Presented by Laura Hummers, MD of John Hopkins University.

1. October 20, 2018 1
Biomarkers
What they are and how could we use them in
scleroderma?
Presented by: Laura K. Hummers, MD, ScM

2. Goals for today
• Introduce biomarker concept
– Definition
– Possible uses
• Common patient scenarios
– Highlight existing biomarker data
– Explore areas where biomarkers may be
useful
November 13, 2018 2

3. Definition of a Biomarker
• Biological marker
• A measurable characteristic of a biological
process, either normal or in a disease state
• A clinical endpoint is a measure that reflects
how a patient “feels, functions or survives”
• A biomarker may be a “surrogate endpoint”
when it reliably predicts a clinical endpoint
November 13, 2018 3

4. Biomarkers
• Ideally would have a simple test to tell if there
was ongoing activity or progression in
scleroderma
• The perfect biomarker is predictive of
outcome, in the causal pathway and
modifiable by treatment
• No true biomarkers are available for
scleroderma….YET

5. Value of Biomarkers
Predisposition
Disease
Biologic Process
Biomarkers
Treatment

6. Progression
Muangchan C. J Rheumatol. 2013 Sep;40(9):1545-56.
• There is no uniform progression
• Subsets of patients develop scleroderma
complications
• Understanding one patients individual
trajectory is the goal in caring for patients
• Understanding trajectories as a group is
crucial for design of clinical trials
investigating new therapies

7. The importance of
phenotype
• Phenotype = an observable characteristic
– Based on skin subtype: limited or diffuse
– Based on organ dysfunction: how much lung fibrosis
– Based on autoantibody type
• If you can sufficiently phenotype you can correlate
this with:
– Specific outcomes
– Treatment response
– Complication risk
• If you combine phenotype with other measures
(genotype, molecular markers, biomarkers) you will
get meaningful answers

8. Skin Subsets

9. Centromere
Fibrillarin
B23
Th/To
Topoisomerase-1
(Scl-70)
RNA
Polymerase I/III
UI RNP
Scleroderma Antibodies
C.R.E.S.T.
MCTD
Lung Fibrosis
Diffuse Skin
Kidney
Diffuse skin
PAH
PM-Scl
Muscle
Steen, V.D. The many faces of scleroderma. Rheum Dis Clin North Am, 2008. 34(1): p. 1-15
U3 RNP
Diffuse Skin
Lung Fibrosis
PH

10. Phenotypes
Duration Skin
Subtype
Antibody Lung
Severity
Raynaud
Severity
Biomarker
Short Limited Centromere Mild Severe High
Long Diffuse Topo Moderate Mild Low
Short Limited None Severe Mild High
Long Diffuse RNAPol Mild Mild High
Short Diffuse Topo Severe Moderate Low
Long Limited Centromere Moderate Moderate Low
Muscle inflammation
Calcinosis
Pulmonary Hypertension
Kidney disease
Joint inflammation
Heart involvement
Cancer-associated

11. Case Presentation
Ms. H is a 45 yo woman who was well until fall of 2016.
• October: New cold sensitivity and Raynaud phenomenon
• November: New swelling in hands and feet
• December: progressive tightness in the skin
• January 2017
– Skin tightness in fingers, hands, forearms, feet (mRSS 14)
– Labs notable for positive RNA polymerase 3 antibodies
– PFT with FVC of 84% predicted; DLCO 79% predicted
– CT scan with mild bibasilar fibrosis (scar)
• What is the risk for this patient to develop progressive lung
disease?
• What will happen to the skin, should we treat?
• What else should be worried about? What may happen next?

12. Progression of Skin
November 13, 2018 12

13. Skin Subsets

14. Modified Rodnan Skin Score

15. Limitations of the mRSS
• Subjective
• Not reliable between assessors
• Not specific
– Swelling vs. tethering vs. dermal thickening
• Not sensitive to change in short intervals
– Patients note improvement before skin changes
• Reflection of severity but not necessarily
activity

16. What is the natural history of
diffuse skin disease?
Shand L et al. Arthritis Rheum. 2007 Jul;56(7):2422-31.

17. Impact of skin score trajectory
Shand L et al. Arthritis Rheum. 2007 Jul;56(7):2422-31.

18. Skin Score in Clinical Trials
Le EN, et al. Ann Rheum Dis. 2011 Jun;70(6):1104-7.

19. Antibody and Skin Score
0
5
10
15
20
25
30
Yr 1 Yr 2 Yr 3 Yr 4
MRSS
Skin Score Over Time
RNA Pol
CENP
TOPO
U3

20. Skin Score-RNA Pol III

21. Skin Score-Scl70

22. Biomarkers-Skin
• CXCL4
– Chemokine
– Inhibits blood vessel growth and stimulates
fibrosis (collagen/scar)
– Correlates well with skin score
– Elevated levels predict development of lung
scarring, worsening skin disease
– May help identify patients more likely to respond
to treatment
November 13, 2018 22
Van Bon L et al. NEJM. 2014; 370 (5):433-43
Haddon DJ et al. J Rheumatol. 2017 May; 44(5): 631–638

23. Biomarkers-Skin
• Gene score/signature
– Gene expression (measure thousands of genes;
turned on/off; high/low)
– Skin biopsies
– Combination of genes score
– Involved in inflammation fibrosis
• Correlates with skin score and changes in
gene “score” correlate with changes in skin
score with or without treatment
November 13, 2018 23
Rice LM et al. Arthritis Rheumatol. 2015 Nov;67(11):3004-15
Stifano G et al. Arthritis Rheumatol. 2018 Jun;70(6):912-919
Hinchcliff M et al. J Invest Dermatol. 2013 Aug;133(8):1979-89

24. Biomarkers: Possible uses-skin
• Skin activity
• Prediction of worsening skin disease
• Predict earlier who is responding/not
responding to treatment
November 13, 2018 24

25. Our patient-Skin
Phenotype:
• Early disease
• RNA polymerase III antibody
Therefore:
• High risk for progression of skin disease
• Should receive treatment directed at improving skin
progression
• Should be a candidate for trials of new therapy

26. Scleroderma Renal Disease

27. Scleroderma Renal Disease
• Initial case series
1971 (data from 1950-
1970)
• 16/309 cases with
renal crisis, all died
within several months
of the diagnosis and
noted to be the worst
prognostic feature in
scleroderma
Medsger et al. Ann Int Med, 1971

28. Renal Crisis - outcome
Poor outcome
• Creat >3 at presentation
• Incomplete BP control
within 3 days
• Male
• Older
• CHF
Steen, Ann Int Med, 2000

29. Risk Factors for Development
• Diffuse skin disease, with rapid progression
• <4 years from onset of disease (75%)
• African Americans
• Anti-RNA polymerase III (25-30%)
• Corticosteroids (>15 mg/day) (3 fold risk)
• NOT
– Pre-existing hypertension
– Other antibodies
– Plasma renin levels
– Abnormal UA or creatinine at baseline

30. RNA Polymerase III Antibodies
• Comprises 5-18% of scleroderma
patients
• Most with aggressive skin diffuse skin
• 15% have skin precede Raynaud
• Highest risk for renal crisis (25-30%)
• Low risk for significant ILD (7%)
Emilie S et al. Scand J Rheumatol. 2011;40(5):404-6.
Steen VD. Rheum Dis Clin North Am. 2008 Feb;34(1):1-15

31. Our Patient-Kidney
Phenotype:
• Rapid skin progression
• Early disease
• RNA polymerase III antibody
Treatment:
• Education of the patient
• Frequent blood pressure monitoring
• Develop a plan for abnormal BP reading

32. Scleroderma Lung Disease

33. Epidemiology of lung
fibrosis in Scleroderma
• Depends on the definition
– PFT
– XRAY, CT scan
– Pathology
• 25-90% of scleroderma patients have lung
involvement
• Only ~15% will progress
• In the subset that have progression, lung fibrosis may
lead to
– Limitations in activity
– Shortness of breath
– Need of oxygen use
– Need for lung transplantation

34. Who is at risk?
Progression of ILD
• (+) Early (<5 years)
• (+) Low FVC
• (+) Extensive CT
fibrosis
• (-) Normal baseline
CT
Presence of ILD
• (+) African American
• (+) Topoisomerase
antibody
• (+) U1, U3, Th/To
• (+) Diffuse skin subtype
• (-) Centromere
• (-) RNA polymerase
Steen V et al. Arthritis Rheum, 2012
Walker UA et al. Ann Rheum Disease, 2007
Nihtyanova SL, et al. Arthritis Rheum, 2014
Goh, NS et al. Am J Respir Crit Care Med, 2008.

35. Skin Subsets

36. Disease Subset:
Limited vs. Diffuse
Clements PJ et al. Ann Rheum Dis. 2007 Dec;66(12):1641-7
Cytoxan
Placebo

37. Scl-70 Positive Patients

38. Responder Analysis
Roth et al. Arthritis Rheum. 2011 Sep;63(9):2797-808.

39. Possible Biomarkers of Progression:
SPD/KL-6
• Glycoproteins secreted by type 2
pneumocytes (lung cells)
• Correlation with some markers of lung
disease severity
• Predictive of lung function decline?
De Lauretis et al. J Rheumatol. 2013 Apr;40(4):435-46
Elhaj M et al. J Rheumatol. 2013 Jul;40(7):1114-20

40. Possible Biomarkers of Progression:
Chemokines
• CXCL4
– In SLS 2 (Cytoxan compared with Cellcept)
– Levels went down with treatment
– Changes at 12 months predicted lung function improvement
at 12 and 24 months
• CCL18
– Correlated with short term, but not long term decline in lung
function
– High levels associated with decline in lung function and
progression of fibrosis on CT
November 13, 2018 40
Volkmann E et al. Arthritis Res Ther. 2016 Dec 30;18(1):305
Elhaj M et al. J Rheumatol. 2013 Jul;40(7):1114-20
Hoffman-Vold AM. Elhaj M et al. J Rheumatol. 2013 Jul;40(7):1114-20

41. Possible uses of biomarkers-lung
• Ability to predict short and long term
progression of lung fibrosis to identify
patients for treatment and clinical trials
• Predict, in the short term, who may be
responding to treatment
November 13, 2018 41

42. Our Patient: Lung
Phenotype:
• Early
• Diffuse
• RNA poly III
• Normal lung tests at baseline
Treatment plan:
• No treatment required for lung disease
• Monitor with regular screening with PFT

43. What is PAH?

44. PAH
LV Systolic
or Diastolic
Dysfunction
↑LAP
ILD
PVOD
Pulmonary Hypertension in
Scleroderma

45. Instructive Case
• 52 year old white female with limited
scleroderma
• First seen in SSc Center 5/13
• History of joint pain (since 2001), Raynaud’s
(since 2005) with digital ulcers, GERD,
sclerodactyly, centromere +
• Mild stable shortness of breath since 2011

46. Instructive Case
• Dobutamine stress test 6/13
– Negative for inducible ischemia
• High Resolution CT of chest 6/13
– Minimal bibasilar fibrosis
• 2D Echocardiogram 4/12, 9/12, 3/14
– PA pressure of 33, “normal”

47. Instructive Case
• Clinic visit 3/14
– Persistent dyspnea, unchanged
– Otherwise well
• Refer to PH Center 9/04
• Exercise Echocardiogram
– RVSP 59 at rest and 88 with exercise
• Right Heart Catheterization
– Confirmed pulmonary hypertension
• Therapy started

48. Instructive Case
0
20
40
60
80
100
M
ar-10
M
ar-11
M
ar-12
M
ar-13
M
ar-14
FVC %
DLCO %

49. Clinical Background
• Vascular disease is seen in every patient but
is heterogeneous in expression
• Vascular damage is noted diffusely in organs
and can be symptomatic or asymptomatic
• A subpopulation exists with severe vascular
events (digital ischemia, pulmonary
hypertension, renal crisis)
• No current effective way of predicting this
subpopulation

50. Clinical Paradigm/Hypothesis
Onset of Raynaud’s
Phenomenon
Diagnosis of Diffuse
Scleroderma
Diagnosis of Limited
Scleroderma
Fibrosis
Pre-
clinical
vascular
disease
TIME

51. Stupi AM et al. Arthritis Rheum.1986;29:515-524.
Steen V et al. Arthritis Rheum. 2003;48:516-522.
SSc with PAH
(n=20)
(n=106)
SSc without PAH
(n=287)
(n=106)
0
20
40
60
80
100
%cumulativesurvival
1 2 3 4 5
Follow-up (yr)
Stupi AM et al:
Average PA pressure: 82/35 (50) mm Hg
Average PA resistance: 16 Wood units
Average cardiac index: 2.1 L/min/m2
Effect on Survival: Limited
Scleroderma With and Without PAH
Steen V et al:
Average PASP: 76 mm Hg

52. Early Detection: Impact
Humbert M et al. Arthritis Rheum. 2011 Nov;63(11):3522-30.

53. Predictors of Poor Outcome
• Disease association (scleroderma)
• Worse WHO functional class
• Worse 6MWT distance
• Hemodynamics: mPAP (>85), RAP
(>20), CI (<2)
• TAPSE
• Pericardial Effusions

54. Goals for Biomarkers:
Scleroderma Vascular Disease
• Document an ongoing vascular insult in a
subset of patients with scleroderma
• Predict who will develop clinically significant
vascular outcomes (PH, digital ischemia)
• Use marker as surrogate for effectiveness of
therapy
• Understand the underlying biologic
insult/disease pathogenesis lead to new
therapy

55. Risk Factors and predictors of
PAH in scleroderma
• Late age onset of scleroderma
• Severe Raynaud’s phenomenon
• Low Diffusing Capacity
• Pro BNP elevation
• Autoantibody associations
– Anti-U1 RNP
– Anti-U3 RNP
– Anti-Th/To
– Anti-B23
Allanore, Y et al. Arthritis Rheum, 2008. 58(1): p. 284-91.

56. Age and Pulmonary Hypertension
Manno R et al. J Rheumatol. 2011

57. Telangiectasias Associate with
Pulmonary Arterial Hypertension
• Patients with larger number of telangiectasias
had higher rates of pulmonary hypertension
Shah AA et al. J Rheumatol. 2010 Jan;37(1):98-104

58. Pulmonary Function Testing
• Retrospective case control study of 106
patients with PAH versus 106 without PAH
• Patients with PAH had a mean DLCO of 52%
of predicted 4.5 years prior to the diagnosis of
PAH.
• Controls: DLCO was 80% predicted
(p<0.0001)
Steen V et al Arthritis Rheum 2003

59. N-terminal pro-brain natriuretic
peptide
• Marker of stretch or strain on heart
• High pro-BNP and low DLCO independently
predicted development of PAH
BUT:
 Picking up early pulmonary hypertension
 Can we find something earlier
Allanore et al. ArthritisRheum, 2008

60. Soluble Endoglin in Scleroderma
• Fairly robust biomarker for preeclampsia (OR=3.4; when
combined with sFlt-1:PlGF ratio, OR=30.8) elevated 3 months
prior
• Fujimoto et al. 2006: sEng elevated in limited compared with
diffuse scleroderma, lupus and controls and correlated with
telangiectasias and pulmonary hypertension
• Wipff et al. 2008: sENG elevated in scleroderma compared with
controls; association with cutaneous ulcerations, centromere
antibodies and low DLCO
• Our telangiectasia study noted positive correlation between
sEndoglin levels and telangiectasia score (p=0.07) (N=11)

61. sEndoglin
.5
1
1.5
No PAH PAH
Soluble endoglin levels by PAH status
.5
1
1.5
solubleendoglin,ng/ml
0 1 2 3
Last Medsger Raynaud's Severity Score
Soluble endoglin levels by Raynaud's severity
.5
1
1.5
No Yes
sEndoglin in those with and without DLCO <60%
.5
1
1.5
endoglin
Negative Positive
sEndoglin by Centromere status

62. Placental Growth Factor (PLGF)
November 13, 2018 62
Kylhammar D et al. Scand J Rheumatol. 2018 Jul;47(4):319-324
McMahan Z et al. Arthritis Res Ther. 2015 Aug 6;17:201
0
204060
PlGFPlasmaLevels(pg/mL)
No PH PH
PlGF Levels by PH Status in Scleroderma

63. Conclusions
• There has been great progress in our clinical abilities
to predict progression in scleroderma
• Recent work highlights that biomarkers may play a
role in doing this better going forward
• Our understanding of the underlying biology
continues to improve
• Data tells us that early detection of complications
improves outcomes
• Multiple trials now with promise
• Biomarker development has been incorporated into
trials
November 13, 2018 63

64. Director
Fredrick M. Wigley, MD
Co-Director
Laura K. Hummers, MD, ScM
Ami Shah, MD, MHS
Zsuszanna McMahan, MD, MHS
Julie Paik, MD, MHS
Christopher Mecoli, MD
Nadia Morgan, MD
Clinical Coordinator
Regina Greco RN, CRNP
Research Coordinator
Gwen Leatherman RN
The Johns Hopkins Scleroderma Center
http://www.hopkinsscleroderma.org