BACKGROUND AND OBJECTIVE:Patients diagnosed with benign central airway stenosis who are ineligible for surgical intervention require airway stents. The high complication rates associated with conventional silicone and metallic stents have led to the development of new devices with lower complication rates and easier insertion and removal. This paper presents our results, including the indications, patient characteristics, and outcomes. METHODS:We reviewed patients who underwent bronchoscopy for airway stenosis due to a benign cause between January 2015 and February 2023 in the interventional pulmonology unit of a tertiary university hospital. The causes and locations of stenosis, outcomes, and complications were analysed in patients who received a minimum of one biodegradable (BD) stent. All procedures were performed under general anaesthesia using a rigid bronchoscope. RESULTS:A total of 136 BD stents were implanted at 22 airway sites in 18 patients, with a median age of 56. Thirteen patients, three with prior metal stents and 10 with prior silicone stents, had a history of non-BD stent usage. Twelve procedures (54.5%) used bronchial stents, whereas 10 procedures (45.4%) used tracheal stents. The median duration of BD stent use was 10.6 months (range: 0.1-72.0 months). Early complications included one moderate granulation formation and two dislocations that necessitated stent fixation: one using clips and the other sutured to an additional stent. CONCLUSION:The study indicates that BD stents are both safe and feasible for treating benign stenosis, offering a safer alternative to silicone and metallic stents while providing personalised treatment for patients.

Background: Lung fibrosis is the leading cause of death in patients with systemic sclerosis (SSc). Single nucleotide polymorphisms (SNPs) in TOLLIP-coding gene, which are associated with mRNA expression, have been linked to clinical course, prognosis and treatment response in idiopathic pulmonary fibrosis (IPF). The aim of the present study was to investigate TOLLIP levels in serum of SSc patients with and without ILD, and explore a possible correlation with demographics, clinical characteristics and other markers. Patients and methods: 106 consecutive SSc patients (77 F) with (N=53) and without (N=53) ILD were retrospectively studied. 60 healthy subjects were recruited as controls. All subjects were genotyped for two SNPs in the TOLLIP gene (rs3750920, rs5743890) using the TaqMan™ SNP Genotyping Assay (Thermo Fisher Scientific, USA). Serum TOLLIP concentration was measured by ELISA (Cloud-Clone Corp., USA). Allele, genotype, and haplotype frequencies were calculated using SNPStats. Results: SSc patients showed significantly lower TOLLIP concentrations than healthy controls (0.14 ±0.02 ng/μl vs. 0.55±0.19 ng/μl, p=0.037). Patients with SSc-associated ILD had significantly higher TOLLIP levels than those without ILD (0.17±0.03 ng/μl vs. 0.10±0.01 ng/μl, p=0.028). Carriers of the rs3750920 major allele (C) had significantly higher TOLLIP concentrations compared to the T/T genotype (0.32±0.09 ng/μl vs. 0.13±0.02 ng/μl, p=0.040). An inverse correlation between TOLLIP serum concentration and age was found (Pearson r=-0.256, p<0.001), but no association with sex, BMI, and CRP was observed. We didn´t find any association with lung function tests at time of blood sampling. Conclusion: Patients with SSc have lower TOLLIP serum concentrations compared to healthy subjects. SSc-ILD patients show higher and genotype-dependent serum levels compared to those without ILD. TOLLIP might potentially become a biomarker of ILD in patients with SSc.

Background: Interstitial lung diseases (ILDs) have a highly variable clinical course. Validated prognostic biomarkers are missing. Bronchoalveolar lavage is a noninvasive, safe tool widely used in the ILD diagnostic workup. Stains are routinely applied to broaden the diagnostic performance of BAL. Sudan III is used to detect lipid-laden alveolar macrophages (AM), which are associated with recurrent pulmonary aspirations. Aim of the present study was to investigate the prevalence and prognostic significance of lipid-laden macrophages in patients with different ILDs. Patients and Methods: We retrospectively studied 300 consecutive patients with a board-certified ILD, who underwent a diagnostic BAL between 2014 and 2020. After differential cytology evaluation, the BAL fluid (BALF) was stained with Sudan III. Disease progression was defined as a relative decline of forced vital capacity (FVC) of ≥ 10% over the observation period. Results: In 117 patients (61 M) with ILDs (37 HP, 29 IPF, 18 NSIP, 14 COP, 10 sarcoidosis, 5 uILD, 2 CTD-ILD, 2 DIP/RB-ILD) BALF was stained with Sudan III. In BALF from 76 patients (65%), most frequently with HP and IPF, ≥5% Sudan III positive AM were seen. Patients with gastroesophageal reflux disease (GERD) tended to have higher percentage of Sudan III positive AM in BALF than those without.During follow-up (13 months on average, min-max: 1-63 months), 36 patients showed disease progression and 24 died. Patients with <3% Sudan III positive AM in BALF showed a significantly higher disease progression rate compared to those with ≥ 3% Sudan III positive AM (40% vs. 29%, p<0.001). A trend towards higher mortality was observed in patients with <3% Sudan III positive AM compared to those with ≥3% (30% vs. 11%, p=0.062). Conclusion: Lipid-laden macrophages were more frequently detected in BALF of patients with HP and IPF. A lower proportion of lipid-laden macrophages seems to be associated with an increased risk of disease progression. Potentially, Sudan staining in BALF may provide prognostic information in patients with ILD.

Background:Pulmonary fibrosis is a leading cause of death in patients with Systemic sclerosis (SSc). Single nucleotide polymorphisms (SNPs) within Toll interacting protein (TOLLIP) coding gene have been associated with progression and prognosis of Idiopathic Pulmonary Fibrosis (IPF). Aim of the present study was to investigate the association of TOLLIP SNPs with the presence, severity and outcome of interstitial lung disease (ILD) in patients with SSc. Patients and methods:106 consecutive SSc patients (77 female) with (N = 53) and without ILD (N = 53) and 212 healthy controls (HC) (154 female) were genotyped for two SNPs within TOLLIP (rs3750920, rs5743890) by using TaqMan™ SNP Genotyping Assay (Thermo Fischer Scientific, USA). Disease progression was defined as ≥ 10% relative decline in FVC% pred. or ≥ 5 to < 10% decline in relative FVC% pred. and 15% relative decline in DLCO% pred. From baseline. Results:The TOLLIP rs5743890 minor Allele (C) was more frequent in HC than in SSc patients (41% vs. 16%, p = 0.021). The homozygote alleles of rs5743890 were significantly overrepresented in SSc patients compared to HC (84% vs. 71%, p = 0.008). Among SSc patients with ILD, those carrying the rs5743890 T/C genotype had a tendentially worse survival (158 vs. 213 months, p = 0.162) and a significantly higher rate of disease progression (66% vs. 22%, p = 0.003) compared to homozygotes. The rs5743890 minor allele C was an independent predictor of progression after adjustment for a number of covariates (HR 4.29, 95% CI 1.48-12.48, p = 0.008). Moreover, the TC haplotype appeared to be an even stronger predictor of progression than rs5743890 alone (HR 7.71, 95% CI 1.79-33.12, p = 0.006). Conclusion:TOLLIP SNP rs5743890 genotype distribution seems to differ in SSc patients compared to HC. The rs5743890 heterozygote genotype and the TC haplotype may be associated with an increased risk of progression in patients with SSc-ILD.

BACKGROUND:Idiopathic pulmonary fibrosis (IPF) is characterized by an increase in proteolytic enzymes, including matrix metalloproteinases that degrade the extracellular matrix and markers of localized inflammation. Protein fragments (neoepitopes) are detectable in the circulation. RESEARCH QUESTION:Can short-term trajectories of neoepitopes after initiation of antifibrotic treatment predict therapy-related outcomes, including mortality, in patients with IPF? STUDY DESIGN AND METHODS:Two hundred three treatment-naive patients with IPF from 2 German tertiary centers were prospectively recruited. At baseline and within 6 months of nintedanib or pirfenidone treatment, serum concentrations of matrix metalloproteinase-degraded C-reactive protein neoepitope (CRPM), collagen III, and collagen 6 fragments, as well as procollagen 6, were measured. Association of neoepitopes and their longitudinal kinetics (positive/increasing or negative/declining slope) with mortality and progression- and transplant-free survival (PTFS) was analyzed. Modes of action of anti-fibrotic therapy on neoepitope kinetics were further investigated by cell culture experiments. RESULTS:Patient mean age was 71 years, and 20.7% were female. After baseline measurements, 50% received nintedanib, 35% received pirfenidone, and 15% received no antifibrotic treatment. Patients with a positive CRPM slope, treated with nintedanib, showed increased 5-year mortality (adjusted hazard ratio, 2.27; P = .020). In contrast, PTFS was significantly reduced with positive slopes of all tested neoepitopes. The association between positive CRPM slopes and impaired PTFS was confirmed by means of propensity score matching. In both cohorts, effects on PTFS were driven by the nintedanib-treated subcohort. Intercohort validation of the association between CRPM slopes and PTFS was evident. In cell-culture experiments, nintedanib exclusively modulated CRPM kinetics in human umbilical vein-derived endothelial cells, but not IPF-derived fibroblasts. This suggests that the observed nintedanib/CRPM related effect is partly mediated by endothelial cells. INTERPRETATION:Our results show that positive/increasing CRPM serum levels (slopes) were associated with worse 5-year survival in patients with IPF treated with nintedanib, but not pirfenidone. Nintedanib, but not pirfenidone, reduced endothelial CRPM formation in vitro. GERMAN CLINICAL TRIALS REGISTRATION:Nos.: DRKS00000017 and DRKS00000620; URL: https://drks.de/search/en/trial/.

Introduction: PAP is due to accumulation of phospholipids and lipoproteins in the alveoli. WLL is still the treatment of choice. Light microscopy examination of WLL fluid reveals a moderate to high lymphocytosis but lymphocyte subpopulations have not been further characterized at yet. Aims: To investigate T lymphocyte subsets in WLL fluid from patients with PAP. Methods: From the first recovered fluid portion during WLL, samples of 50 mL each were collected and analyzed fresh. Pancoll density-gradient centrifugation was performed to separate mononuclear (MN) cells. MACS® enrichment was used to separate T lymphocytes from remaining MN cells and acellular particles after adding anti-CD3 microbeads to the MN cell layer. Flow cytometry for T cell immunophenotyping was performed by using a 9-color antibody panel and a FACSAria™ Fusion cytometer (Becton Dickinson, Germany). Zombie UV™ fluorescent dye was used to assess cell viability. T lymphocyte counts were expressed as proportion of CD3+ viable lymphocyte counts. Results: WLL fluid from 3 consecutive PAP patients (2 M, 1 F, age 44±12) who underwent therapeutic WLL was analyzed. The mean T lymphocyte count was 87±1%. CD4+ T cells were the dominant T cell subset across all samples (73±7%), followed by CD8+ cytotoxic T cells (19±7%). Th17.1 cells were the most frequent Th cell subset (33±14%), followed by Th1 cells (29±2%), Tregs (17±6%), Th17 cells (4±2%), and Th2 cells (0.7±0.2%). Conclusions: Our study identified different T lymphocyte subsets, mostly related to autoimmunity, in WLL fluid obtained from PAP patients. Flow cytometry may be used to unravel pathogenetic mechanisms of this rare disease.

Introduction: Hypersensitivity pneumonitis (HP) is a complex disease caused by inhalation of many different antigens. Despite exposure avoidance and immunosuppressive therapy, some patients develop a progressive phenotype (PP). Aim of this study was to investigate the prevalence of PP, describe the lung function decline and the impact on survival in patients with cHP. Methods: We retrospectively investigated consecutive patients with cHP followed at our center between 2001 and 2021. HP was diagnosed according to the most recent guidelines, and stratified into fibrotic and non-fibrotic. PP was defined as an absolute functional decline (FVC >5% or DLCO >10% from baseline)and/or an increase in fibrosis on HRCT with or without worsening of symptoms within one year. Results: 75 patients with cHP (44 women, age 64±12 years) were studied, of whom 64% had fibrotic HP. An inciting antigen was identified in 88% of patients, most frequently birds. 29 (39%) of patients had progression within 12 months and twenty patients (27%) had loss of follow-up. The median survival was 18 (IQR: 13-30) years in the overall cohort, 14 years in patients with and 19.5 years in those without PP (p=0.38). At logistic regression analysis, BALF lymphocytosis at baseline and fibrotic HP type were significant predictors of progression at one year (OR 1.064 and 19.989 respectively), whereas specific antigen positivity against more than 1 antigen tended to be protective (OR 0.020, p=0.061). Conclusions: Approximately one-third of patients with HP developed a PP within one year, most of them had fibrotic HP. The impact on survaival remains unclear.

The development of a progressive phenotype of interstitial lung disease (ILD) is still unpredictable. Whereas tools to predict mortality in ILD exist, scores to predict disease progression are missing. The aim of this study was to investigate whether baseline serum KL-6 as an established marker to assess disease activity in ILD, alone or in combination with clinical variables, could improve stratification of ILD patients according to progression risk at any time. Consecutive patients with fibrotic ILD, followed at our institution between 2008 and 2015, were investigated. Disease progression was defined as relative decline of ≥10% in forced vital capacity (FVC) or ≥15% in diffusing capacity of the lung for carbon monoxide (DLco)% from baseline at any time. Serum KL-6 was measured using an automated immunoassay (Fujirebio Europe, Gent, Belgium). A stepwise logistic regression was performed to select variables to be included in the score. A total of 205 patients (49% idiopathic pulmonary fibrosis (IPF), 51% fibrotic nonspecific interstitial pneumonia (NSIP)) were included, of them 113 (55%) developed disease progression during follow up. Male gender (G) and serum KL-6 strata (K) were significant predictors of progression at regression analysis and were included in the GK score. A threshold of 2 GK score points was best for discriminating patients at high risk versus low risk to develop disease progression at any time. Serum KL-6 concentration, alone or combined in a simple score with gender, allows an effective stratification of ILD patients for risk of disease progression at any time.

Introduction: IL-9, mainly produced by T helper 9 (Th9) cells, promotes allergic airway inflammation and remodeling through the interaction with its receptor (IL-9R). Th9 cells and IL-9 have also been implicated in tissue fibrosis and autoimmunity pathways. However, the role of IL-9/IL-9R in the pathogenesis of interstitial lung disease (ILD) is unknown. Aim: To evaluate IL-9/IL-9R expression in bronchoalveolar lavage fluid (BALF) lymphocytes of patients with various ILDs. Methods: Consecutive patients with ILD, who underwent BAL for diagnostic purposes, were studied. As control group, consecutive patients without evidence of ILD were included. Immunocytochemical staining of BALF lymphocytes for IL-9 and IL-9R was performed and evaluated by two independent readers. Results: 45 patients, of them 8 had idiopathic pulmonary fibrosis (IPF), 12 nonspecific interstitial pneumonia (NSIP), 10 sarcoidosis, 9 hypersensitivity pneumonitis (HP), 6 cryptogenic organizing pneumonia (COP), and 24 controls were studied. In the ILD group, the highest BALF lymphocyte count was seen in HP followed by NSIP, COP, sarcoidosis, and IPF (p < 0.05 for HP vs IPF). The highest percentages of IL-9 and IL-9R positive lymphocytes were seen in COP. Conversely, NSIP showed the lowest rate of IL-9, and sarcoidosis the lowest rate of IL -9R positive lymphocytes. Only in NSIP, a direct correlation between IL and 9 and IL-9R positive lymphocytes was seen (r = 0.639, p = 0.025). Conclusion: BALF lymphocytes IL-9 and IL-9R expression differs between various ILDs and could reflect different pathogenetic mechanisms.

Background: Genetic variants of TOLLIP and MUC5B, both on chromosome 11, have been reported to be associated with the development and/or prognosis of idiopathic pulmonary fibrosis (IPF). This retrospective study was conducted to investigate the association of MUC5B and TOLLIP SNPs with disease outcome in IPF. 62 IPF patients and 50 healthy controls (HC) from our Institution were genotyped for SNPs within MUC5B (rs35705950) and TOLLIP (rs3750920 and rs5743890). Correlation of SNPs genotypes with survival, acute exacerbation (AE) or disease progression (defined as a decline of ≥ 5% in FVC and or > 10% in DLco in one year) was investigated. Results: The MUC5B rs35705950 minor allele (T) was more frequent in IPF subjects than in HC (35% vs 9% p<0.001). TOLLIP SNPs alleles and genotype distribution did not differ between IPF and HC and did not vary according to gender, age, BMI and lung functional impairment at baseline. The minor allele (C) in TOLLIP rs5743890 was associated with worse survival and with disease progression in all performed analyses. The MUC5B rs35705950 or the TOLLIP rs3750920 minor allele, were not associated with disease progression or acute exacerbation. Conclusion: We confirm that the minor allele of MUC5B rs35705950 is associated with IPF. The minor allele of TOLLIP rs5743890 appears to be a predictor of worse survival and more rapid disease progression, therefore being of potential utility to stratify IPF patients at baseline.

Background: Immunosuppressive therapy still is the standard treatment for patients with connective tissue disease-associated interstitial lung disease (CTD-ILD). Objectives: This retrospective study aimed to provide data on the tolerability and efficacy of azathioprine in progressive CTD-ILDs. Methods: A total of 56 patients with CTD-ILD treated with azathioprine between 2003 and 2014 were included in the study. The patients were assessed every 3 months during follow-up. Results: The mean treatment duration was 34 months, with a range of 3–105 months. Fifteen patients (27%) discontinued treatment due to side effects, mostly due to elevated liver enzymes, within the first 3 months. Forty-one patients were treated for longer than 3 months, and 27 of those (66%) had stabilization or improvement of pulmonary function during treatment. In patients who remained stable or improved, the mean FVC was 62 ± 17% predicted (% pred) at initiation of treatment and 65 ± 17% pred at the last follow-up visit (p = 0.036), and the mean DLCO was 38 ± 16% pred at initiation of treatment and 39 ± 17% pred at the last follow-up visit (p = 0.06). Conclusions: Azathioprine can stabilize or improve CTD-ILD. While early drug intolerance is frequent, most patients who have tolerated the drug well achieve long-term stabilization or improvement of lung function.

BACKGROUND:Anti-DFS70 antibodies, corresponding to the dense fine speckled antinuclear antibody (ANA) pattern in HEp-2 substrates, have been observed in chronic inflammatory conditions, cancer and in healthy individuals but in only a small percentage of patients with connective tissue diseases (CTD).OBJECTIVES:The study was aimed to investigate the possible role of Anti-DFS70 antibodies to distinguish CTD associated interstitial lung disease (CTD-ILD) from idiopathic interstitial pneumonia (IIP) and to explore potential correlations between anti-DFS70 antibodies and clinical parameters.METHODS:Serum samples were collected from 49 healthy controls (HC), 35 scleroderma-ILD (SSc-ILD) patients as negative controls for anti-DFS70 antibody, and 260 patients with the initial diagnosis IIP including 100 nonspecific interstitial pneumonia (NSIP) and 160 idiopathic pulmonary fibrosis (IPF) patients. ANA pattern was identified by indirect immunofluorescence on HEp-2 cells and anti-DFS70 antibodies were measured in serum by ELISA.RESULTS:Serum anti-DFS70 antibodies were less frequently seen in ILD and SSc-ILD patients compared to HCs. Thirty-seven patients (34 initial idiopathic NSIP and 3 initial IPF patients) developed CTD during 24 months of follow-up, most of them combined with ANA positivity and anti-DFS70 antibody negativity. Anti-DFS70 antibody positivity was not significantly different between CTD-ILD and idiopathic ILD.CONCLUSIONS:The frequency of serum anti-DFS70 antibody is markedly decreased in patients with ILDs. Anti-DFS70 antibodies may be useful to predict CTD development in ILD patients.

The mechanisms of idiopathic pulmonary fibrosis (IPF), a rare, devastating disease with a median survival of 3-5 years, are not fully understood. Gastroesophageal reflux disease (GERD) is a frequent comorbidity encountered in IPF. Hypothetically, GERD-associated microaspiration may lead to persistent inflammation impairing lung infrastructure, thereby possibly accelerating the progression of IPF. IPF may increase intrathoracic pressure, which can aggravate GERD and vice versa. On the basis of the possible beneficial effects of antireflux or antacid therapy on lung function, acute exacerbation, and survival, the recent international IPF guideline recommends antacid therapies for patients with IPF, regardless of symptomatic GERD. However, due to newer conflicting data, several national guidelines do not support this recommendation. Elucidation of these questions by further clinical and bench-to-bedside research may provide us with rational clinical diagnostic and therapeutic approaches concerning GERD in IPF. The present review aims to discuss the latest data on the controversial association of IPF and GERD.

Introduction: IL-9, mainly produced by Th9 cells, a new Th subpopulation distinct from Th2 cells, promotes allergic airway inflammation and remodeling through the interaction with its receptor (IL-9r). Th9 cells and IL-9 have been implicated in fibrosis and remodeling, as demonstrated in skin fibrosis in systemic sclerosis. A possible role of IL-9/IL-9r in the development of ILDs is unknown. Aim: Evaluate the expression of IL-9/IL-9r in BALF lymphocytes in patients with ILD. Methods: 69 consecutive ILD Patients underwent diagnostic BAL. 35 patients (9 IPF, 9 NSIP, 9 sarcoidosis, 4 EAA, 4 COP) had BALF lymphocytosis (>13%). Immunocytochemistry staining of lymphocytes for CD3, CD4, CD8 (Orthon, NJ, USA), IL-9 and IL-9r (Novus Biologicals LCC, CO, USA) was performed. To evaluate the percentage of positive cells, lymphocytes were counted by two independent readers. Results: The highest BALF lymphocyte count (mean 59%) was seen in EAA followed by sarcoidosis (41%), COP (41%), NSIP (39%), and IPF (23%) (p<0.05 for EAA and COP vs IPF). Sarcoidosis BALF had the highest CD4/CD8 ratio (4±2) and EAA the lowest (1.4±1.1). In COP the highest percentage of IL-9 and IL-9r positive lymphocytes (50±20% and 46±25%, respectively, p<0.05 vs IPF and NSIP) was seen, while sarcoidosis showed the lowest IL-9r positivity (14±12%, p<0.05 vs all). Only in NSIP a direct correlation between IL-9 and IL-9r expression was seen (r=0.714, p=0.04). There was a positive correlation between the CD4/CD8 ratio and IL-9r expression across ILD groups (r=0.51, p=0.04). Conclusion: IL-9 and IL9r expression in BALF lymphocytes differs between various ILDs.

Background: Anti-DFS70 antibody, corresponding to the dense fine ANA speckled pattern at indirect immunofluorescence (IIF) in HEp-2 substrates, have been detected in a variety of chronic inflammatory conditions, cancer and in healthy individuals, but only in a small percentage of systemic ANA- associated rheumatic disease (SARD). In a previous study we found that anti-DFS70 positivity can be used to largely exclude SARD in patients with ILD and ANA positivity (IPAF). Aim of this study: To investigate whether serum anti-DFS70 levels correlate with clinical parameters in ILD. Patients and Methods: 260 patients with ILD (100 NSIP and 160 IPF), 49 healthy controls (HC) and 35 scleroderma-ILD (SSc-ILD) patients as negative control were studied. Serum anti-DFS70 at baseline was measured by ELISA (MBL Co., Ltd., Japan). Results: During 24 months of follow-up, 37 ILD patients (34 NSIP and 3 IPF) developed connective tissue disease (CTD). Anti-DFS70 levels in the ILD group were significantly lower than in HC (119 vs 320 U/ml, p<0.05), but not significantly different from CTD-ILD (104 U/ml) and SSc-ILD (97 U/ml). In patients with idiopathic NSIP (iNSIP) anti-DFS70 titers did not differ from those of IPF patients or CTD-NSIP (119 vs 123 vs 101 U/ml, respectively). In iNSIP patients, anti-DFS70 titers inversely correlated with FVC (%pred.) (r=-0.320, p<0.05), FEV1 (%pred.) (r=-0.393, p<0.01), TLC (%pred.) (r=-0.360, p<0.01), and positively with AaDO2 (mmHg) (r=0.263, p<0.05). Conclusions: iNSIP patients with higher anti-DFS70 levels showed more impairment of lung function and gas exchange than CTD-NSIP.