes. We provide herein a comprehensive review and a critical discussion of the literature regarding potential treatable traits in SSc, focusing on established and candidate biomarkers, with the purpose of setting the bases for a precision medicine-based approach. The discussion, structured based on the organ involvement, allows to conjugate the pathogenetic mechanisms of tissue injury with the proposed predictors, particularly autoantibodies and other serum biomarkers. Ultimately, we are convinced that precision medicine is the ideal guide to manage a complex condition such as SSc for which available treatments are largely unsatisfactory.

The role of PET/CT in connective tissue disorders: systemic sclerosis, Sjögren's syndrome and systemic lupus erythematosus

Advanced imaging techniques are needed to help clinicians in the diagnosis, in the choice of the right time for therapeutic interventions or for modifications and monitoring of treatment response in patients with autoimmune connective tissue diseases. Nuclear medicine imaging, especially PET/CT and PET/MRI, may play an important role in detecting disease activity, assessing early treatment response as well as in clarifying the complex mechanisms underlying systemic sclerosis, Sjögren's syndrome or systemic lupus erythematosus. In addition, [¹⁸F]FDG PET/CT may help in excluding or detecting coexisting malignancies. Other more specific radiopharmaceuticals are being developed and investigated, targeting specific cells and molecules involved in connective tissue diseases. Further larger studies with standardized imaging protocol and image interpretation are strongly required before including PET/CT in the diagnostic work-up of subsets of patients with autoimmune connective tissue diseases.

Cytokeratin 19 fragment is associated with severity and poor prognosis of interstitial lung disease in anti-MDA5 antibody-positive dermatomyositis

OBJECTIVES

In the present study, we aimed to assess the clinical significance of cytokeratin 19 fragment (CYFRA21-1) in patients with anti-melanoma differentiation-associated gene 5 (MDA5) antibody-positive DM-interstitial lung disease (MDA5-DM-ILD).

METHODS

A total of 73 MDA5-DM-ILD patients were retrospectively analysed in this work. Their clinical characteristics, including clinical manifestations, laboratory findings, peripheral blood lymphocyte subsets and lung function, were compared between patients with acute/subacute interstitial pneumonia (A/SIP) and chronic interstitial pneumonia (CIP). The level of serum CYFRA21-1 was also compared between the above-mentioned two groups of patients, and its association with the clinical features and mortality of MDA5-DM-ILD was also evaluated.

RESULTS

Of the 73 MDA5-DM-ILD patients, 26 patients exhibited the A/SIP pattern. The level of serum CYFRA21-1 was higher in MDA5-DM patients with A/SIP compared with the CIP group (P = 0.009). Lower oxygenation index (OI), CD3+CD4+ T cell counts and percentage of CD3+CD4+ cells were also observed in MDA5-DM patients with A/SIP compared with the CIP group. Higher serum CYFRA21-1, lower OI, and lower zone consolidation were associated with a higher risk of A/SIP in MDA5-DM-ILD. In addition, 38 decedents with MDA5-DM-ILD exhibited a greater level of CYFRA21-1 compared with 35 survivors (P < 0.001). Furthermore, it was a prognostic factor and also associated with a higher mortality rate (log-rank test, P < 0.001).

CONCLUSIONS

CYFRA21-1 could be a useful serum indicator associated with occurrence of A/SIP in MDA5-DM-ILD. Moreover, it was associated with a poor survival in MDA5-DM-ILD patients.

Prediction of a Competing Endogenous RNA Co-expression Network by Comprehensive Methods in Systemic Sclerosis-Related Interstitial Lung Disease

Systemic sclerosis (SSc) is an immune-mediated connective tissue disease characterized by fibrosis of multi-organs, and SSc-related interstitial lung disease (SSc-ILD) is a leading cause of morbidity and mortality. To explore molecular biological mechanisms of SSc-ILD, we constructed a competing endogenous RNA (ceRNA) network for prediction. Expression profiling data were obtained from the Gene Expression Omnibus (GEO) database, and differential expressed mRNAs and miRNAs analysis was further conducted between normal lung tissue and SSc lung tissue. Also, the interactions of miRNA–lncRNA, miRNA–mRNA, and lncRNA–mRNA were predicted by online databases including starBase, LncBase, miRTarBase, and LncACTdb. The ceRNA network containing 11 lncRNAs, 7 miRNAs, and 20 mRNAs were constructed. Based on hub genes and miRNAs identified by weighted correlation network analysis (WGCNA) method, three core sub-networks—SNHG16, LIN01128, RP11-834C11.4(LINC02381)/hsa-let-7f-5p/IL6, LINC01128/has-miR-21-5p/PTX3, and LINC00665/hsa-miR-155-5p/PLS1—were obtained. Combined with previous studies and enrichment analyses, the lncRNA-mediated network affected LPS-induced inflammatory and immune processes, fibrosis development, and tumor microenvironment variations. The ceRNA network, especially three core sub-networks, may be served as early biomarkers and potential targets for SSc, which also provides further insights into the occurrence, progression, and accurate treatment of SSc at the molecular level.

Serum KL-6, CA19-9, CA125 and CEA are Diagnostic Biomarkers for Rheumatoid Arthritis-Associated Interstitial Lung Disease in the Chinese Population

Introduction

This study aimed to evaluate the role of tumor marker carbohydrate antigen (CA) 125 (CA125), CA19-9, carcinoembryonic antigen (CEA) and Krebs von den Lungen-6 (KL-6) in the diagnosis and determination of the severity of interstitial lung disease (ILD) in rheumatoid arthritis (RA) patients.

Methods

A retrospective analysis was performed. Fifty RA patients (24 patients with ILD and 26 patients without ILD), 10 healthy subjects and 14 patients with other connective tissue disease-associated interstitial lung disease were included. Serum levels of KL-6 and tumor markers CA19-9, CA125 and CEA were measured. Chest HRCT of patients with ILD was scored quantitatively according to the degree of fibrosis. Data on the C-reactive protein, erythrocyte sedimentation rate, rheumatoid factors and anti-cyclic peptide containing citrulline (anti-CCP) were also collected.

Results

Serum levels of KL-6, CA19-9, CA125 and CEA in the RA-ILD group were significantly higher than those in the RA-no-ILD group. The serum KL-6 level was positively correlated with the HRCT fibrosis score (r = 0.63, p = 0.002). The logistic regression analysis showed that CA19-9 and smoking were associated with RA-ILD [OR = 1.118, 95% CI = (1.038, 1.204), p = 0.003 for CA19-9, OR = 14.969, 95% CI = (1.750, 128.043), p = 0.013 for smoking].

Conclusions

KL-6 level and tumor markers were elevated in RA-ILD, and strongly associated with the severity of ILD, supporting their value as pathogenically relevant biomarkers, which can contribute to noninvasive detection of this extra-articular disease complication.

Interstitial lung disease (ILD) is a common pulmonary manifestation of RA associated with high morbidity and mortality. Our retrospective study was performed to investigate the clinical utility of tumor marker carbohydrate antigen (CA) 125 (CA125), CA19-9, carcinoembryonic antigen (CEA) and Krebs von den Lungen-6 (KL-6) in the diagnosis and determining the severity of RA-ILD. Fifty RA patients (24 patients with ILD and 26 patients without ILD), 10 healthy subjects and 14 patients with other connective tissue disease-associated interstitial lung disease (CTD-ILD) were included. The results showed KL-6 level and tumor markers were elevated in RA-ILD, and strongly associated with the severity of ILD, which meant KL-6 and tumor markers might be useful pathogenically relevant biomarkers and could be predictors for the diagnosis and determination of severity of ILD in RA.

Advances at the Interface of Cancer and Systemic Sclerosis

The interface between systemic sclerosis (SSc) and cancer has offered valuable insights into our understanding of SSc disease pathogenesis. Defining SSc subgroups both temporally and serologically has been instrumental in stratifying cancer risk, with autoantibodies to RNA polymerase 3 (RNApol3), RNA polymerase I large subunit (RPA194), RNA Binding Region Containing 3 (RNPC3), and centromere identifying subgroups at increased or decreased risk of cancer. Clinically, improved subgrouping of SSc patients provides the opportunity to detect cancer at earlier stages of disease while increasing our efficiency of cancer assessment. Additional studies are needed to define the optimal approach to cancer screening in SSc, and validation studies in different cohorts will be needed to confirm all findings.

Therapeutic strategies for virus-negative myocarditis: a comprehensive review

Virus-negative or autoimmune myocarditis(VNM) is an inflammatory disease affecting the myocardium that may occur as a distinct disease with exclusive cardiac involvement, or in the context of systemic autoimmune or inflammatory disorders. The pathogenesis of VNM involves both innate and acquired immunity and is not completely elucidated: an early immune-mediated pathogenic process lead to subacute and chronic stages and eventually results in tissue remodeling, fibrosis, contractile dysfunction, dilated cardiomyopathy and arrhythmic burden, accounting for a dismal prognosis. Treatment interventions effectively curbing the acute inflammatory process at an early stage can prevent late cardiac remodeling and improve patient's outcome. The mainstay of treatment of VNM remains symptomatic therapy of heart failure and arrhythmia, while the use of immunosuppressive treatments has long been considered controversial until recently, and strategies effectively targeting the inflammatory and immune-mediated substrate of the disease remain elusive. Only steroids and azathioprine have been tested in clinical trials, and nowadays represent the therapy of choice. A substantial proportion of patients are resistant to first line strategies, suggesting that some critical inflammatory mechanisms are not responsive to conventional immunosuppression with steroids and azathioprine, or experience drug-related adverse events. Thus, second-line targeted therapeutic strategies to treat VNM are eagerly awaited. Recent data on the pathogenic mechanisms underlying myocardial inflammation are paving the way to novel, promising treatment strategies for myocarditis, which could reformulate future treatment strategies for VNM. In this review, we summarize the current therapeutic opportunities, beyond corticosteroids, to treat VNM, including conventional and biologic immunosuppressive drugs and cytokine blocking agents.

Diagnostic and Prognostic Biomarkers for Chronic Fibrosing Interstitial Lung Diseases With a Progressive Phenotype

Biomarkers have the potential to become central to the clinical evaluation and monitoring of patients with chronic fibrosing interstitial lung diseases (ILDs) with a progressive phenotype. Here we summarize the current understanding of putative serum, BAL fluid, and genetic biomarkers in this setting, according to their hypothesized pathobiologic mechanisms: evidence of epithelial cell dysfunction (eg, Krebs von den Lungen-6 antigen), fibroblast proliferation and extracellular matrix production or turnover (eg, matrix metalloproteinase-1), or immune dysregulation (eg, CC chemokine ligand 18). While most of the available data come from idiopathic pulmonary fibrosis (IPF), the prototypic progressive fibrosing ILD, data are available in the broader patient population of chronic fibrosing ILDs. A number of these biomarkers show promise, however, none have been validated. In this review article, we assess both the status of proposed biomarkers for chronic fibrosing lung diseases with a progressive phenotype in predicting disease risk or predisposition, diagnosis, prognosis, and treatment response and provide a direct comparison between IPF and other chronic fibrotic ILDs. We also reflect on the current clinical usefulness and future direction of research for biomarkers in the setting of chronic fibrosing ILDs with a progressive phenotype.

Circulating biomarkers of systemic sclerosis - interstitial lung disease

Interstitial lung disease is a frequent organ manifestation in systemic sclerosis and is associated with high mortality. It is crucial to diagnose interstitial lung disease in systemic sclerosis and to assess severity and identify patients prone to progression at an early stage to ultimately decrease organ damage and improve outcome. Circulating anti-topoisomerase-I autoantibodies have long been associated with the presence and development of systemic sclerosis - interstitial lung disease, evidence on their potential to further predict the clinical course of systemic sclerosis is however conflicting. C-reactive protein is a marker of infection and systemic inflammation with widespread clinical application and is elevated in systemic sclerosis with a tendency towards higher abundancy in patients with early disease. The role of other circulating biomarkers is promising but hampered by the lack of standardized criteria and guidelines for sample/data collection, analyses, reporting and validation and has not reached prime time for clinical application. However, epithelial markers including Krebs von den Lungen-6 and surfactant protein D and several cytokines and chemokines including CCL2 and CCL18 for severity assessment of systemic sclerosis - interstitial lung disease patients at the time of interstitial lung disease diagnosis and to predict interstitial lung disease progression have been reported and seem to be promising candidate biomarkers in the future.

Pulmonary function tests as outcomes for systemic sclerosis interstitial lung disease

Interstitial lung disease (ILD) is the leading cause of morbidity and mortality in systemic sclerosis (SSc). We performed a systematic review to characterise the use and validation of pulmonary function tests (PFTs) as surrogate markers for systemic sclerosis-associated interstitial lung disease (SSc-ILD) progression.Five electronic databases were searched to identify all relevant studies. Included studies either used at least one PFT measure as a longitudinal outcome for SSc-ILD progression (i.e. outcome studies) and/or reported at least one classical measure of validity for the PFTs in SSc-ILD (i.e. validation studies).This systematic review included 169 outcome studies and 50 validation studies. Diffusing capacity of the lung for carbon monoxide (DLCO) was cumulatively the most commonly used outcome until 2010 when it was surpassed by forced vital capacity (FVC). FVC (% predicted) was the primary endpoint in 70.4% of studies, compared to 11.3% for % predicted DLCO Only five studies specifically aimed to validate the PFTs: two concluded that DLCO was the best measure of SSc-ILD extent, while the others did not favour any PFT. These studies also showed respectable validity measures for total lung capacity (TLC).Despite the current preference for FVC, available evidence suggests that DLCO and TLC should not yet be discounted as potential surrogate markers for SSc-ILD progression.

Environmental Pollution by Benzene and PM10 and Clinical Manifestations of Systemic Sclerosis: A Correlation Study

Atmospheric air pollution has been associated with a range of adverse health effects. The environment plays a causative role in the development of Systemic Sclerosis (SSc). The aim of the present study is to explore the association between particulate (PM₁₀) and benzene (B) exposure in Italian patients with systemic sclerosis and their clinical characteristics of the disease. A correlation study was conducted by enrolling 88 patients who suffer from SSc at the Fondazione Policlinico “A. Gemelli” in Rome (Italy) in the period from January 2013 to January 2014. The average mean concentrations of B (in 11 monitoring sites) and PM₁₀ (in 14 sites) were calculated using data from the Regional Environmental Protection Agency’s monitoring stations located throughout the Lazio region (Italy) and then correlated with the clinical characteristics of the SSc patients. Of the study sample, 92.5% were female. The mean age was 55 ± 12.9 years old and the mean disease duration from the onset of Raynaud’s phenomenon was 13.0 ± 9.4 years. The Spearman’s correlation showed that concentrations of B correlate directly with the skin score (R = 0.3; p ≤ 0.05) and inversely with Diffusing Lung Carbon Monoxide (DLCO) results (R = −0.36; p = 0.04). This study suggests a possible role of B in the development of diffuse skin disease and in a worse progression of the lung manifestations of SSc.