1 3 Exhaled NO predicts cyclophosphamide response in scleroderma-related 4 lung disease 5 6 7 Kiet Phong Tiev a Q1 , Sébastien Rivière b , Thong Hua-Huy c , Jean Cabane b , Anh Tuan Dinh-Xuan c,⇑ 8 a Private Hospital of Vitry sur Seine, Site Pasteur, Department of Internal Medicine, 22 rue de la petite Saussaie, 94400 Vitry sur Seine, France Q2 9 b University Paris Pierre et Marie Curie, Department of Internal Medicine, Saint Antoine Hospital, 184 rue du faubourg Saint Antoine, 75571 Paris cedex 12, France 10 c University Paris Descartes, Sorbonne Paris Cité, Department of Physiology, Cochin Hospital, 27 rue du faubourg Saint-Jacques, 75679 Paris cedex 14, France 11 13 article info 14 Article history: 15 Received 30 January 2014 16 Available online xxxx 17 Keywords: 18 Systemic sclerosis 19 Cyclophosphamide 20 Exhaled nitric oxide 21 Lung fibrosis 22 23 abstract 24 Cyclophosphamide (CYC) is not always effective in patients with scleroderma-related interstitial lung dis- 25 ease (SSc-ILD), hence the need for biomarkers able to predict beneficial responses to CYC therapy. We 26 therefore assessed whether baseline alveolar concentration of nitric oxide (C A NO) could predict the 27 favourable response to CYC therapy in patients with SSc-ILD. 28 Nineteen non-smoker patients with SSc-ILD, were enrolled and treated with 6 courses of CYC (0.75 29 g/m2/monthly) for lung function decline the year before inclusion, and followed-up for 2 years period. 30 We assessed the proportion of favourable response to CYC, defined as improvement of forced vital 31 capacity (FVC) or total pulmonary capacity (TLC) more than 10% between the inclusion and each follow- 32 ing visit, according to the validated cut-off of Q3 CANO at 8.5 ppb identifying progressive SSc-ILD subset. 33 At inclusion, 7 patients out of 19 had CANO >8.5 ppb. Clinical parameters were comparable between 34 patients with high (>8.5 ppb) and low level of C A NO (68.5 ppb). After CYC therapy, and during the 35 follow-up, 9 out of 19 patients had favourable response to CYC therapy, 10 did not meet responder’s 36 criteria, from whom 4 patients died from respiratory failure. Six out of 7 patients with CANO >8.5 ppb 37 at inclusion had favourable response to CYC therapy, while only 3 out of 12 patients with CANO 38 68.5 ppb responded favourably to CYC therapy (p = 0.001). 39 High level of C A NO >8.5 ppb reflecting alveolar inflammation identify SSc patients with a greater 40 chance to benefit from CYC treatment with a significant lung function improvement. 41 Ó 2014 Elsevier Inc. All rights reserved. 42 43 44 45 1. Introduction 46 Systemic sclerosis (SSc) is a chronic autoimmune disease char- 47 acterized by immune activation, vascular damage, and fibrosis of 48 various organs [1]. Scleroderma-related interstitial lung disease 49 (SSc-ILD) is a life-threatening condition occurring in more than half 50 of patients [2], and a leading cause of death in SSc [3]. Although 51 beneficial effects of treatment with cyclophosphamide (CYC) in 52 patients with SSc-ILD is modest [4,5], it is commonly admitted that 53 this latter therapy remains a gold standard in SSc-ILD. The progres- 54 sion profiles of SSc-ILD are heterogeneous, and its favourable 55 response to CYC therapy is unpredictable. There is therefore a need 56 for biomarkers that can identify patients who will likely benefit 57 from CYC therapy [6]. 58 Nitric oxide (NO), a key cellular mediator, is both a powerful 59 endogenous vasodilator and a highly reactive biomarker of inflam- 60 mation [7]. Alveolar inflammation releases both pro-inflammatory 61 cytokines that induce greatly the inducible NO synthase activity, 62 that produce in turn a high amount of gas nitric oxide in the 63 exhaled air [7–9]. We [10] and other [11] have previously shown 64 that increase C A NO was related to severity of SSc-ILD and the abil- 65 ity of serum to induce from patients with SSc to induce fibrosis 66 in vitro [12]. Moreover, we have recently described and validated 67 the cut-off of C A NO at 8.5 ppb identifying with high specificity 68 more than 90% patients with high risk to develop subsequent lung 69 function deterioration, and may help to initiate early appropriate 70 treatment [13]. 71 We hypothesized that immunosuppressive therapy is more 72 likely to have greater beneficial effects in patients with SSc-ILD 73 with active rather than quiescent alveolar inflammation. In this 74 prospective study, we assessed whether baseline C A NO could 75 predict the favourable response to intravenous CYC therapy 76 (0.75 g/m2/monthly) for 6 to 9 months in patients with SSc-ILD. http://dx.doi.org/10.1016/j.niox.2014.04.011 1089-8603/Ó 2014 Elsevier Inc. All rights reserved. ⇑ Corresponding author. Address: Service de Physiologie-Explorations Fonctionn- elles, Hôpital Cochin, 27 rue du faubourg Saint-Jacques, 75014 Paris, France. Fax: +33 158412345. E-mail address: [email protected](A.T. Dinh-Xuan). Nitric Oxide xxx (2014) xxx–xxx Contents lists available at ScienceDirect Nitric Oxide journal homepage: www.elsevier.com/locate/yniox YNIOX 1373 No. of Pages 5, Model 5G 14 May 2014 Please cite this article in press as: K.P. Tiev et al., Exhaled NO predicts cyclophosphamide response in scleroderma-related lung disease, Nitric Oxide (2014), http://dx.doi.org/10.1016/j.niox.2014.04.011
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Nitric Oxide xxx (2014) xxx–xxx
YNIOX 1373 No. of Pages 5, Model 5G
14 May 2014
Contents lists available at ScienceDirect
Nitric Oxide
journal homepage: www.elsevier .com/locate /yniox
Exhaled NO predicts cyclophosphamide response in scleroderma-relatedlung disease
http://dx.doi.org/10.1016/j.niox.2014.04.0111089-8603/� 2014 Elsevier Inc. All rights reserved.
⇑ Corresponding author. Address: Service de Physiologie-Explorations Fonctionn-elles, Hôpital Cochin, 27 rue du faubourg Saint-Jacques, 75014 Paris, France.Fax: +33 158412345.
Please cite this article in press as: K.P. Tiev et al., Exhaled NO predicts cyclophosphamide response in scleroderma-related lung disease, Nitric(2014), http://dx.doi.org/10.1016/j.niox.2014.04.011
Kiet Phong Tiev a, Sébastien Rivière b, Thong Hua-Huy c, Jean Cabane b, Anh Tuan Dinh-Xuan c,⇑a Private Hospital of Vitry sur Seine, Site Pasteur, Department of Internal Medicine, 22 rue de la petite Saussaie, 94400 Vitry sur Seine, Franceb University Paris Pierre et Marie Curie, Department of Internal Medicine, Saint Antoine Hospital, 184 rue du faubourg Saint Antoine, 75571 Paris cedex 12, Francec University Paris Descartes, Sorbonne Paris Cité, Department of Physiology, Cochin Hospital, 27 rue du faubourg Saint-Jacques, 75679 Paris cedex 14, France
a r t i c l e i n f o a b s t r a c t
242526272829303132
Article history:Received 30 January 2014Available online xxxx
Cyclophosphamide (CYC) is not always effective in patients with scleroderma-related interstitial lung dis-ease (SSc-ILD), hence the need for biomarkers able to predict beneficial responses to CYC therapy. Wetherefore assessed whether baseline alveolar concentration of nitric oxide (CANO) could predict thefavourable response to CYC therapy in patients with SSc-ILD.
Nineteen non-smoker patients with SSc-ILD, were enrolled and treated with 6 courses of CYC (0.75g/m2/monthly) for lung function decline the year before inclusion, and followed-up for 2 years period.We assessed the proportion of favourable response to CYC, defined as improvement of forced vitalcapacity (FVC) or total pulmonary capacity (TLC) more than 10% between the inclusion and each follow-ing visit, according to the validated cut-off of CANO at 8.5 ppb identifying progressive SSc-ILD subset.
At inclusion, 7 patients out of 19 had CANO >8.5 ppb. Clinical parameters were comparable betweenpatients with high (>8.5 ppb) and low level of CANO (68.5 ppb). After CYC therapy, and during thefollow-up, 9 out of 19 patients had favourable response to CYC therapy, 10 did not meet responder’scriteria, from whom 4 patients died from respiratory failure. Six out of 7 patients with CANO >8.5 ppbat inclusion had favourable response to CYC therapy, while only 3 out of 12 patients with CANO68.5 ppb responded favourably to CYC therapy (p = 0.001).
High level of CANO >8.5 ppb reflecting alveolar inflammation identify SSc patients with a greaterchance to benefit from CYC treatment with a significant lung function improvement.
� 2014 Elsevier Inc. All rights reserved.
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1. Introduction
Systemic sclerosis (SSc) is a chronic autoimmune disease char-acterized by immune activation, vascular damage, and fibrosis ofvarious organs [1]. Scleroderma-related interstitial lung disease(SSc-ILD) is a life-threatening condition occurring in more than halfof patients [2], and a leading cause of death in SSc [3]. Althoughbeneficial effects of treatment with cyclophosphamide (CYC) inpatients with SSc-ILD is modest [4,5], it is commonly admitted thatthis latter therapy remains a gold standard in SSc-ILD. The progres-sion profiles of SSc-ILD are heterogeneous, and its favourableresponse to CYC therapy is unpredictable. There is therefore a needfor biomarkers that can identify patients who will likely benefitfrom CYC therapy [6].
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Nitric oxide (NO), a key cellular mediator, is both a powerfulendogenous vasodilator and a highly reactive biomarker of inflam-mation [7]. Alveolar inflammation releases both pro-inflammatorycytokines that induce greatly the inducible NO synthase activity,that produce in turn a high amount of gas nitric oxide in theexhaled air [7–9]. We [10] and other [11] have previously shownthat increase CANO was related to severity of SSc-ILD and the abil-ity of serum to induce from patients with SSc to induce fibrosisin vitro [12]. Moreover, we have recently described and validatedthe cut-off of CANO at 8.5 ppb identifying with high specificitymore than 90% patients with high risk to develop subsequent lungfunction deterioration, and may help to initiate early appropriatetreatment [13].
We hypothesized that immunosuppressive therapy is morelikely to have greater beneficial effects in patients with SSc-ILDwith active rather than quiescent alveolar inflammation. In thisprospective study, we assessed whether baseline CANO couldpredict the favourable response to intravenous CYC therapy(0.75 g/m2/monthly) for 6 to 9 months in patients with SSc-ILD.
Inclusion period was conducted from November 2006 to May2009 in the department of Internal Medicine, University HospitalSaint Antoine, Paris, France, and the follow-up of this study endedin May 2012. Patients who met the following criteria were eligiblefor the study.
2.2. Inclusion criteria
Patients were considered for inclusion if they were older than18 years and had a diagnosis of SSc [14] with diffuse or limitedforms [15], the presence of ILD diagnosed by chest high-resolutioncomputed tomography (HRCT), and the presence of pulmonaryhypertension (PH) ascertained by right heart catheterization(RHC), irrespective of the level of forced vital capacity (FVC), anddiffusing lung capacity for carbon monoxide (DLCO). Patients musthave a relevant deterioration of lung function during the last year.Deterioration of lung function was considered relevant if there wasa relative decline of more than 10% of FVC or TLC as compared withits respective value at inclusion. Patients with corticosteroids andimmunosuppressive agents are also eligible and recorded as pres-ence of immunosuppressive therapy.
2.3. Exclusion criteria
Exclusion criteria were the presence of recent airway uppertract infection or pneumonia in the three last months, the presenceof lung cancer, asthma, allergic rhinitis, chronic obstructive pul-monary disease, pulmonary hypertension, left ventricular systolicdysfunction, and treatment by NO donors. Patients, who wereunable to perform partitioned exhaled NO at inclusion visit, werealso excluded.
2.4. At inclusion
All patients gave written informed consent to participate in thestudy, which was approved by the local ethics committee (CCP Ilede France V). Demographic data, duration of disease (delaybetween first symptom attributable to SSc and inclusion date),subset of SSc, and history of smoking were recorded. All patientsunderwent pulmonary function tests (PFTs), chest HRCT, an echo-cardiogram, and extended NO analysis.
2.5. Pulmonary function tests
Pulmonary function tests were routinely performed with a stan-dard methodology and quality controls according to the AmericanThoracic Society and the European Respiratory Society (ATS/ERS)recommendations [16].
2.6. Interstitial lung disease
Interstitial lung disease related to SSc was determined by thepresence of reticular or ground glass changes extending at least tothe venous confluence on chest HRCT according to the ATS/ERS con-sensus [17]. The extent of lung fibrosis was scored as in each lobeinto 5 levels for ground glass score and fibrosis score according toscoring described by Kazerooni et al. [18]. Ground-glass attenuationwas defined as a hazy increase of lung parenchymal attenuationand fibrosis score included lobular septal thickening and subpleuralhoneycomb change. In each lobe, five levels of scoring for groundglass and fibrosis was performed as follows: (0) no abnormality;
Please cite this article in press as: K.P. Tiev et al., Exhaled NO predicts cyclo(2014), http://dx.doi.org/10.1016/j.niox.2014.04.011
(1) <5% of the lobe; (2) 6–25% of the lobe; (3) 26–50% of the lobe;(4) 51–75% of the lobe; and (5) 76–100% of the lobe.
2.7. Pulmonary hypertension
We estimated systolic pulmonary artery pressure (sPAP) byechocardiogram using simplified Bernoulli equation to calculatethe maximal transtricuspid pressure gradient. To calculate rightventricular systolic pressure, estimated as equal to sPAP,10 mmHg, as an estimate of right atrial pressure, was added tothe maximal pressure gradient [19]. If patients with SSc had sPAPestimated by echocardiogram more than 40 mmHg, a RHC was per-formed to determine hemodynamically the mean pulmonaryartery pressure that define PH according to the expert consensus2009 [20]. Patients with PH confirmed by RHC were excluded fromthis study.
2.8. Partitioned exhaled NO measurement
Briefly, fractional exhaled NO (FENO) was measured using achemiluminescent analyzer (EndoNO 8000�, SERES, Aix-en-Provence, France), according to the ATS/ERS recommendations[21]. After a full inspiration of room air, the subject exhaled againsta positive pressure to generate exhalation flow rates (V
0
E) of 50, 100,150 and 200 ml/s. For each V
0
E, the elimination rate of NO (V0
NO) wascalculated as a function of V
0
E (V0
NO = V0
E�FENO). At the flow rate>50 ml/s, the latter relationship is linear and can be expressed asV0
NO = V0
E�FENO = CANO�V0E + J0
awNO [12,22]. J0
awNO is the maximal con-ducting airway flux of NO [22,23].
2.9. Follow-up
Clinical assessment, pulmonary function tests (PFTs), and parti-tioned measurement of exhaled NO were performed every6 months during the first year after inclusion and at the end ofthe second year of the follow-up. The decision to give a mainte-nance therapy with immunosuppressive agents after 6 courses ofCYC was left to appreciation of the practitioner who follows thepatient in regular basis in the expert centre.
2.10. Endpoint
Favourable therapeutic response to CYC was defined as a rela-tive increase of FVC or TLC more than 10% between the inclusionand each following visit, was recorded a positive event. Eventwas recorded as negative if improvement of FVC or TLC recordedduring the 2 year-period of follow-up did not achieve 10% of itsrespective value at inclusion.
2.11. Statistical analysis
First, we split the studied population into 2 subgroups accord-ing to the cut-off at 8.5 ppb, and compared clinical parameters,PFTs’ parameters, and extent of lung fibrosis on chest HRCT scanbetween these subgroups to insure that they were comparable atinclusion. Continuous and categorical variables were presented asmedian (interquartile range (IQR)), and percentages, and comparedbetween groups by U Mann–Whitney tests and v2 testsrespectively.
Next, we assessed the influence of immunosuppressive mainte-nance therapy after 6 monthly courses of CYC on lung functionimprovement outcome. We compared the proportion of favourabletherapeutic response according to presence of immunosuppressivemaintenance therapy. We also assessed the performance of CANO,J0awNO, and FENO0.05 for predicting favourable therapeutic responseto CYC therapy within the 2 years after inclusion (positive if
phosphamide response in scleroderma-related lung disease, Nitric Oxide
favourable response to CYC therapy occurred within 2 years of fol-low-up and negative if favourable event did not occur) by usingreceiver operating characteristic curves (ROC) analysis.
Finally, we compared the rate of favourable therapeuticresponse to CYC according to the cut-off of CANO at 8.5 ppb usingFisher test. The change in CANO levels from patients with SSc-ILDbefore and after CYC therapy was compared between group ofpatients with CANO >8.5 ppb and the group of remaining patientsusing Wilcoxon signed rank test.
All tests were two-sided with a significance level of 5%. All anal-yses were performed with STATA� Statistical Software: Release 10(Stata Corporation, College Station, 192 TX).
3. Results
3.1. Baseline characteristics of population
Twenty patients with SSc were eligible in this prospectivestudy. One patient was excluded for pulmonary hypertensiondetected on echocardiogram and confirmed by RHC. Nineteennon-smoker patients with SSc who were treated by intravenouspulse of CYC for rapid decline of lung function, refractory to con-ventional therapy the year before inclusion were enrolled in thisprospective study. At inclusion, median age was 55.0 years (IQR:43.4–61.5), and 4 were men (21.0%). Thirteen patients had diffuseform of SSc (68.4%). 10 out of 19 (52.6%) took immunosuppressiveagents (Methotrexate (n = 2), and corticosteroids (n = 10)). Cortico-steroids doses ranged between 7 mg/day to 25 mg/day, and 2patients took the both treatments. The course of CYC started atinclusion and after 6 courses of CYC (0.75 g/m2 of body surface).
3.2. Clinical features of patients with systemic sclerosis according tothe cut-off of CANO at 8.5 ppb
At inclusion, 7 out of 19 patients with SSc-ILD (36.8%) had CANO>8.5 ppb. Comparisons of clinical features between patients withSSc-ILD and CANO >8.5 ppb and those with CANO 68.5 ppb weresummarized in Table 1. Median age, sex ratio, proportion of diffuseform of SSc, median of modified Rodnan skin score, and thefunctional status including 6 min walk distance (6-MWD), andscleroderma health assessment questionnaire (sHAQ) score werecomparable between patients with CANO >8.5 ppb and the remain-ing patients. Moreover, lung function including FVC, TLC and dif-fusing lung capacity for carbon monoxide levels, extent of lung
Table 1Clinical features from patients with SSc-ILD according to the cut-off of CANO at 8.5 ppb.
SSc-ILD patients with CANO >8.5 p
Age (years) 56.9 (47.0–60.5)Male, n (%) 1 (14.3)Diffuse form of SSc, n (%) 5 (71.4)Modified Rodnan skin score 7 (4–10)6-MWD (meter) 410 (337–460)HAQ score 0.69 (0.19–1.37)sPAP (mmHg) 35 (32–39)Ground glass opacity score* 5 (2–5)Fibrosis score* 5 (5–7)TLC** 72 (66–78)FVC** 72 (59–78)DLCO** 48 (35–56)Immunosuppressive therapy, n (%) 5 (71.4)Favourable response to cyclophosphamide 6 (85.7)
Continuous and categorical variables were presented as medians (interquartile ragnges)lung disease, CANO: alveolar concentration of nitric oxide, ppb: part per billion, 6-MWDsPAP: systolic pulmonary artery pressure estimated by echocardiogram.* scores described by Kazerooni et al., TLC: total pulmonary capacity, FVC: forced vital** proportion of predicted value.
Please cite this article in press as: K.P. Tiev et al., Exhaled NO predicts cyclo(2014), http://dx.doi.org/10.1016/j.niox.2014.04.011
fibrosis scores assessed on chest HRCT, and sPAP were comparablebetween the group of patients with CANO >8.5 ppb and that ofpatients with CANO 68.5 ppb. The proportions of patient treatedwith immunosuppressive therapy were not different between thetwo groups (Table 1).
3.3. Events during follow-up and influence of immunosuppressivemaintenance therapy on lung function outcome
After 6 courses of CYC, and during the 2 year-period of follow-up, 9 out of 19 had favourable response to CYC therapy, 10 didnot meet the responder’s criteria: 4 out of 10 had stable lung func-tion, and 6 out of 10 worsened their lung function. Among 6patients who worsened their lung function, 4 patients died dueto end-stage of lung fibrosis. Twelve out 19 had immunosuppres-sive maintenance therapy after 6 monthly courses of CYC includingMycophenolate mofetil (n = 9), and Azathioprine (n = 4), and 6patients did not have immunosuppressive maintenance therapy.The rate of favourable response to CYC therapy in subgroup withmaintenance therapy was comparable with that from the subgroupwithout immunosuppressive maintenance therapy (Table 2).
3.4. Association between high level of alveolar concentration of nitricand favourable response to cyclophosphamide
The area under ROC curve (AUROC) of CANO for prediction offavourable response to CYC therapy achieved 0.78 (95%CI: 0.54–0.99; p < 0.001), whereas the AUROCs of FENO0.05 (AUROC = 0.47,95% CI: 0.19–0.74, p = 0.29), and J’awNO (AUROC = 0.41, 95%CI:0.14–0.67, p = 0.37) were lower and did not have predictive valuefor favourable response to CYC therapy. The best cut-off of CANOobtained in this present population (n = 19) for identifying patientswho are going to have favourable response to CYC therapy within2 years after inclusion was 8.0 ppb (95%CI: 5.5–11.7) very near tothe threshold at 8.5 ppb that we previously described and vali-dated in a large population of patients with SSc as threshold fordefining active and progressive form of SSc-ILD with specificitymore than 90%.13[v] Therefore, we choose the validated cut-offfor all analyses.
Among 7 patients with CANO >8.5 ppb, 6 improved more than10% of FVC or TLC as compared with its respective value at inclu-sion during the 2 year-period of the follow-up, while only 3 outof 12 patients with CANO 68.5 ppb met the favourable responder’scriteria (p = 0.001).
pb (n = 7) SSc-ILD patients with CANO 68.5 ppb (n = 12) p
, and numbers (percentages) respectively, SSc-ILD: scleroderma-related interstitial: six minutes walk distance, sHAQ: scleroderma health assessment questionnaire,
capacity, DLCO: diffusing lung capacity for carbon monoxide.
phosphamide response in scleroderma-related lung disease, Nitric Oxide
Table 2Proportion of favourable outcome according to a adding of immunosuppressivemaintenance therapy.
Immunosuppressivemaintenancetherapy
Patients withSSc-ILD(n = 19)
Favourable responseto CYC therapy(n = 9)
Death due torespiratory failure(n = 4)
Mycophenolatemofetil
9 4 0
Azathiprine 4 2 1None 6 3 3
SSc-ILD: scleroderma-related interstitial lung disease, CYC: cyclophosphamide,p value of comparison of favourable response to CYC proportion between patientswith and without immunosuppressive maintenance therapy was 0.88.
Fig. 2. Change of alveolar concentration of nitric oxyde.s White dots representsystemic sclerosis (SSc) patients with CANO 68.5 ppb at inclusion of the study;Grey dots, SSc patients with CANO >8.5 ppb at inclusion of the study; j blacksquares, SSc patents who died during the follow-up; h white square, the SSc patientwho cannot perform again CANO measurement Only 14 paired dots joined bydotted lines and full lines represent CANO levels of SSc patients at inclusion andafter 6 monthly courses of cyclophosphamide (0.75 g/m2 of body surface).
The ground glass opacity and fibrosis scores did not have pre-dictive value on the responsiveness of CYC therapy.
3.5. Impact of immunosuppressive therapy on alveolar concentrationof nitric oxide
There were no significant changes in CANO before and after CYCtherapy in the whole population. However, CANO decreased signif-icantly after CYC therapy (p = 0.02) in patients with CANO >8.5 ppb,but not in patients with CANO 68.5 ppb (p = 0.05, Fig. 1).
4. Discussion
In this present study, we found that high level of CANO >8.5 ppb,reflecting a progressive form of SSc-ILD, was accurate to identifypatients with SSc-ILD who were the most likely able to restoretheir lung function with CYC therapy. Our findings shows thatamong SSc patients recent relevant deterioration of lung functionduring the last year (a relative decline of more than 10% of FVCor TLC), only those with high level of alveolar inflammation asshown by a level of CANO >8.5 ppb have benefited from thecyclophosphamide therapy. Moreover, after 6 monthly courses ofcyclophosphamide (0.75 g/m2 of body surface), levels of CANOwas not significantly reduced suggesting that cyclophosphamidecan lower alveolar inflammation if this latter was intense andcan partly affect the heterogeneous inflammatory cells contribut-ing to lung inflammation (see Fig. 2 and Tables 1 and 2).
Although previous reports have shown great benefits of CYC inpatients with SSc-ILD [24,25], recent large randomized trial withCYC versus placebo reported modest impact of CYC therapy on
Systemic sclerosis pa�ents with releva(decline ≥ 10% of FVC or TLC as compare
past year (n
19 pa�ents wereCANO measuremen
Clinical outcome: «Favourable responsedefined as improvement of forced vit
capacity more than 10% between the i
7 Pa�ents with CANO > 8.5 ppb: •6 had favourable response to CYC•1 pa�ent unmet favourable response criteria
Fig. 1. Flow chart
Please cite this article in press as: K.P. Tiev et al., Exhaled NO predicts cyclo(2014), http://dx.doi.org/10.1016/j.niox.2014.04.011
improvement of lung function [5,26,27]. This inconsistencybetween these studies underlined the heterogeneity of SSc-ILDand the critical need to have accurate tool to select patients forCYC therapy. Up to now, there are few markers of activity of SSc-ILD. Broncho-alveolar lavage fluid cells count may assess alveolarinflammation, but alveolitis on BAL fluid failed to predict theresponsiveness of CYC therapy [28]. Fibrosis score on baselinechest HRCT [29], and modified Rodnan skin score might providesome information on the responsiveness of CYC therapy [6], incon-sistently with our findings.
As SSc-ILD gradually and irreversibly reduces lung volumes,and impairs lung gas exchanges, it is commonly admitted thatmaintaining the lung volumes and slowing down course of thedisease is yet a relevant goal. Here, we demonstrate that CANO isaccurate tool to select patients whose lung function was still revers-ible when treated with CYC therapy. Although the cut-off of CANOat 5.3 ppb provided the best Youden index, a cut-off of CANO at8.5 ppb is more effective to specifically identify SSc patients with
nt deteriora�on of lung func�on d with its respec�ve value of the = 21)
Pa�ents excluded for : Pneumonia (n=1) Pulmonary hypertension (n=1)
enrolled t at inclusion to cyclophosphamide (CYC)» was al capacity or total pulmonary
nclusion and each following visit
12 Pa�ents with CANO ≤ 8.5 ppb: •3 had favourable response to CYC•4 pa�ents died •5 unmet favourable response criteria
of the study.
phosphamide response in scleroderma-related lung disease, Nitric Oxide
high risk to develop subsequent lung function deterioration. As thechanged profiles of scleroderma lung disease are heterogeneousand side effects of available therapy to slow down the course lungfibrosis are notable, it is important to target precisely the subgroupof the SSc patients with high risk to develop subsequent lung func-tion deterioration in order to treat this subgroup of patients theappropriate therapy with the best risk–benefit balance.
During the follow-up, CANO decreased significantly after 6courses of CYC in patients with active form of SSc-ILD reflectingby the high level of CANO >8.5 ppb, suggesting that CYC therapyis more likely to be when alveolar inflammatory pattern of SSc-ILD was present (CANO >8.5 ppb). CANO levels were lowered byimmunosuppressive therapy but did not return to normal ranges.It is plausible that other biological pathway in the fibrosis pro-cesses including oxidative stress, and pro-fibrogenic activity ofmyofibroblasts that may contribute in part to the NO output. Otherplausible explanation is that CYC was not enough effective to ter-minate extinguish the whole inflammatory processes in the alveoli.
In selected population of this present study, i.e. Patients musthave a deteriorated lung function during the last year. Deteriora-tion of lung function was considered relevant if there was a relativedecline of more than 10% of FVC or TLC as compared with theirrespective values from last year, the level of CANO are not relatedto lung function at inclusion or after 6 months of cyclophospha-mide therapy.
The limit of our study is its relative small sample size of studiedpopulation. However, the high performance of identifying patientswith SSc-ILD who were going to favorably response to CYC therapysuggested that CANO is a sturdy tool for monitoring SSc-ILD.
Our findings showed that high level of CANO >8.5 ppb reflectingalveolar inflammation could identify SSc patients with a greaterchance to benefit from CYC treatment with a significant improve-ment in lung function.
References
[1] A. Gabrielli, E.V. Avvedimento, T. Krieg, T, Scleroderma, N. Engl. J. Med. 360(2009) 1989–2003.
[2] V.D. Steen, C. Conte, G.R. Owens, T.A. Jr, Medsger, Severe restrictive lungdisease in systemic sclerosis, Arthritis Rheum. 37 (1994) 1283–1289.
[3] V.D. Steen, T.A. Jr, Medsger, Changes in causes of death in systemic sclerosis,1972–2002, Ann. Rheum. Dis. 66 (2007) 940–944.
[4] D.P. Tashkin, R. Elashoff, P.J. Clements, J. Goldin, M.D. Roth, D.E. Furst, E. Arriola,R. Silver, C. Strange, M. Bolster, J.R. Seibold, D.J. Riley, V.M. Hsu, J. Varga, D.E.Schraufnagel, A. Theodore, R. Simms, R. Wise, F. Wigley, B. White, V.D. Steen, C.Read, M. Mayes, E. Parsley, K. Mubarak, M.K. Connolly, J. Golden, M. Olman, B.Fessler, N. Rothfield, M. Metersky, Scleroderma Lung Study Research Group,Cyclophosphamide versus placebo in scleroderma lung disease, N. Engl. J. Med.354 (2006) 2655–2666.
[5] C. Nannini, C.P. West, P.J. Erwin, E.L. Matteson, Effects of cyclophosphamide onpulmonary function in patients with scleroderma and interstitial lung disease:a systematic review and meta-analysis of randomized controlled trials andobservational prospective cohort studies, Arthritis. Res. Ther. 10 (2008) R124.
[7] B. Thébaud, J.F. Arnal, J.C. Mercier, A.T. Dinh-Xuan, Inhaled and exhaled nitricoxide, Cell. Mol. Life Sci. 55 (1999) 1103–1112.
[8] F.L. Ricciardolo, P.J. Sterk, B. Gaston, G. Folkerts, Nitric oxide in health anddisease of the respiratory system, Physiol. Rev. 84 (2004) 731–765.
[10] K.P. Tiev, J. Cabane, F. Aubourg, A. Kettaneh, M. Ziani, L. Mouthon, S. Duong-Quy,I. Fajac, L. Guillevin, A.T. Dinh-Xuan, Severity of scleroderma lung disease isrelated to alveolar concentration of nitric oxide, Eur. Respir. J. 30 (2007) 26–30.
[11] R.E. Girgis, M.K. Gugnani, J. Abrams, M.D. Mayes, Partitioning of alveolar andconducting airway nitric oxide in scleroderma lung disease, Am. J. Respir. Crit.Care Med. 165 (2002) 1587–1591.
[12] T. Hua-Huy, K.P. Tiev, C. Chereau, S. Duong-Quy, J. Cabane, A.T. Dinh-Xuan,Increased alveolar concentration of nitric oxide is related to serum-induced
462
Please cite this article in press as: K.P. Tiev et al., Exhaled NO predicts cyclo(2014), http://dx.doi.org/10.1016/j.niox.2014.04.011
lung fibroblast proliferation in patients with systemic sclerosis, J. Rheumatol.37 (2010) 1680–1687.
[13] K.P. Tiev, T. Hua-Huy, A. Kettaneh, Y. Allanore, N.N. Le-Dong, S. Duong-Quy, J.Cabane, A.T. Dinh-Xuan, Alveolar concentration of nitric oxide predictspulmonary function deterioration in scleroderma, Thorax 67 (2012) 157–163.
[14] Preliminary criteria for the classification of systemic sclerosis (scleroderma).Subcommittee for scleroderma criteria of the American RheumatismAssociation Diagnostic and Therapeutic Criteria Committee, Arthritis.Rheum. 23 (1980) 581–590.
[15] E.C. LeRoy, C. Black, R. Fleischmajer, S. Jablonska, T. Krieg, T.A. Jr, Medsger, N.Rowell, F. Wollheim, Scleroderma (systemic sclerosis): classification, subsetsand pathogenesis, J. Rheumatol. 15 (1988) 202–205.
[16] M.R. Miller, J. Hankinson, V. Brusasco, F. Burgos, R. Casaburi, A. Coates, R.Crapo, P. Enright, C.P. van der Grinten, P. Gustafsson, R. Jensen, D.C. Johnson, N.MacIntyre, R. McKay, D. Navajas, O.F. Pedersen, R. Pellegrino, G. Viegi, J.Wanger, ATS/ERS Task Force Standardisation of spirometry, Eur. Respir. J. 26(2005) 319–338.
[17] American Thoracic Society/European Respiratory Society InternationalMultidisciplinary Consensus Classification of the Idiopathic InterstitialPneumonias. This joint statement of the American Thoracic Society (ATS),and the European Respiratory Society (ERS) was adopted by the ATS board ofdirectors and by the ERS Executive Committee, Am. J. Respir. Crit. Care Med.165 (2002) 277–304.
[18] E.A. Kazerooni, F.J. Martinez, A. Flint, D.A. Jamadar, B.H. Gross, D.L. Spizarny,P.N. Cascade, R.I. Whyte, J.P. Lynch 3rd, G. Toews, Thin-section CT obtained at10-mm increments versus limited three-level thin-section CT for idiopathicpulmonary fibrosis: correlation with pathologic scoring, A.J.R. Am. J.Roentgenol. 169 (1997) 977–983.
[19] P.G. Yock, R.L. Popp, Noninvasive estimation of right ventricular systolicpressure by Doppler ultrasound in patients with tricuspid regurgitation,Circulation 70 (1984) 657–662.
[20] V.V. McLaughlin, S.L. Archer, D.B. Badesch, R.J. Barst, H.W. Farber, J.R. Lindner,M.A. Mathier, M.D. McGoon, M.H. Park, R.S. Rosenson, L.J. Rubin, V.F. Tapson, J.Varga, R.A. Harrington, J.L. Anderson, E.R. Bates, C.R. Bridges, M.J. Eisenberg,V.A. Ferrari, C.L. Grines, M.A. Hlatky, A.K. Jacobs, S. Kaul, R.C. Lichtenberg, J.R.Lindner, D.J. Moliterno, D. Mukherjee, G.M. Pohost, R.S. Rosenson, R.S.Schofield, S.J. Shubrooks, J.H. Stein, C.M. Tracy, H.H. Weitz, D.J. Wesley, ACCF,AHA. ACCF, AHA expert consensus document on pulmonary hypertension: areport of the American College of Cardiology Foundation Task Force on ExpertConsensus Documents and the American Heart Association: developed incollaboration with the American College of Chest Physicians, AmericanThoracic Society Inc, and the Pulmonary Hypertension Association,Circulation 119 (2009) (2009) 2250–2294.
[21] ATS/ERS recommendations for standardized procedures for the online andoffline measurement of exhaled lower respiratory nitric oxide and nasal nitricoxide, Am. J. Respir. Crit. Care. Med. 171 (2005) 912–930.
[22] N.M. Tsoukias, S.C. George, A two-compartment model of pulmonary nitricoxide exchange dynamics, J. Appl. Physiol. 85 (1998) 653–666.
[23] S.C. George, M. Hogman, S. Permutt, P.E. Silkoff, Modeling pulmonary nitricoxide exchange, J. Appl. Physiol. 96 (2004) 831–839.
[24] B. White, W.C. Moore, F.M. Wigley, H.Q. Xiao, R.A. Wise, Cyclophosphamide isassociated with pulmonary function and survival benefit in patients withscleroderma and alveolitis, Ann. Intern. Med. 132 (2000) 947–954.
[25] A. Bérezné, B. Ranque, D. Valeyre, M. Brauner, Y. Allanore, D. Launay, V. LeGuern, J.E. Kahn, L.J. Couderc, J. Constans, P. Cohen, A. Mahr, C. Pagnoux, E.Hachulla, A. Kahan, J. Cabane, L. Guillevin, L. Mouthon, Therapeutic strategycombining intravenous cyclophosphamide followed by oral azathioprine totreat worsening interstitial lung disease associated with systemic sclerosis: aretrospective multicenter open-label study, J. Rheumatol. 35 (2008) 1064–1072.
[26] D.P. Tashkin, R. Elashoff, P.J. Clements, M.D. Roth, D.E. Furst, R.M. Silver, J.Goldin, E. Arriola, C. Strange, M.B. Bolster, J.R. Seibold, D.J. Riley, V.M. Hsu, J.Varga, D. Schraufnagel, A. Theodore, R. Simms, R. Wise, F. Wigley, B. White,V.D. Steen, C. Read, M. Mayes, E. Parsley, K. Mubarak, M.K. Connolly, J. Golden,M. Olman, B. Fessler, N. Rothfield, M. Metersky, D. Khanna, N. Li, G. Li,Scleroderma Lung Study Research Group, Effects of 1-year treatment withcyclophosphamide on outcomes at 2 years in scleroderma lung disease, Am. J.Respir. Crit. Care Med. 176 (2007) 1026–1034.
[27] R.K. Hoyles, R.W. Ellis, J. Wellsbury, B. Lees, P. Newlands, N.S. Goh, C. Roberts, S.Desai, A.L. Herrick, N.J. McHugh, N.M. Foley, S.B. Pearson, P. Emery, D.J. Veale,C.P. Denton, A.U. Wells, C.M. Black, R.M. du Bois, A multicenter, prospective,randomized, double-blind, placebo-controlled trial of corticosteroids andintravenous cyclophosphamide followed by oral azathioprine for thetreatment of pulmonary fibrosis in scleroderma, Arthritis Rheum. 54 (2006)3962–3970.
[28] C. Strange, M.B. Bolster, M.D. Roth, et al., Broncho-alveolar lavage and responseto cyclophosphamide in scleroderma interstitial lung disease, Am. J. Respir.Crit. Care Med. 177 (2008) 91–98.
