• Joseph Jacob, Brian J Bartholmai, Srinivasan Rajagopalan, van MoorselColine H MCHM4 St. Antonius ILD Center of Excellence, Department of Pulmonology, and.5 Division of Heart and Lungs, University Medical Center Utrecht, Utrecht, the Netherlands., Hendrik W van Es, Frouke T van Beek, Marjolijn H L Struik, Maria Kokosi, Ryoko Egashira, Anne Laure Brun, Arjun Nair, WalshSimon L FSLF11 Department of Radiology, King's College Hospital NHS Foundation Trust, London, United Kingdom., Gary Cross, Joseph Barnett, Angelo de Lauretis, Eoin P Judge, Sujal Desai, Ronald Karwoski, Sebastien Ourselin, Elisabetta Renzoni, Toby M Maher, Andre Altmann, and Athol U Wells.
• 1 Department of Respiratory Medicine.
• Am. J. Respir. Crit. Care Med. 2018 Sep 15; 198 (6): 767776767-776.

RationaleQuantitative computed tomographic (CT) measures of baseline disease severity might identify patients with idiopathic pulmonary fibrosis (IPF) with an increased mortality risk. We evaluated whether quantitative CT variables could act as a cohort enrichment tool in future IPF drug trials.ObjectivesTo determine whether computer-derived CT measures, specifically measures of pulmonary vessel-related structures (VRSs), can better predict functional decline and survival in IPF and reduce requisite sample sizes in drug trial populations.MethodsPatients with IPF undergoing volumetric noncontrast CT imaging at the Royal Brompton Hospital, London, and St. Antonius Hospital, Utrecht, were examined to identify pulmonary function measures (including FVC) and visual and computer-derived (CALIPER [Computer-Aided Lung Informatics for Pathology Evaluation and Rating] software) CT features predictive of mortality and FVC decline. The discovery cohort comprised 247 consecutive patients, with validation of results conducted in a separate cohort of 284 patients, all fulfilling drug trial entry criteria.Measurements And Main ResultsIn the discovery and validation cohorts, CALIPER-derived features, particularly VRS scores, were among the strongest predictors of survival and FVC decline. CALIPER results were accentuated in patients with less extensive disease, outperforming pulmonary function measures. When used as a cohort enrichment tool, a CALIPER VRS score greater than 4.4% of the lung was able to reduce the requisite sample size of an IPF drug trial by 26%.ConclusionsOur study has validated a new quantitative CT measure in patients with IPF fulfilling drug trial entry criteria-the VRS score-that outperformed current gold standard measures of outcome. When used for cohort enrichment in an IPF drug trial setting, VRS threshold scores can reduce a required IPF drug trial population size by 25%, thereby limiting prohibitive trial costs. Importantly, VRS scores identify patients in whom antifibrotic medication prolongs life and reduces FVC decline.

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