Suzana Pinheiro Pimenta

Doxiciclina em pacientes com linfangioleiomiomatose: segurança e eficácia no bloqueio de metaloproteinases

OBJECTIVE: Lymphangioleiomyomatosis (LAM) is characterized by lung cysts, whose development is associated with matrix metalloproteinase (MMP) hyperactivity, principally that of MMP-2 and MMP-9. Our objective was to compare LAM patients and controls in terms of the levels of these MMPs, as well as to determine the safety and efficacy of treatment with doxycycline, a potent MMP inhibitor. METHODS: Prospective clinical study involving female LAM patients who received doxycycline (100 mg/day) for six months. Urine and blood samples were collected for the quantification of MMP-2 and MMP-9 before and after the treatment period. Samples from 10 healthy women were also collected. RESULTS:Of the 41 LAM patients who started the treatment, 34 completed the protocol. Serum and urinary MMP-9 levels were significantly lower in the controls than in the LAM patients (p < 0.0001). Comparing pre- and post-treatment values, we found that the median level of MMP-9 in serum decreased from 919 ng/mL to 871 ng/mL (p = 0.05), whereas that of MMP-9 in urine decreased from 11,558 pg/mL to 7,315 pg/mL (p = 0.10). After treatment, the median level of MMP-2 in serum was significantly lower (p = 0.04) and urinary MMP-2 levels were undetectable. Nausea, diarrhea, and epigastric pain were the most prevalent adverse affects and were often self-limiting. There was only one case in which the patient discontinued the treatment because of side effects. CONCLUSIONS: We have demonstrated, for the first time, a decrease in serum and urine levels of MMPs in LAM patients treated with doxycycline, which proved to be a safe medication, with mild and well-tolerated side effects.OBJECTIVE Lymphangioleiomyomatosis (LAM) is characterized by lung cysts, whose development is associated with matrix metalloproteinase (MMP) hyperactivity, principally that of MMP-2 and MMP-9. Our objective was to compare LAM patients and controls in terms of the levels of these MMPs, as well as to determine the safety and efficacy of treatment with doxycycline, a potent MMP inhibitor. METHODS Prospective clinical study involving female LAM patients who received doxycycline (100 mg/day) for six months. Urine and blood samples were collected for the quantification of MMP-2 and MMP-9 before and after the treatment period. Samples from 10 healthy women were also collected. RESULTS Of the 41 LAM patients who started the treatment, 34 completed the protocol. Serum and urinary MMP-9 levels were significantly lower in the controls than in the LAM patients (p < 0.0001). Comparing pre- and post-treatment values, we found that the median level of MMP-9 in serum decreased from 919 ng/mL to 871 ng/mL (p = 0.05), whereas that of MMP-9 in urine decreased from 11,558 pg/mL to 7,315 pg/mL (p = 0.10). After treatment, the median level of MMP-2 in serum was significantly lower (p = 0.04) and urinary MMP-2 levels were undetectable. Nausea, diarrhea, and epigastric pain were the most prevalent adverse affects and were often self-limiting. There was only one case in which the patient discontinued the treatment because of side effects. CONCLUSIONS We have demonstrated, for the first time, a decrease in serum and urine levels of MMPs in LAM patients treated with doxycycline, which proved to be a safe medication, with mild and well-tolerated side effects.

Doxiciclina em pacientes com linfangioleiomiomatose:biomarcadores e resposta funcional pulmonar

OBJECTIVE: To assess blockade of matrix metalloproteinase (MMP)-2 and MMP-9, as well as the variation in FEV1, in patients with lymphangioleiomyomatosis (LAM) treated with doxycycline (a known MMP inhibitor) for 12 months. METHODS: An open-label, single-arm, interventional clinical trial in which LAM patients received doxycycline (100 mg/day) for 12 months. Patients underwent full pulmonary function testing, a six-minute walk test, and quality of life assessment, as well as blood and urine sampling for quantification of MMP-2, MMP-9, and VEGF-D levels-at baseline, as well as at 6 and 12 months after the initiation of doxycycline. RESULTS: Thirty-one LAM patients received doxycycline for 12 months. Although there was effective blockade of urinary MMP-9 and serum MMP-2 after treatment, there were no significant differences between pre and post-doxycycline serum levels of MMP-9 and VEGF-D. On the basis of their response to doxycycline (as determined by the variation in FEV1), the patients were divided into two groups: the doxycycline-responder (doxy-R) group (n = 13); and the doxycycline-nonresponder (doxy-NR) group (n = 18). The patients with mild spirometric abnormalities responded better to doxycycline. The most common side effects were mild epigastric pain, nausea, and diarrhea. CONCLUSIONS: In patients with LAM, doxycycline treatment results in effective MMP blockade, as well as in improved lung function and quality of life in those with less severe disease. However, these benefits do not seem to be related to the MMP blockade, raising the hypothesis that there is a different mechanism of action.OBJECTIVE: To assess blockade of matrix metalloproteinase (MMP)-2 and MMP-9, as well as the variation in FEV1, in patients with lymphangioleiomyomatosis (LAM) treated with doxycycline (a known MMP inhibitor) for 12 months. METHODS: An open-label, single-arm, interventional clinical trial in which LAM patients received doxycycline (100 mg/day) for 12 months. Patients underwent full pulmonary function testing, a six-minute walk test, and quality of life assessment, as well as blood and urine sampling for quantification of MMP-2, MMP-9, and VEGF-D levels-at baseline, as well as at 6 and 12 months after the initiation of doxycycline. RESULTS: Thirty-one LAM patients received doxycycline for 12 months. Although there was effective blockade of urinary MMP-9 and serum MMP-2 after treatment, there were no significant differences between pre- and post-doxycycline serum levels of MMP-9 and VEGF-D. On the basis of their response to doxycycline (as determined by the variation in FEV1), the patients were divided into two groups: the doxycycline-responder (doxy-R) group (n = 13); and the doxycycline-nonresponder (doxy-NR) group (n = 18). The patients with mild spirometric abnormalities responded better to doxycycline. The most common side effects were mild epigastric pain, nausea, and diarrhea. CONCLUSIONS: In patients with LAM, doxycycline treatment results in effective MMP blockade, as well as in improved lung function and quality of life in those with less severe disease. However, these benefits do not seem to be related to the MMP blockade, raising the hypothesis that there is a different mechanism of action. (Brazilian Registry of Clinical Trials - ReBEC; identification number RBR-6g8yz9 [http://www.ensaiosclinicos.gov.br])

Destaques das diretrizes de doenças pulmonares intersticiais da Sociedade Brasileira de Pneumologia e Tisiologia

Interstitial lung diseases (ILDs) are heterogeneous disorders, involving a large number of conditions, the approach to which continues to pose an enormous challenge for pulmonologists. The 2012 Brazilian Thoracic Association ILD Guidelines were established in order to provide Brazilian pulmonologists with an instrument that can facilitate the management of patients with ILDs, standardizing the criteria used for the diagnosis of different conditions and offering guidance on the best treatment in various situations. The objective of this article was to briefly describe the highlights of those guidelines.

Desaturation – distance ratio: a new concept for a functional assessment of interstitial lung diseases

INTRODUCTION: The functional evaluation has become increasingly important in the understanding and management of patients with interstitial lung diseases. The cardiopulmonary exercise test and the six‐minute walk test (6MWT), through their isolated variables, have been used to do this evaluation, with some limitations. OBJECTIVES: We proposed a new composite index (desaturation distance ratio using continuous peripheral oxygen saturation (SpO2) and the distance walked as a more reliable tool for doing a functional evaluation of these patients. METHODS: 6MWT was performed by interstitial lung diseases patients and controls. Analyzed parameters were walked distance and desaturation area (DAO2), obtained by taking the difference between maximal SpO2 possible (100%) and patients SpO2 every 2 seconds. desaturation distance ratio was calculated using the ratio between DAO2 and distance walked. RESULTS: Forty‐nine interstitial lung diseases patients and 11 control subjects completed the protocol. The mean (SD) age was 60 (12) years and 65 (9) years, respectively (p:NS). Data obtained from 6MWT showed a significant statistical difference between interstitial lung diseases patients and controls: mean walked distance (430 and 602 meters, respectively); SpO2 minimal maintained at least 10 seconds ‐ SpO2 min (85% and 94%, respectively), and median desaturation distance ratio (10 and 2.5, respectively). A correlation analysis, considering interstitial lung diseases patients, revealed the best correlation between desaturation distance ratio and DLco (r =  ‐ 0.72; p<0.001), being the correlation between SpO2 min and DLco of 0.61 (p<0.001) and among walked distance and DLco of 0.58 (p<0.05). CONCLUSION: Desaturation distance ratio is a promising concept and a more reliable physiologic tool to assess pulmonary diseases characterized by involvement of the alveolar‐capillary membrane, such as interstitial lung diseases.

Evolução da função pulmonar após tratamento com goserelina em pacientes com linfangioleiomiomatose

In the atypical smooth muscle cells that are characteristic of lymphangioleiomyomatosis (LAM), there are estrogen and progesterone receptors. Therefore, anti-hormonal therapy, despite having produced controversial results, can be considered a treatment option. The objective of this retrospective study was to evaluate hormonal and spirometric data for nine women with LAM after one year of treatment with goserelin. The mean increase in FEV1 and FVC was 80 mL and 130 mL, respectively. There was effective blockage of the hormonal axis. It is still not possible to exclude a potential beneficial effect of the use of gonadotropin-releasing hormone analogues in LAM patients, which underscores the need for randomized trials.

Exercise Performance and Dynamic Hyperinflation in Lymphangioleiomyomatosis

RATIONALE Lymphangioleiomyomatosis (LAM) is characterized by exercise performance impairment. Although airflow limitation is common, no previous studies have evaluated the prevalence and impact of dynamic hyperinflation (DH) in LAM. OBJECTIVES To investigate the dynamic responses during maximal exercise and the prevalence, predictors, and repercussions of DH in LAM. METHODS Forty-two patients with LAM performed symptom-limited incremental cycle exercise and pulmonary functions tests (PFTs) and were compared with 10 age-matched healthy women. Dyspnea intensity, inspiratory capacity, oxygen saturation, and cardiac, metabolic, and respiratory variables were assessed during exercise. Patients with LAM also performed a 6-minute walk test (6MWT). MEASUREMENTS AND MAIN RESULTS Patients with LAM had higher baseline dyspnea, poorer quality of life, obstructive pattern, air trapping, and reduced diffusing capacity of carbon monoxide in PFTs. Although they had the same level of regular physical activity, their maximal exercise performance was reduced and was associated with ventilatory limitation, greater desaturation, and dyspnea. The prevalence of DH was high in LAM (55%), even in patients with mild spirometric abnormalities, and was correlated with airflow obstruction, air trapping, and diffusing capacity of carbon monoxide. Compared with the non-DH subgroup, the patients who developed DH had a ventilatory limitation contributing to exercise cessation on cycling and higher desaturation and dyspnea intensity during the 6MWT. CONCLUSIONS Ventilatory limitation and gas exchange impairment are important causes of exercise limitation in LAM. DH is frequent in LAM, even in patients with mild spirometric abnormalities. DH was associated with the severity of disease, higher dyspnea, and lower oxygen saturation. In the 6MWT, desaturation and dyspnea were greater in patients with DH.

Sleep desaturation and its relationship to lung function, exercise and quality of life in LAM.

BACKGROUND Lymphangioleiomyomatosis (LAM) is characterised by progressive airway obstruction and hypoxaemia in young women. Although sleep may trigger hypoxaemia in patients with airway obstruction, it has not been previously investigated in patients with LAM. METHODS Consecutive women with lung biopsy proven LAM and absence of hypoxaemia while awake were evaluated with pulmonary function test, echocardiography, 6-min walk test, overnight full polysomnography, and Short Form 36 health-related quality-of-life questionnaire. RESULTS Twenty-five patients with (mean±SD) age 45±10 years, SpO(2) awake 95%±2, forced expiratory volume in the first second (median-interquartile) FEV(1)(% predicted) 77 (47-90) and carbonic monoxide diffusion capacity, DL(CO) (%) 55 (34-74) were evaluated. Six-minute walk test distance and minimum SpO(2) (median-interquartile) were, respectively, 447m (411-503) and 90% (82-94). Median-interquartile apnoea-hypopnoea index was in the normal range 2 (1-5). Fourteen patients (56%) had nocturnal hypoxaemia (10% total sleep time with SpO(2) <90%), and the median sleep time spent with SpO(2) <90% was 136 (13-201)min. Sleep time spent with SpO(2) <90% correlated with the residual volume/total lung capacity ratio (r(s)=0.5, p: 0.02), DL(CO) (r(s)=-0.7, p: 0.001), FEV(1) (r(s)=-0.6, p: 0.002). Multivariate linear regression model showed that RV/TLC ratio was the most important functional variable related to sleep hypoxaemia. CONCLUSION Significant hypoxaemia during sleep is common in LAM patients with normal SpO(2) while awake, especially among those with some degree of hyperinflation in lung function tests.

Pulmonary arterial involvement leading to alveolar hemorrhage in lymphangioleiomyomatosis

Lymphangioleiomyomatosis (LAM) is a rare disorder of unknown cause that affects women of reproductive age. The disorder is characterized by the proliferation of atypical smooth muscle cells (LAM cells) around airways, blood vessels, and lymphatics with cystic destruction of the lung.1-3 LAM may occur sporadically or may be associated with tuberous sclerosis complex (TSC).1 Clinically, patients may develop progressive dyspnea, cough, wheezing, spontaneous pneumothorax, chylothorax, and hemoptysis.3 The diagnosis is confirmed by the identification of diffuse thin-walled lung cysts via thoracic high resolution computed tomography (HRCT) that are associated with a positive tissue biopsy or by the presence of chylothorax, angiomyolipoma, or TSC.1,2 Acute respiratory failure that is secondary to diffuse alveolar hemorrhage is an extremely rare manifestation in LAM patients, with only two previous cases described. The mechanism responsible for the comorbid presentation of acute respiratory failure and diffuse alveolar hemorrhage, however, is unknown. Nonetheless, it is speculated to be secondary to the obstruction of pulmonary venules by LAM cell proliferation, thereby promoting pulmonary venous hypertension.4,5 In the present work, we describe a patient with a diffuse alveolar hemorrhage that led to acute respiratory failure and death. A diagnosis of LAM and pulmonary arterial disruption caused by LAM cells was confirmed during the autopsy.

A pilot study assessing the effect of bronchodilator on dynamic hyperinflation in LAM

INTRODUCTION Positive responses to bronchodilators (BDs) on spirometry can be found in up to 30% of patients with lymphangioleiomyomatosis (LAM). However, no previous studies have investigated the impact of BDs on exercise outcomes, including dynamic hyperinflation (DH). METHODS A randomised, double-blind, placebo-controlled, crossover trial was conducted on 38 patients with LAM, comparing inhaled placebo versus salbutamol. Pulmonary function tests and a cycle endurance test at 75% of the maximal work capacity, with evaluation of DH by serial measurement of inspiratory capacity (IC), which was the primary endpoint, were performed after each intervention. RESULTS Although salbutamol produced a slight improvement in airway obstruction, compared with placebo, there was no significant variation in resting IC or air trapping. A total of 18% of the patients met the criteria for a positive response to BD. During submaximal exercise, BD did not reduce DH or dyspnoea nor did it improve exercise tolerance in the entire population. In addition, BD produced only slight improvement in FEV1 and air trapping in patients who had DH during incremental cardiopulmonary exercise testing, without the beneficial effects on exercise outcomes. CONCLUSIONS Although salbutamol produced a slight improvement in airway obstruction, it did not lead to a reduction in DH or increase in exercise tolerance in patients with LAM. CLINICAL TRIAL REGISTRATION Brazilian Registry of Clinical Trials (ReBEC); www.ensaiosclinicos.gov.br; registration number: RBR-49sk2j.

Birt-Hogg-Dubé syndrome: metalloproteinase activity and response to doxycycline

Birt-Hogg-Dube syndrome (BHDS) is a rare, inherited autosomal-dominant genodermatosis caused by mutations in the folliculin gene (FLCN), which is located within the chromosomal band 17p11.2 (1). Patients with BHDS are prone to fibrofolliculomas, trichodiscomas, and acrochordons on the face, neck, and upper trunk; renal tumors; pulmonary cysts; and spontaneous pneumothorax (2-4). The pathogenesis of lung cyst formation and pneumothorax remains unclear, but studies have shown that folliculin is strongly expressed in lung fibroblasts and macrophages. Folliculin mutations may alter cytokines and proteases, which are important in maintaining extracellular matrix (ECM) integrity, leading to an inflammatory response and matrix degradation with subsequent remodeling (5,6). The pulmonary architecture depends on interactions between collagen and elastin fibers in the ECM, which maintain alveoli wall integrity (7). The overexpression of metalloproteinases (MMPs), regardless of whether they are associated with the suppression of tissue inhibitors of metalloproteinases (TIMPs), leads to matrix breakdown, tissue destruction and cystic lesions (7,8). Because there is currently no treatment for BHDS, we decided to describe our experience treating one BHDS patient with doxycycline, which is an MMP inhibitor (9) that has been previously used to treat cystic lung disease (10). Case Description A 44-year-old female non-smoker complained of mild dyspnea upon exertion in 2004 and presented with a spontaneous pneumothorax in 2005. Chest computed tomography (CT) demonstrated bilateral thin-walled cystic lesions (Figure 1). Pulmonary functional tests (PFTs) showed normal carbon monoxide diffusion capacity (DLCO = 81% of the predicted value), lung volume, and expiratory flow rate, but an increased residual volume (RV) and total lung capacity (TLC) ratio (RV/TLC = 0.45) were found, as shown in Table 1. An abdominal CT was also normal. A lung biopsy and pleurodesis by videothoracoscopy were performed, and the patient was diagnosed with lymphangioleiomyomatosis (LAM). She was referred to our institution in 2006 to participate in a doxycycline treatment protocol. Figure 1 High-resolution chest CT. A) A CT scan showing thin-walled, air-filled cystic lesions, including one dominant cyst (6×5 cm). B) In addition to the cystic lesions, posterior pleural thickening due to previous pleurodesis is observed on the right ... Table 1 Pulmonary function tests performed before and during doxycycline treatment and 18 months after doxycycline interruption. All patients with a diagnosis of LAM who were enrolled in this protocol were submitted to lung function evaluation and ELISA-based quantitative serum and urinary MMP-2 and -9 analysis (RD Minneapolis, MN, USA) before and after doxycycline treatment (11). After six months of receiving doxycycline (100 mg/day), the patient noticed resolution of the exertional dyspnea and improvement in exercise tolerance. After treatment, DLCO and forced vital capacity (FVC) showed increases from 16.8 to 19.7 mL/min/mmHg and 2.87 to 3.12 L, respectively. The forced expiratory volume in the first second (FEV1), RV and RV/TLC values pre- and post-doxycycline were, respectively, 2.36 and 2.35 L, 2.23 and 1.51 L, and 0.45 and 0.32 (Table 1). The MMP blockade induced by doxycycline was effective, resulting in a reduction in serum MMP-9 levels from 143 to 36 ng/mL, and urinary levels of MMP-9 became untraceable (55 pg/mL before doxycycline). MMP-2 levels were not detectable before or after treatment. During follow-up, the patient presented with soft and pedunculated papules on her neck and upper thorax. The biopsy of these lesions was compatible with acrochordons. The patients family medical history also revealed other cases of cystic lung disease (Figure 2). Figure 2 Pedigree of the family. Square = male member, circle = female member; solid symbol = pneumothorax, open symbol = no pneumothorax; slash through symbol = cystic lesions on ... The lung biopsy specimen was reviewed in 2007. Histological analysis of the lung tissue revealed several cystic areas with an emphysematous aspect in the lung parenchyma, mostly in the subpleural region. Cyst walls were formed by collapsed alveolar parenchyma or slightly thickened pleural tissue. LAM cells were not observed in the cyst walls, and monoclonal antibody HMB-45 (human melanoma black-45), S100 protein and alpha smooth muscle actin were also not observed (Figure 3). Figure 3 Histopathological analysis of cystic lung lesions. A) A large subpleural cyst within the lung parenchyma. The cyst formed by the collapse of the alveolar walls with a connective tissue lining (HE 40x magnification). B) Details of a ... Based on the family history, the presence of cutaneous lesions (acrochordons), the CT findings and the lung histological review, the diagnosis of BHDS was established. The positive response to doxycycline treatment, which had never been demonstrated in BHDS, and the association between the loss-of-function mutation in folliculin and pulmonary extracellular matrix degradation (6), led us to evaluate MMP behavior in lung tissue. Immunohistochemical analysis in the patients lung tissue revealed a large number of MMP-9-positive cells, mostly macrophages and neutrophils, in the cyst wall, whereas the adjacent lung parenchyma presented scattered MMP-9-positive cells along the alveolar walls (figure 3). MMP-2 staining showed scattered positive inflammatory cells in the lung parenchyma with no specific cyst staining. During the subsequent months, the patient developed gastric intolerance symptoms, leading to the interruption of doxycycline therapy. Spirometry performed 18 months after doxycycline interruption revealed a decrease in lung volume and expiratory flow rates (Table 1) with worsening of the pulmonary symptoms.