The role of lung biopsy for diagnosis and prognosis of interstitial lung disease in systemic sclerosis: a systematic literature review

BACKGROUND

The prognostic and theragnostic role of histopathological subsets in systemic sclerosis interstitial lung disease (SSc-ILD) have been largely neglected due to the paucity of treatment options and the risks associated with surgical lung biopsy. The novel drugs for the treatment of ILDs and the availability of transbronchial cryobiopsy provide a new clinical scenario making lung biopsy more feasible and a pivotal guide for treatment. The aim of our study was to investigate the usefulness of lung biopsy in SSc ILD with a systematic literature review (SLR).

METHODS

PubMed, Embase and Cochrane databases were searched up to June 30, 2023. Search terms included both database-specific controlled vocabulary terms and free-text terms relating to lung biopsy and SSc-ILD diagnostic and prognosis. The SLR was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA). Studies were selected according to the PEO (population, exposure, and outcomes) framework and Quality assessment of diagnostic accuracy studies (QUADAS) were reported.

RESULTS

We selected 14 articles (comprising 364 SSc-ILD patients). The paucity and heterogeneity of the studies prevented a systematic analysis. Diffuse cutaneous SSc was present in 30-100% of cases. Female predominance was observed in all studies (ranging from 64 to 100%). Mean age ranged from 42 to 64 years. Mean FVC was 73.98 (+/-17.3), mean DLCO was 59.49 (+/-16.1). Anti-Scl70 antibodies positivity was detected in 33% of cases (range: 0-69.6). All patients underwent surgical lung biopsies, and multiple lobes were biopsied in a minority of studies (4/14). Poor HRCT-pathologic correlation was reported with HRCT-NSIP showing histopathologic UIP in up to 1/3 of cases. Limited data suggest that SSc-UIP patients may have a worse prognosis and response to immunosuppressive treatment compared to other histopathologic patterns.

CONCLUSIONS

The data from this SLR clearly show the paucity and heterogeneity of the studies reporting lung biopsy in SSc ILD. Moreover, they highlight the need for further research to address whether the lung biopsy can be helpful to refine prognostic prediction and guide therapeutic choices.

POS0487 THE CROSSTALK OF THE SKIN-ORAL-GUT MICROBIOME AXIS IN LIMITED AND DIFFUSE CUTANEOUS SYSTEMIC SCLEROSIS

Background

Systemic sclerosis (SSc) is a complex and still unclear rare disease. Microbiota has recently emerged as an important environmental factor in SSc pathogenesis, either at gut, oral and skin level.

Objectives

To investigate the role of microbiota in SSc subsets, focusing on the skin-oral-gut microbiota axis and serum and fecal free fatty acids (FFA) profile.

Methods

Twenty-six consecutive SSc patients (22 females) (mean disease duration (SD): 13 ± 6.91 yrs), classified according to the ACR/EULAR2013 criteria, were enrolled. Demographic, clinical and laboratory data were recorded. Gastrointestinal symptoms were investigated with UCLA GIT-2.0-questionnaire. Fecal, unstimulated saliva and superficial epidermal samples were collected. Microbiota was assessed through 16S ribosomal RNA Next Generation gene-sequencing analysis. Gas Cromatography-Mass Spettroscopy was used to measure FFAs in serum and fecal samples.

Results

Thirteen patients had limited cutaneous SSc (lcSSc), 13 diffuse cutaneous (dcSSc). The two subsets displayed a different cutaneous and fecal microbiota profile. In detail, the class of cutaneous Sphingobacteria was significantly higher in lcSSc (p<0.05), while the phylum of Lentisphaerae, the family of Victivallaceae and the genus of Victivallis were significantly higher in fecal samples of lcSSc (all p<0.05). A significant increase of fecal propionic acid was observed in lcSSc patients (p<0.05). Moreover, all fecal medium-chain FAs and hexanoic acids were significantly higher in lcSSc (p<0.05 and p<0.001, respectively). The analysis of serum FFAs levels showed an increase of valeric and octanoic acids in lcSSc (both p<0.05). A negative correlation between UCLA-GIT-2.0 total score and fecal octanoic acid (rho=-0.61; p=0.03), and a positive correlation with serum propionic acid (rho=0.55; p=0.05) was found in lcSSc.

Conclusion

Our findings show a different microbiota signature in the skin and gut, and a different FFAs profile in lcSSc and dcSSc. Such a differential regulation of microbiota composition and bacterial metabolite production suggests different dynamics of skin-oral-gut microbiota axis in SSc subsets. This data could be useful to develop personalized therapies targeting gastrointestinal and skin involvement.

Disclosure of Interests

None declared.

AB0747 Oral microbiome in rheumatic diseases.What involvement?

Background

The concept of core-microbiome in health is useful for investigating the possible role of the oral microbiome in autoimmune disease, such as Rheumatoid Arthritis, Spondyloarthritis, Sjogren Syndrome or Systemic Sclerosis (SSc), whose pathogenesis has not been fully understood. Environmental factors and certain genetic backgrounds have been proposed. Among the various environmental factors, the microbiota stands out, the entire composition of microorganisms, mainly bacteria but also fungi and viruses, which populate the human body.

Objectives

The aim of the study was to verify whether there were quantitative differences between the microorganisms present in the oral cavity, in particular between the lactobacillus spp., of patients with SSc compared to those present in the oral cavity of healthy subjects taken as controls.

Methods

Twenty-nine SSc female patients (mean age 62.) classified according to the ACR/EULAR2013 criteria and twenty-three female healthy subjects (HS, mean age 57.6) were enrolled and underwent tongue and gum swab sampling. Quantitative PCR was conducted in triplicates using Lactobacillus specific primers rpoB1, rpoB1o and rpoB2 for RNA-polymerase β subunit gene.

Results

Our data showed Lactobacillusspp.rpoB sequences significantly lower in the tongue of SSc patients than in HS (p=0.0211).The statistical analysis in HS highlighted a significant lower amount of rpoB on the gums than on the tongue.

Conclusion

Our preliminary data show that the number of Lactobacillus on the tongue in SSc patients is about half that of HS. These data make it more likely that Lactobacillus in SSc patients may play a protective role. Further investigations will also be needed in other autoimmune diseases.

References

[1]Zaura E, Keijser BJ, Huse SM, Crielaard W Defining the healthy “core microbiome” of oral microbial communities. BMC Microbiol. 2009 Dec 15;9:259. doi: 10.1186/1471-2180-9-259.

[2]Nikitakis NG, Papaioannou W, Sakkas LI, Kousvelari E.The autoimmunity-oral microbiome connection. Oral Diseases (2017) 23, 828-839.

Disclosure of Interests

None declared

AB0334 THE FIRST 1000 DAYS OF LIFE AND REPRODUCTIVE DISORDERS IN WOMAN WITH RHEUMATIC DISEASE (RDS)

Background:

Gynaecological problems are often ignored by rheumatologist and have a negative impact on quality of life of RDs patients.

Objectives:

The aim of this study was to describe gynaecological, reproductive and sexual problems in premenopausal woman with RDs.

Methods:

A monocentric, cross-sectional observational study was conducted in the Rheumatology Department of Careggi Hospital in Florence. Inclusion criteria: female gender, premenopausal age (and≥18 years old), diagnosis of rheumatic diseases. All patients have been investigated about gynaecological anamnesis and symptoms and subjected to a self-administered validated questionnaire.

Results:

From May 4 th to November 30th, 2020, 200 patients were enrolled (mean age 39.1± 8.7 years (M±SD)): 58% arthritis, 40% connective tissue disease and 1.5% systemic vasculitis. In the history, spontaneous, full-term birth in 91% and 93% of patients, respectively, was observed and pre-term birth was reported in 8.1%. 63% of patients were breastfed. In family history, menorrhagia, dysmenorrhea, or chronic pelvic pain were reported in 59%, 55 and 7% of patients, respectively. The first menstruation was at 12.3±2.0 years (M±DS) and mostly woman reported menstrual disorders during adolescence (56% experienced dysmenorrhea and 52% menorrhagia). Menstrual disorders and abnormal bleeding were frequently reported also in adulthood: 71% had dysmenorrhea, 38% heavy menstrual cycles and 9% metrorrhagia. Moreover, 26% of patients referred non- menstrual pelvic pain, 19% urinary pain and 18% pain during defecation. Vaginal symptoms were frequently reported: 36% of patients referred vaginal dryness, 29% burning, 19% recurrent vaginal infections and dyspareunia in 39% of patients. Uterine fibroma was present in 23% and endometriosis in 10% of patients. Fertility problems were reported by 10% of patients in a time frame of 7.5±6.4 years and 30% of patients experienced at least one miscarriage; otherwise, 56% of patients have had at least one full-term pregnancy.

Conclusion:

RDs patients show a high prevalence of various gynaecological problems affecting their quality of life. The management of female RDs patients is a challenge for the clinician and should include an accurate evaluation of the gynaecological aspects (menstruation, fertility, maternity, sexuality) as well as a multidisciplinary teamwork (rheumatologist and gynaecologists).

References:

[1]Critchley H., Babayev E., Bulun E., et al. Menstruation: Science and society | Elsevier Enhanced Reader. (s.d.). https://doi.org/10.1016/j. American Journal of Obstetrics & Gynecology 2020.06.004

[2]Østensen M, Andreoli L, Brucato A,et al. State of the art: Reproduction and pregnancy in rheumatic diseases. Autoimmun Rev. 2015 May;14(5):376-86. doi: 10.1016/j.autrev.2014.12.011. Epub 2014 Dec 30. PMID: 25555818.

[3]Marder W, Johnson TRB. Rheumatic diseases and maternal-fetal medicine. Best Pract Res Clin Obstet Gynaecol. 2020 Apr;64:1-2. doi: 10.1016/j.bpobgyn.2019.11.007. Epub 2019 Dec 17. PMID: 31983554.

[4]Sammaritano LR, Bermas BL, Chakravarty EE,et al. 2020 American College of Rheumatology Guideline for the Management of Reproductive Health in Rheumatic and Musculoskeletal Diseases. Arthritis Rheumatol. 2020 Apr;72(4):529-556. doi: 10.1002/art.41191. Epub 2020 Feb 23. PMID: 32090480.

Disclosure of Interests:

None declared

POS0317 THE PERFORMANCE OF DIFFUSING CAPACITY FOR MONOXIDE CARBON (DLCO) AND FORCED VITAL CAPACITY (FVC) IN PREDICTING THE ONSET OF SYSTEMIC SCLEROSIS (SSc)-INTERSTITIAL LUNG DISEASE (ILD) IN THE EUROPEAN SCLERODERMA TRIALS AND RESEARCH (EUSTAR) DATABASE

Background:

In SSc, ILD is a major cause of morbidity and mortality. High resolution computed tomography (HRCT) is the gold standard for the diagnosis. Predictors of ILD onset are eagerly awaited to improve SSc-ILD management. Pulmonary function test (PFTs) are routinely performed to measure lung function changes.

Objectives:

Our aim was to investigate the performance of DLCO (diffusing capacity of lung carbon monoxide) and FVC (forced vital capacity) in predicting the development of SSc-ILD.

Methods:

The longitudinal data of DLCO, FVC and ILD on HRCT of SSc patients from the EUSTAR database were evaluated at baseline (t0), after 12 (±4) (t1) and 24 (±4) (t2) months. Patients with negative HRCT for any sign of ILD both at t0 and t1 were included. Patients who presented or developed pulmonary hypertension during the study period were excluded. At baseline, demographic data, disease duration from Raynaud’s onset, disease subsets, autoantibodies and other laboratory and instrumental data were recorded.

Results:

474/17805 patients were eligible for the study (403 females, 71 males): 26.0% dcSSc, 58.3% lcSSc, 220 (48.0%) patients with positive anticentromere antibodies (ACA) and 117 (25.4%) with positive antitopoisomerase I antibodies (Topo-I abs). Among all enrolled patients, 46 (9.7%) developed HRCT signs of ILD at t2. Patients with Topo-I abs showed an association with ILD development at t2 (16.7% vs 7.8%, p=0.0031), contrarily ACA positive patients were negatively associated with ILD appearance after 2 years of follow-up (4.4% vs 14.4%, p=0.0001). Positive t2 HRCT patients had a significant lower value of DLCO and FVC at all three assessments when compared to patients with a negative HRCT at t2 (Table 1) and both t0 DLCO and FVC values negatively correlated with ILD development (Table 1). The mean t0 to t1 change (Δ) of DLCO in patients with negative t2 HRTC and positive t2 HRCT were -0.5 (±12.6) and -1.0 (±15.1), respectively. The mean t0 to t1 ΔFVC in patients with negative t2 HRTC and positive t2 HRCT were -0.2 (±10.6) and 0.1 (±11.5), respectively. None of them predicted the appearance of ILD at t2 (ΔDLCO: OR (IC) 0.997 (0.97-1.02), p=0.8024; ΔFVC OR (IC) 1.002 (0.97-1.03), p=0.8664). The data showed an association between t0 DLCO value<80% and ILD appearance after 2 years of follow-up [OR(IC): 3.09(1.49-6.40), p=0.0023]. Such association was not observed for t0 FVC value<80% [OR(IC): 1.95(0.81-4.68), p=0.1329]. The predictive capability of t0 DLCO<80% was moderate but stronger than FVC<80% [AU ROC: 0.62 (0.56-0.69), 0.53 (0.48-0.59) respectively, p=0.0205].

Conclusion:

Our data suggest that an impaired baseline DLCO (<80%) may have a predictive value for the development of ILD on HRCT after 2 years of follow-up. Further rigorous prospective studies are warranted to understand the role of DLCO evaluation in the course of SSc.

Table 1.

DLCO and FVC values at t0, t1 and t2 values in patients with positive or negative HRCT for ILD at t2 and their statistical differences.

Patients without ILD at t2 (mean±SD)Patients with ILD at t2 (mean±SD)OR (95%CL)p-valueDLCO at t079.0 ± 16.669.9 ± 17.40.97 (0.95 - 0.99)0.0006DLCO at t178.4 ± 16.868.9 ± 18.60.97 (0.95 - 0.98)0.0005DLCO at t278.0 ± 17.065.1 ± 19.10.95 (0.93 - 0.97)<0.0001FVC at t0102.2 ± 17.394.6 ± 16.20.97 (0.96 - 0.99)0.0052FVC at t1101.9 ± 17.994.7 ± 16.50.98 (0.96 - 0.99)0.0092FVC at t2101.6 ± 17.694.5 ± 20.00.98 (0.96 - 1)0.0126

Disclosure of Interests:

Gemma Lepri: None declared, Cosimo Bruni Speakers bureau: CB reports personal fees from Actelion, personal fees from Eli Lilly, Grant/research support from: CB reports personal fees from Actelion, personal fees from Eli Lilly, grants from European Scleroderma Trial and Research (EUSTAR) group, grants from New Horizon Fellowship, grants from Foundation for Research in Rheumatology (FOREUM), grants from Fondazione Italiana per la Ricerca sull’Artrite (FIRA), outside the submitted work, Lorenzo Tofani: None declared, Alberto Moggi Pignone: None declared, Martina Orlandi: None declared, Tomasetti Sara Speakers bureau: Speaker’s fees for Roche and Boehringer Ingelheim, Mike Hughes: None declared, Francesco Del Galdo: None declared, Rosaria Irace: None declared, Oliver Distler Grant/research support from: OD (last three years) has/had consultancy relationship and/or has received research funding in the area of potential treatments for systemic sclerosis and its complications from (last three years): Abbvie, Acceleron Pharma, Amgen, AnaMar, Arxx Therapeutics, Baecon Discovery, Blade Therapeutics, Bayer, Boehringer Ingelheim, ChemomAb, Corbus Pharmaceuticals, CSL Behring, Galapagos NV, Glenmark Pharmaceuticals, GSK, Horizon (Curzion) Pharmaceuticals, Inventiva, iQvia, Italfarmaco, iQone, Kymera Therapeutics, Lilly, Medac, Medscape, Mitsubishi Tanabe Pharma, MSD, Novartis, Pfizer, Roche, Sanofi, Serodapharm, Topadur, Target Bioscience and UCB. Patent issued “mir-29 for the treatment of systemic sclerosis” (US8247389, EP2331143)., Valeria Riccieri: None declared, Yannick Allanore Speakers bureau: YA received personal fees from Boehringer, Sanofi, Menarini and Medsenic and grants from Alpine with regards to the management of systemic sclerosis, Grant/research support from: YA received personal fees from Boehringer, Sanofi, Menarini and Medsenic and grants from Alpine with regards to the management of systemic sclerosis, Ana Maria Gheorghiu: None declared, Elise Siegert: None declared, Jeska de Vries-Bouwstra: None declared, Eric Hachulla: None declared, Mohammed Tikly: None declared, Nemanja Damjanov: None declared, Francois Spertini: None declared, Luc Mouthon: None declared, Anna-Maria Hoffmann-Vold Speakers bureau: AMHV: received consulting fees from Actelion, ARXX, Bayer, Boehringer Ingelheim, Lilly, Medscape, Merck Sharp & Dohme and Roche; and grants from Boehringer Ingelheim., Consultant of: AMHV: received consulting fees from Actelion, ARXX, Bayer, Boehringer Ingelheim, Lilly, Medscape, Merck Sharp & Dohme and Roche; and grants from Boehringer Ingelheim., Grant/research support from: AMHV: received consulting fees from Actelion, ARXX, Bayer, Boehringer Ingelheim, Lilly, Medscape, Merck Sharp & Dohme and Roche; and grants from Boehringer Ingelheim., Armando Gabrielli: None declared, Serena Guiducci: None declared, Marco Matucci-Cerinic Speakers bureau: has received consulting fees or honorarium from Actelion, Janssen, Inventiva, Bayer, Biogen, Boehringer, CSL Behring, Corbus, Galapagos, Mitsubishi, Samsung, Regeneron, Acceleron, MSD, Chemomab, Lilly, Pfizer, Roche, Grant/research support from: has received consulting fees or honorarium from Actelion, Janssen, Inventiva, Bayer, Biogen, Boehringer, CSL Behring, Corbus, Galapagos, Mitsubishi, Samsung, Regeneron, Acceleron, MSD, Chemomab, Lilly, Pfizer, Roche, Daniel Furst: None declared, Silvia Bellando Randone: None declared

POS0842 LUNG ULTRASOUND TO ASSESS THE SEVERITY OF INTERSTITIAL LUNG DISEASE IN SYSTEMIC SCLEROSIS

Background:

Interstitial lung disease (ILD) is one of the most common complications and one of the main causes of morbidity and mortality in Systemic Sclerosis (SSc). High-resolution computed tomography (HRCT) is the gold standard for the diagnosis of ILD and it allows its quantification. Among semi-quantitative methods, Goh et al proposed a semi-quantitative scoring system to visually quantify ILD extent, with categorical cut-off of 20% to distinguish limited and extensive parenchymal involvement with prognostic implications. More recently, the use of radiomics has allowed the objective quantification of ILD through the use of dedicated software, which calculate different parameters of lung density.

Given the exposure to ionizing radiation that the procedure entails, other methods of ILD evaluation are being studied, among which lung ultrasound (LUS) identifies the B-lines as a main feature of ILD. So far, different evidences have proposed the use of LUS for the screening of ILD, even in the early phases of the disease and in subclinical lung involvement.

Objectives:

the aim of this study is to test the role of LUS in quantifying the severity of SSc-ILD, evaluated with both semi-quantitative visual radiological and quantitative radiomic scores.

Methods:

Adult SSc patients classified according to the ACR/EULAR 2013 criteria patients were assessed with pulmonary function test (PFTs), lung ultrasound and HRCT over 60 days. CT images were analysed qualitatively (by presence/absence of ILD), semi-quantitatively (categorical Goh score <20% vs> 20% of extent and the continuous extent Goh score made from 5 levels’ assessment– 0 to 100%) and quantitatively [with the densitometric radiomic data obtained through the Horos software - Mean lung attenuation (MLA), Standard Deviation (SD), Kurtosis, Skewness and Lung volume (LV)]. LUS was used to quantify the B-lines detected in each patient by scanning a total of 13 intercostal spaces, on both anterior and posterior chest wall.

Results:

Among 59 SSc patients (81% women, mean age 48±14 years, 45% anti-Scl70 positive), 23 (39%) presented ILD on HRCT, of which 14 limited and 9 extensive. The mean visual semi-quantitative score was 6%, ranging from 0 to 66%. Our data showed a significantly different number of B-Lines in ILD vs non-ILD patients (median 38 vs 9, p <.005), a result which was further confirmed among non-ILD vs ILD> 20% (median 47 vs 9, p=.001) and ILD <20% (median 36 vs 9, p=.001) patients. Conversely, the number of B-lines was not statistically different between patients with ILD <20% and >20% (median 47 vs 36, p=.78). We observed a significant negative correlation between the number of B-lines and FVC (r=-.472, p<.05) TLC (r=-.436, p=.003), DLco (r=-.515, p<.001), DLCO/VA (r=.-306, p=.03). Finally, the number of B-lines showed a statistically significant correlation with the Goh score on 5 levels (r=.437, p=.001), MLA (r=.571, p<.001), kurtosis (r=-.285, p=.028), skewness (r=-.370, p = .004) and LV (r=-.277, p=.033). All data were confirmed analysing anterior and posterior B-Lines separately.

Conclusion:

Our study confirms that LUS represents a useful tool for the identification of SSc-ILD. In addition, we showed that LUS may be useful also for the quantification of the severity of SSc-ILD, by correlating with PFT parameters, radiomics parameters and visual radiological evaluation. Together with the PFTs, LUS could be used to increase the accuracy of the screening and, potentially, of the follow-up of SSc-ILD patients.

Disclosure of Interests:

Cosimo Bruni: None declared, Lavinia Mattolini: None declared, Lorenzo Tofani: None declared, Luna Gargani Consultant of: GE Healthcare, Philips Healthcare and Caption Health, Nicholas Landini: None declared, Gemma Lepri: None declared, Martina Orlandi: None declared, Serena Guiducci: None declared, Silvia Bellando Randone: None declared, Marco Matucci-Cerinic: None declared

SAT0553 QUANTITATIVE ANALYSIS OF IMAGING FEATURES AT CHEST CT OF PULMONARY ARTERIAL AND VENOUS COMPONENTS IN SYSTEMIC SCLEROSIS-INTERSTITIAL LUNG DISEASE (SSc-ILD)

Background:

Interstitial lung disease (ILD) and pulmonary arterial hypertension carry a negative impact on SSc prognosis. Chest CT is the gold standard in assessing ILD and helps in evaluating associated vascular involvement.

Objectives:

As qualitative analysis of CT scans is limited by low reproducibility and time constraints, we aimed at evaluating parenchymal and vascular features in SSc-ILD by quantitative analysis (QA) of CT scans and testing the relationship with clinical-functional data.

Methods:

We prospectively enrolled 80 patients who underwent PFTs and chest CT scan spirometry gated at TLC on the same day. Clinical, lung functional and diffusion data, as well as disability indexes were collected. CT images were analyzed by a computational platform for texture analysis of ILD patterns (CALIPER), through Imbio LTA. It quantified the extent of normal pattern (NP %), ground glass opacities (GG %), reticulation (RET %), honeycombing (HC %), total ILD extent (ILD EXT %) and hyperlucent (HL %). Low density areas, representing emphysematous area, were also quantified (LDA %). For lung vessel analysis, a software program developed by the Ludwig Boltzmann Institute for Lung Vascular Research was used. This software determined total, arterial, and venous vascular volumes (TV, AV, VV), and relative volumes (TV%, AV%, VV%), as well as density and number for total, arterial and venous vessels.

Results:

43/80 patients/CT scans were eligible for both software analyses, while 36/43 for arterial and venous separation. TV% and total vessel density were correlated positively with mRSS and negatively with %FVC (r=-0.537 and r=-0.382) and %TLC (r=-0.511 and r=-0.648), while vessel tortuosity correlated positively with %DLco. This was confirmed when separately analyzing arterial vessels, while VV% negatively correlated with %FVC, %TLC and %DLco. There was a positive correlation between %ILD patterns and %vascular volumes, being significant for TV%-AV%, total vessels and arterial density. Conversely, %ILD patterns were negatively correlated with VV and number of veins detected, despite positive correlation between VV% and ILD_EXT%. When clustering patients according to %FVC and %DLco with 80% normal cutoff, %FVC allowed clustering according to significantly different ILD patterns extents and vascular features, while %DLCO for vascular features only. Moreover, the consecutive addition of functional impairment and worsening of ILD (from both normal %FVC and %Dlco, to %DLco impairment only to both %FVC and %Dlco impairment), there was a significant increase in %TV, % AV and %VV, with the exception of decrease in %VV and venous density in patients with double impairment versus DLco single impairment.

Conclusion:

This is the first study showing in SSc a direct correlation between ILD and the increase in lung vascular volume, which is characterized by increase in arterial volume and density and reduction in venous volume and number. These results might be explained by the reduction of pulmonary volume due to fibrosis. However, also a para-physiological mechanism of redistribution of blood flow in lung areas, less involved by ILD, might be considered. Further studies on lung vessel quantification and distribution are ongoing.

Disclosure of Interests:

Cosimo Bruni Speakers bureau: Actelion, Eli Lilly, Mariaelena Occhipinti Consultant of: Imbio, Gianna Camiciottoli: None declared, Maurizio Bartolucci: None declared, Michael Pienn: None declared, Gemma Lepri: None declared, Alessio Fabbrizzi: None declared, Alessandra Tottoli: None declared, Giuglia Ciardi: None declared, Dilia Giuggioli: None declared, Giovanna CUOMO: None declared, Francesco Masini: None declared, Horst Olschewski: None declared, Federico Lavorini: None declared, Linda Calistri: None declared, Marco Matucci-Cerinic Grant/research support from: Actelion, MSD, Bristol-Myers Squibb, Speakers bureau: Acetelion, Lilly, Boehringer Ingelheim

AB0550 DIFFUSING CAPACITY OF THE LUNG FOR CARBON MONOXIDE (DLCO) VS FORCED VITAL CAPACITY (FVC): SYSTEMATIC LITERATURE REVIEW AND META-ANALYSIS TO EXAMINE THEIR ABILITY TO MEASURE CHANGE IN CLINICAL TRIALS IN SYSTEMIC SCLEROSIS (SSC)

Background:

Lung involvement remains the main cause of morbidity and mortality in SSc. In 1 year clinical trials to assess lung involvement, FVC is usually evaluated and changes while the DLCO usually remains unchanged. In longer term observational studies, the DLCO often changes more than the FVC.

Objectives:

To examine, through a systematic literature review(SLR) and meta-analysis, whether DLCO%pred or FVC%pred (both to be designated solely as DLCO and FVC henceforth), responds more in assessing SSC interstitial lung disease in first year and longer term follow-up(FU).

Methods:

PubMed, EMBASE and COCHRANE databases were searched for english language articles on SSc published between 1960 and 31st October 2018. Any study that made reference to FVC and DLCO evaluation in SSc and reported their changes over the years was included. Reviewers double extracted articles to obtain agreement on>95% of pre-defined critical outcomes:DLCO and FVC at baseline,1 yr of FU and at the last assessment interstitial lung disease by HRCT of the lungs study design, duration of FU. Other variables included demographics. In all cases I^2 test for heterogeneity was used and a result from 75 to 100% was considered as high heterogeneity.A random effects meta-analysis was used. Differences in the degree of change in FVC and DLCO were tested with t-test without compensation for repeated analysis.

Results:

1870 articles were screened for eligibility and 21 were selected for the SLR and meta-analysis The analysis used 21 studies to evaluate changes of FVC and DCLO at 1 yr of FU. Only 5 studies were eligible to evaluate changes during longer FU (24.7 months(SD=20.4)). Heterogeneity was high at baseline and FU, (at 1 yr and >1 yr),both for the 21 studies at 1 yr (FVC:I^2 99.74%, 99.78%; DLCO: I^2=99.91%99.92%) and the 5 studies at > 1 year (FVC:I^2 92.86%;DLCO:I^2=99.54%), diminishing the confidence in the results. Table 1 gives the results of the random effects meta-analysis both for 21 and for the 5 studies evaluated. Regarding changes over 1 yr in the 21 studies, change of mean FVC was 2.7 (78.8vs81.5) while change in mean DLCO was 3.07(SE 8.20) (59.7vs 63.4). Considering the 5 studies during long term follow up, change in mean FVC was 2.0(7.36)(81.1vs83.1), and change in mean DLCO was -0.96 (16.95)(55.6vs54.7). Comparing the 1 yr changes in the 21 studies, change in mean FVC was 2.7(5.2)and change in mean DLCO was 3.07(8.2); difference in changes was not statistically significant (p=0.5791). During long term FU (24.7 months), change in mean FVC was 2.0(7.36)and change in mean DLCO was -0.96 (16.95); difference in changes was not statistically different (p=0.4698).

Table 1.

Results from Random Effect Meta-Analysis

21 studies5 studiesFVC % predmean valueSEDLCO % pred mean valueSEFVC % predmean valueSEDLCO % pred mean valueSEBASELINE78.83.4359.75.5281.15.6855.611.591 YEAR FOLLOW UP81.53.8563.46.07---->1 YEAR FOLLOW UP----83.44.6854.712.37

Conclusion:

Our data are limited by great heterogeneity. Given this limitation, this SLR and meta-analysis indicates that there is no difference in the changes comparing FVC to DLCO at either 1 yr or during longer term follow-up. Corroboration of these results in prospective studies and in registries to make clear, comparable comparisons will be needed.

Disclosure of Interests:

Silvia Bellando Randone: None declared, Eleonora Cappellini: None declared, Letizia Nidiaci: None declared, Gemma Lepri: None declared, Maria Grazia Lazzaroni: None declared, Corrado Campochiaro Speakers bureau: Novartis, Pfizer, Roche, GSK, SOBI, Gianluca Bagnato: None declared, Domenico Sambataro: None declared, Gianluca Sambataro: None declared, Marco Matucci-Cerinic Grant/research support from: Actelion, MSD, Bristol-Myers Squibb, Speakers bureau: Acetelion, Lilly, Boehringer Ingelheim, Daniel Furst Grant/research support from: AbbVie, Actelion, Amgen, BMS, Corbus Pharmaceuticals, the National Institutes of Health, Novartis, Pfizer, and Roche/Genentech, Consultant of: AbbVie, Actelion, Amgen, BMS, Cytori Therapeutics, Corbus Pharmaceuticals, the National Institutes of Health, Novartis, Pfizer, and Roche/Genentech, Speakers bureau: CMC Connect (McCann Health Company)

OP0181 FUNCTIONAL CUT-OFFS TO DISTINGUISH PULMONARY VASCULAR AND PARENCHYMAL INVOLVEMENT IN SYSTEMIC SCLEROSIS (SSC): A QUANTITATIVE ANALYSIS OF IMAGING FEATURES AT CHEST COMPUTED TOMOGRAPHY (CT)

Background:

Interstitial lung disease (ILD) and pulmonary arterial hypertension represent the most frequent causes of morbidity and mortality in SSc, with chest CT representing the gold standard in ILD assessment, while FVC and DLco allow functional assessment.

Objectives:

As qualitative analysis of given chest CT scans is hampered by low reproducibility, we aimed to perform a quantitative analysis (QA) of CT scans able to investigate the parenchymal and vascular features in SSc-ILD and thus testing the relationship with clinical-functional data.

Methods:

We prospectively enrolled 80 patients who underwent PFTs and spirometry-gated chest CT scan at TLC on the same day. Clinical, lung functional and diffusion data, as well as disability indexes were collected. CT images were analyzed by a computational platform for texture analysis of ILD patterns (CALIPER) through Imbio LTA. It quantified the extent of normal lung (%N), ground-glass opacities (%GG), reticulation (%RET), honeycombing (%HC), hyperlucent (%HL), absolute (PVV, cm3) and normalized (PVV/LV, %) pulmonary vascular volumes. Cut-offs of normality for %FVC and %DLco of 80% and 70% were tested to differentiate parenchymal and vascular features.

Results:

73 patients/CT scans were eligible for both software analyses. CALIPER showed GG% as the most frequent radiological pattern (mean 5.5±10.4%). %FVC and % TLC negatively correlated with all ILD patterns, while %DLco with RET% only; PVV and PVV/LV negatively correlated with %FVC and %TLC, while %DLco with PVV/LV only. Positive correlations were found between all ILD patterns and vascular volumes (Table 1).

LV (cm3)%N%GG%RET%HC%HLPVV (cm3)% PVV/LVFVC%r.60-.19-.40-.34-.30.35-.26-.44p<.001-<.001.004.01.003.04<.001FEV1%r.58-.02-.38-.25-.24.23-.35-.49p<.001-.002.04.05-.004<.001FEV1/FVCr-.16.33.22.16.21-.35-.15-.08p-.02------TLC%r.71-.14-.42-.37-.48.40-.43-.64p<.001-.001.01<.001.002<.001<.02DLco%r.38-.05-.21-.31-.22.30-.21-.33p.01--.01---.006FVC/DLcor.03-.08-.06-.003-.09.08-.06-.08p--------

Cut-offs equal to 80 for %FVC and 70 for %DLco distinguished both parenchymal and vascular features, while 80 for %DLco characterized vascular features only. These results were confirmed also when patients were stratified according to absent/single/combined %FVC and %DLCO impairments with 80% cut-offs (Table 2).

FVC<80%FVC ≥80%pDLco<80%DLco ≥80%pDLco <70%DLco ≥70%p%N82.7 (9.6)86.2 (14.7)-86.6 (12.7)80.8 (15.8)-84.1 (13.9)86.4 (13.5)-%GG10.3 (8.9)2.4 (3.9)<.0015.0 (6.7)3.9 (6.9)-6.2 (7.5)2.4 (4.8).002%RET2.9 (2.9)0.8 (1.3)<.0011.6 (2.1)0.7 (0.9)-1.9 (2.4)0.6 (0.8).007%HC0.4 (0.6)0.1 (0.1)<.0010.2 (0.3)0.1 (0.1)-0.2 (0.4)0.05 (0.2).010%HL3.6 (6.8)8.9 (12.1)-5.4 (8.8)14.1 (15.4).0506.3 (10.1)9.2 (12.7)-PVV125.6 (39.1)90.9 (26.9)<.001101.9 (34.8)84.7 (19.4).016106.9 (38.3)87.5 (20.5).012PVV/LV3.8 (1.6)2.0 (0.7)<.0012.51 (1.3)1.7 (0.6).0022.76 (1.4)1.83 (0.6).001

Conclusion:

In SSc a cut-off at 80 for %DLco may help identifying vascular changes as automatically assessed on chest CT scan, without any underlying ILD. The 80% cut-off for %DLco may be proposed to identify isolated vascular involvement, while %FVC at 80% or %DLco at 70% to identify significant parenchymal involvement. These results need to be confirmed in larger multi-centric cohorts.

Disclosure of Interests:

Cosimo Bruni Speakers bureau: Actelion, Eli Lilly, Mariaelena Occhipinti Consultant of: Imbio, Gianna Camiciottoli: None declared, Maurizio Bartolucci: None declared, Gemma Lepri: None declared, Alessio Fabbrizzi: None declared, Alessandra Tottoli: None declared, Anna Bassetto: None declared, Giuglia Ciardi: None declared, Dilia Giuggioli: None declared, Giovanna CUOMO: None declared, Francesco Masini: None declared, Federico Lavorini: None declared, Linda Calistri: None declared, Marco Matucci-Cerinic Grant/research support from: Actelion, MSD, Bristol-Myers Squibb, Speakers bureau: Acetelion, Lilly, Boehringer Ingelheim

THU0360 EFFICACY OF A SELF-TREATMENT PROTOCOL FOR FACE AND TEMPOROMANDIBULAR JOINTS REHABILITATION IN SYSTEMIC SCLEROSIS (SSC)

Background:

In SSc, skin involvement of the face is frequent and extremely disabling, resulting in limited mouth opening, an altered dentition, difficulty in teeth care, as well as having a strong impact on the emotional and psychological well-being, thus impairing quality of life.

Objectives:

to evaluate the efficacy of a self-treatment protocol (created by AMURR A Multidisciplinary Association of Rheumatological Rehabilitation) for face and tempomandibular joints (TMJs) rehabilitation with two devices used in the dental field.

Methods:

40 SSc patients (37 female and 3 male) with a mouth opening ≤ 40 mm, were recruited and randomized in two groups of treatment: Group 1 (20 patients: mean age 50,650 yrs ± 13,937 SD, mean disease duraton 10,45 yrs ± 7,877 SD, opening mouth 32,250 mm ± 5,590 SD) treated with a home self-treatment protocol consisting of 23 exercises carried out at home in front of a mirror, 22/23 exercises were performed once a day, one of these using a device to obtain uniform stretching of the buccal rhyme, another one usingused three times a day to reduce tension of muscles of the TMJs, facilitating the mouth opening; group 2 (20 patients: mean age 58,05 yrs ± 18,103 SD, mean disease duration 17,4 yrs ± 15,017 SD, opening mouth 34,950 mm ± 5,753) without physical rehabilitation, only drugs as treatments of SSc and its complications. All patients underwent a baseline (T0) and 45 days (T1) clinimetric assessment by self-assessment of quality of life with SF-36 (Short-Form 36 Health Survey), of the degree of disability of the mouth with MHISS (of the Mouth Handicap in Systemic Sclerosis scale), Muscle pain evaluated by numerical rating scale (NRS) of the temporomandibular joint with TMD (Temporo mandibular Disorders), evaluation of mouth opening and ROM of the cervical spine. Statistical analysis was performed using the t-test or the Mann-Whitney test for assessing changes in all measurement scales between treatment groups.

Results:

The protocol of home physiotherapy exercises resulted in a statistically significant improvement in the treated group compared to group 2 both for mouth opening (T0: 32,250 ± 5,590, T1: 35,650 ± 6,046) vs (T0: 34,950 ± 5,753 T1: 34,300 ± 6,001) (p<0.001), cervical flexion (T0: 2,950 ± 1,939 T1: 1.700 ± 1,525) vs (T0: 4,450 ± 2,282 T1:4,075 ± 2,238) (p<0.01), cervical extension (T0: 17,025 ± 1,895 T1: 17,625 ± 1,605) vs (T0: 17,050 ± 2,089 T1: 16,525 ± 3,110) (p<0.05), cervical right lateral flexion (T0: 14,075 ± 2,386 T1:13,400 ± 2,431) vs (T0: 14,200 ± 1,765 T1: 14,425 ± 1,742) (p<0.01), cervical right rotation (T0: 14,200 ± 3,416 T1:13,750 ± 3,206) vs (T0: 14,900 ± 1,683 T1: 15,550 ± 2,188) (p<0.01), cervical left rotation (T0: 14,725 ±3,640 T1:14,450 ± 3,710) vs (T0: 15,900 ± 2,614 T1: 16,450 ± 2,964) (p<0.05), mouth disability at MHISS (T0: 19,100 ± 10,356 T1: 16,000 ± 9,989) vs (T0: 20,950 ± 9,950, T1: 21,100 ± 10,775) (p<0.01).

Conclusion:

The use of the home exercises protocol associated with the two devices has shown a significant improvement of the disability linked to skin involvement of the face. This highlights the fundamental role that home rehabilitation self therapy has in practice. These data will need to be confirmed in a larger cohort of patients

Disclosure of Interests:

Mauro Passalacqua: None declared, Cristian Foggi: None declared, Nicola Mauro: None declared, Lorenzo Tofani: None declared, Serena Guiducci: None declared, Cosimo Bruni Speakers bureau: Actelion, Eli Lilly, Gemma Lepri: None declared, Jelena Blagojevic: None declared, Khadija El Aoufy: None declared, Ginevra Fiori: None declared, Francesca Bartoli: None declared, Susanna Maddali Bongi: None declared, Marco Mitola: None declared, Marco Gizduloch: None declared, Marco Matucci-Cerinic Grant/research support from: Actelion, MSD, Bristol-Myers Squibb, Speakers bureau: Acetelion, Lilly, Boehringer Ingelheim, Silvia Bellando Randone: None declared

SAT0308 SCREENING TOOLS FOR PULMONARY ARTERIAL HYPERTENSION (PAH) IN SYSTEMIC SCLEROSIS (SSC): A SYSTEMATIC LITERATURE REVIEW (SLR)

Background:

in SSc, PAH has a high morbidity and mortality burden. Therefore, screening and early detection are pivotal to achieve an early diagnosis of PAH.

Objectives:

to search the literature for all screening modalities for SSc-PAH in reference to right heart catheterization as diagnostic gold standard.

Methods:

papers from 2 previously published SLRs [22 fromGlaude et al(1) – from inception to 19/06/2012 - and 22 fromYoung et al 2018– from 20/06/2012 to 02/10/2017] were included. The articles’ database was integrated with a systematic search on Pubmed, EMBASE, Web of Science for papers published from 03/10/2017 to 31/12/2018. A total of 199 papers were reviewed and 32 were finally extracted. Bias risk was assessed through QUADAS2 tool.

Results:

167 papers were excluded from data extraction mainly for PAH screening non as main focus or for non-including SSc patients. The 32 papers extracted presented a low bias risk according to QUADAS2. Screening methods reported were:

Conclusion:

in the literature, the screening of SSc-PAH is largely investigated by echocardiographic parameters. In particular, sPAP and TRV, both as single items or part of a composite algorithm, including also serum biomarkers, clinical and functional parameters, are the most frequent parameters evaluated.

(supported by an Actelion Pharmaceuticals unrestricted research grant)

References:

[1]Gladue H, et al. Screening and diagnostic modalities for connective tissue disease-associated pulmonary arterial hypertension: a systematic review. Semin Arthritis Rheum. 2014 Feb;43(4):536-41.

[2]Young A, et al. Update of screening and diagnostic modalities for connective tissue disease-associated pulmonary arterial hypertension. Semin Arthritis Rheum. 2019 Jun;48(6):1059-1067.

Acknowledgments:

(supported by an Actelion Pharmaceuticals unrestricted research grant)

Disclosure of Interests:

Cosimo Bruni Speakers bureau: Actelion, Eli Lilly, Giacomo De Luca Speakers bureau: SOBI, Novartis, Celgene, Pfizer, MSD, Maria Grazia Lazzaroni: None declared, Elisabetta Zanatta: None declared, Gemma Lepri: None declared, Marco Matucci-Cerinic Grant/research support from: Actelion, MSD, Bristol-Myers Squibb, Speakers bureau: Acetelion, Lilly, Boehringer Ingelheim

Orbital cobalt irradiation combined with systemic corticosteroids for Graves' ophthalmopathy: comparison with systemic corticosteroids alone

The effects of different methods of treatment of Graves' ophthalmopathy were evaluated in a series of 48 patients. Thirty-six patients were given combined treatment with orbital cobalt irradiation and systemic 6 alpha-methylprednisolone (methylprednisolone). Included in this group were 12 of 24 consecutive patients who were randomly assigned to either combined therapy or systemic methylprednisolone alone. The degree of ocular involvement and responses to treatment were evaluated by numerical scoring (ophthalmopathy index) and clinical assessment. Of the 36 patients treated by combined therapy, 12 (33%) showed excellent responses, 14 (39%) showed good responses, 9 (25%) showed slight responses, and 1 (3%) had no response. Treatment was more effective for soft tissue involvement, newly developed ophthalmoplegia, and optic neuropathy, while proptosis and longstanding ophthalmoplegia were less responsive. There was an inverse relationship between the duration of ophthalmopathy and the efficacy of treatment, more favorable results being observed when symptoms had been present for less than 2 yr. Treatment with systemic methylprednisolone alone was also effective, but, in general, responses were less satisfactory; 4 of the 12 patients of this group (33%) had good responses, 6 (50%) had slight responses, and 2 (17%) had no response. The results obtained in the 24 patients randomly assigned to combined therapy or steroid treatment alone were compared by evaluating changes in the ophthalmopathy index. Mean initial ophthalmopathy indices (6.4 vs. 6.2, respectively) showed no significant differences between the 2 groups, whereas the mean decrease in the group receiving combined therapy (4.8) was significantly greater (P less than 0.05) than that in the other group (3.2). In conclusion, the present study indicates that both orbital cobalt irradiation combined with systemic methylprednisolone treatment and systemic methylprednisolone therapy alone are valuable methods of treatment for Graves' ophthalmopathy, but the combined therapy proved to be more effective.