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Zhao Y, Li Y, Wang L, Li XF, Huang CB, Wang GC, Zhang XW, Zhang ZL, Zhang X, Xiao WG, Dai L, Wang YF, Hu SX, Li HB, Gong L, Liu B, Sun LY, Zhang MJ, Zhang X, Li YZ, Du DS, Zhang SH, Sun YY, Zhang FC. Primary Sjögren syndrome in Han Chinese: clinical and immunological characteristics of 483 patients. Medicine (Baltimore) 2015; 94:e667. [PMID: 25906094 PMCID: PMC4602699 DOI: 10.1097/md.0000000000000667] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Revised: 02/24/2015] [Accepted: 02/25/2015] [Indexed: 11/25/2022] Open
Abstract
The epidemiological characteristics of Sjögren syndrome (SS) are significantly varied in different countries. We conducted the present study to survey the epidemiological characteristics of primary SS in China. We recruited 483 primary SS patients from 16 Chinese medical centers nationwide from January 2009 to November 2011 and assessed salivary and lacrimal gland dysfunction, organ involvement, and autoimmunity in these patients. The cohort included 456 women and 27 men (ratio, 17:1; mean age at onset, 42 ± 11 years; median age at diagnosis, 49 years; range, 41-56 years). Male patients showed a lower frequency of xerophthalmia (37.0% vs 60.7%) and a higher frequency of arthritis (40.7% vs 16.4%). Young-onset patients showed a higher frequency of low C3 levels (57.7% vs 36.3%) and pancytopenia (22.2% vs 8.8%). Patients with systemic involvement had a higher frequency of immunoglobulin A (IgA) (39.4% vs 22.5%) and immunoglobulin M (IgM) (12.4% vs 37.9%). Patients with pulmonary involvement had a higher parotid enlargement (21.4% vs 10.2%), purpura (12.1% vs 5.7%) and higher anti-La/SS-B (61.7% vs 41.8%), immunoglobulin G (IgG) (80.7% vs 64.6%) and IgA (48.9% vs 30.6%) levels. Patients with anti-Ro/SSA antibodies had more frequent exocrine gland symptoms and some extraglandular symptoms and immunological alterations. Compared with previous studies performed in other countries, SS patients in China showed particular clinical manifestation, systemic involvement, and immunological alterations.
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Affiliation(s)
- Yun Zhao
- From the Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Key Laboratory of Rheumatology & Clinical Immunology, Ministry of Education, Beijing (YZ, YL, LW, XZ, Y-ZL, Y-YS, F-CZ); Department of Rheumatology and Immunology, Shanxi Medical University Second Hospital, Taiyuan (X-FL); Department of Rheumatology and Immunology, Beijing Hospital (C-BH); Department of Rheumatology and Immunology, China-Japan Friendship Hospital (G-CW); Department of Rheumatology and Immunology (X-WZ); Department of Rheumatology and Immunology, Peking University First Hospital, Beijing (ZZ); Department of Rheumatology and Immunology, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou (XZ); Department of Rheumatology and Clinical Immunology, The First Hospital, China Medical University, Shenyang (W-GX); Department of Rheumatology and Clinical Immunology, SUN Yat-sen Memorial Hospital of SUN Yat-sen University, Guangzhou (LD); Department of Rheumatology and Immunology, The First Affiliated Hospital of Baotou Medical College, Baotou (Y-FW); Department of Immunology and Rheumatology, Tongji Hospital, Tongji Medical College, Huazhong University of Science & Technology,Wuhan (S-XH); Department of Rheumatology and Clinical Immunology, Affiliated Hospital of Inner Mongolia Medical College, Hohhot (H-BL); Department of Rheumatology and Clinical Immunology, General Hospital of Tianjin Medical University, Tianjin (LG); Department of Rheumatology and Immunology, The Affiliated Hospital of Medical College Qingdao University, Qingdao (BL); Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School (L-YS); Department of Rheumatology and Clinical Immunology, Jiangsu Provincial People's Hospital, Nanjing (M-JZ); Department of Stomatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College (D-SD); Department of Ophthalmology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China (S-HZ)
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Papageorgiou A, Ziogas DC, Mavragani CP, Zintzaras E, Tzioufas AG, Moutsopoulos HM, Voulgarelis M. Predicting the outcome of Sjogren's syndrome-associated non-hodgkin's lymphoma patients. PLoS One 2015; 10:e0116189. [PMID: 25723713 PMCID: PMC4344229 DOI: 10.1371/journal.pone.0116189] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 12/08/2014] [Indexed: 01/14/2023] Open
Abstract
Background Non-Hodgkin's lymphoma (NHL) development in Sjögren’s syndrome (SS) remains a potentially lethal complication and efforts should focus on the identification of predictors that could aid in appropriate therapeutic decisions. Methods In order to identify potential prognostic factors for outcome in SS-associated NHL, we retrospectively analyzed a cohort of 77 patients, diagnosed with NHL according to WHO classification criteria and meeting the American-European Consensus Classification (AECC) criteria for SS and examined the effect of SS-activity (defined as the EULAR SS disease activity index-ESSDAI) in the prognosis of SS-related NHLs, as defined in terms of overall and event-free survivals (OS and EFS). An event was defined as lymphoma relapse, treatment failure, disease progression, histological transformation or death. The effect of NHL clinical and laboratory characteristics was also investigated. Results MALT lymphomas constituted the majority (66.2%) of lymphomas. During the follow-up (median = 57.93 months), the 5-year OS was 90.91% (95% CI: 82.14–95.80%) and the EFS was 77.92% (95% CI: 67.37–85.82%). Patients with high ESSDAI score at lymphoma diagnosis had a greater risk for death (OR = 5.241, 95% CI: 1.034–26.568) or for event (OR = 4.317, 95% CI: 1.146–9.699, p = 0.008). These patients had also significantly worse EFS (HR = 4.541, 95% CI: 1.772–11.637) and OS (HR = 5.946, 95% CI: 1.259–28.077). In addition, post-chemotherapy ESSDAI improvement was significantly lower in patients who had experienced an event (p = 0.005). An unfavorable International prognostic index (IPI) score (high-intermediate/high) was associated with high risk of death and event (OR = 13.867, 95% CI: 2.656–72.387 and OR = 12.589, 95% CI: 3.911–40.526, respectively), worse EFS (log-rank p<0.001, HR = 8.718, 95% CI: 3.477–21.858), as well as with worse OS (log-rank p<0.001, HR = 11.414, 95% CI: 2.414–53.974). After adjustment for identified risk factors, IPI score retained a significant prognostic role following by a strong effect of ESSDAI in survival outcomes. Conclusions At the point of NHL diagnosis, IPI and ESSDAI might be proved useful predictive tools in SS-associated lymphoma prognosis, directing to a more patient-tailored approach.
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Affiliation(s)
- Aristea Papageorgiou
- Department of Pathophysiology, School of Medicine, University of Athens, Athens, Greece
| | - Dimitrios C. Ziogas
- Department of Pathophysiology, School of Medicine, University of Athens, Athens, Greece
| | - Clio P. Mavragani
- Department of Physiology, School of Medicine, University of Athens, Athens, Greece
| | - Elias Zintzaras
- Department of Biomathematics, School of Medicine, University of Thessaly, Larissa, Greece
| | | | | | - Michael Voulgarelis
- Department of Pathophysiology, School of Medicine, University of Athens, Athens, Greece
- * E-mail:
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103
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Baer AN, Hall JC. Sjögren syndrome. Rheumatology (Oxford) 2015. [DOI: 10.1016/b978-0-323-09138-1.00138-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
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104
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Mandal S, Pile K, Chacko RT, Danda D. Malignancy and autoimmunity: causally or casually related? Int J Rheum Dis 2014; 17:601-5. [DOI: 10.1111/1756-185x.12536] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Santoshkumar Mandal
- Department of Clinical Immunology and Rheumatology; Christian Medical College and Hospital; Vellore India
| | - Kevin Pile
- Department of Medicine; University of Western Sydney; Sydney Australia
| | - Raju Titus Chacko
- Department of Medical Oncology; Christian Medical College and Hospital; Vellore India
| | - Debashish Danda
- Department of Clinical Immunology and Rheumatology; Christian Medical College and Hospital; Vellore India
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105
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Nocturne G, Mariette X. Sjögren Syndrome-associated lymphomas: an update on pathogenesis and management. Br J Haematol 2014; 168:317-27. [PMID: 25316606 DOI: 10.1111/bjh.13192] [Citation(s) in RCA: 183] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Primary Sjögren Syndrome (pSS) is an autoimmune disease associated with an increased risk of lymphoma. Lymphomas complicating pSS are mostly low-grade B cell non-Hodgkin lymphomas, predominantly of marginal zone histological type. Mucosal localization is predominant, notably mucosa-associated lymphoid tissue lymphomas. Lymphomas often develop in organs where pSS is active, such as salivary glands. Germinal centre (GC)-like structures, high TNFSF13B (BAFF) and Flt3-ligand (FLT3LG) levels and genetic impairment of TNFAIP3 are new predictors of lymphoma development. These new findings allow a better understanding of the pathogenic mechanisms leading to lymphoma. We propose the following scenario: auto-immune B cells with rheumatoid factor (RF) activity are continuously stimulated by immune complexes containing antibodies against more specific auto-antigens, such as SSA/Ro, SSB/La or others. Germline abnormality of TNFAIP3 leads to a decreased control of the NF-kB pathway and thus promotes survival of B cells and oncogenic mutations especially in GC structure. Moreover, B cells are stimulated by a positive loop of activation induced by BAFF secretion. Thus, lymphomagenesis associated with pSS exemplifies the development of antigen-driven B-cell lymphoma. The control of disease activity by a well-targeted immunosuppressor is the primary objective of the management of the patient in order to repress chronic B cell stimulation.
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106
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B-cell activating factor genetic variants in lymphomagenesis associated with primary Sjogren's syndrome. J Autoimmun 2014; 51:89-98. [DOI: 10.1016/j.jaut.2013.04.005] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Revised: 04/23/2013] [Accepted: 04/29/2013] [Indexed: 11/20/2022]
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107
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Colafrancesco S, Perricone C, Priori R, Valesini G, Shoenfeld Y. Sjögren's syndrome: another facet of the autoimmune/inflammatory syndrome induced by adjuvants (ASIA). J Autoimmun 2014; 51:10-6. [PMID: 24774584 DOI: 10.1016/j.jaut.2014.03.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Accepted: 03/21/2014] [Indexed: 01/26/2023]
Abstract
Recently, a new syndrome, namely the "Autoimmune/inflammatory syndrome induced by adjuvants" (ASIA) has been defined. In this syndrome different conditions characterized by common signs and symptoms and induced by the presence of an adjuvant are included. The adjuvant is a substance capable of boosting the immune response and of acting as a trigger in the development of autoimmune diseases. Post-vaccination autoimmune phenomena represent a major issue of ASIA. Indeed, despite vaccines represent a mainstay in the improvement of human health, several of these have been implicated as a potential trigger for autoimmune diseases. Sjogren's Syndrome (SjS) is a systemic chronic autoimmune inflammatory disease characterized by the presence of an inflammatory involvement of exocrine glands accompanied by systemic manifestations. Own to the straight association between infectious agents exposure (mainly viruses) and sicca syndrome development, the possible link between vaccine and SjS is not surprising. Indeed, a few cases of SjS following vaccine delivery have been reported. At the same extent, the induction of SjS following silicone exposure has been described too. Thus, the aim of this review was to focus on SjS and its possible development following vaccine or silicone exposure in order to define another possible facet of the ASIA syndrome.
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Affiliation(s)
- S Colafrancesco
- Department of Internal Medicine and Medical Specialities, Rheumatology Unit, Sapienza University of Rome, Italy; The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel
| | - C Perricone
- Department of Internal Medicine and Medical Specialities, Rheumatology Unit, Sapienza University of Rome, Italy; The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel
| | - R Priori
- Department of Internal Medicine and Medical Specialities, Rheumatology Unit, Sapienza University of Rome, Italy
| | - G Valesini
- Department of Internal Medicine and Medical Specialities, Rheumatology Unit, Sapienza University of Rome, Italy
| | - Y Shoenfeld
- The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel; Incumbent of the Laura Schwarz-Kipp Chair for Research of Autoimmune Diseases, Sackler Faculty of Medicine, Tel Aviv University, Israel.
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108
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109
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Ziakas PD, Poulou LS, Thanos L. Towards integrating positron emission tomography for work-up of patients with Sjögren's syndrome and associated lymphomas. Autoimmun Rev 2014; 13:327-9. [DOI: 10.1016/j.autrev.2013.11.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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110
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Affiliation(s)
- Clio P Mavragani
- Departments of Physiology (Mavragani) and Pathophysiology (Moutsopoulos), Faculty of Medicine, University of Athens, Athens, Greece
| | - Haralampos M Moutsopoulos
- Departments of Physiology (Mavragani) and Pathophysiology (Moutsopoulos), Faculty of Medicine, University of Athens, Athens, Greece
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Hershberg U, Meng W, Zhang B, Haff N, St Clair EW, Cohen PL, McNair PD, Li L, Levesque MC, Luning Prak ET. Persistence and selection of an expanded B-cell clone in the setting of rituximab therapy for Sjögren's syndrome. Arthritis Res Ther 2014; 16:R51. [PMID: 24517398 PMCID: PMC3978607 DOI: 10.1186/ar4481] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Accepted: 01/13/2014] [Indexed: 12/14/2022] Open
Abstract
Introduction Subjects with primary Sjögren’s syndrome (SjS) have an increased risk of developing B-cell lymphoma and may harbor monoclonal B-cell expansions in the peripheral blood. Expanded B-cell clones could be pathogenic, and their persistence could exacerbate disease or predispose toward the development of lymphoma. Therapy with anti-CD20 (rituximab) has the potential to eliminate expanded B-cell clones and thereby potentially ameliorate disease. This study was undertaken to identify and track expanded B-cell clones in the blood of subjects with primary SjS who were treated with rituximab. Methods To determine whether circulating B-cell clones in subjects with primary SjS emerge or remain after B cell-depleting therapy with rituximab, we studied the antibody heavy-chain repertoire. We performed single-memory B-cell and plasmablast sorting and antibody heavy-chain sequencing in six rituximab-treated SjS subjects over the course of a 1-year follow-up period. Results Expanded B-cell clones were identified in four out of the six rituximab-treated SjS subjects, based upon the independent amplification of sequences with identical or highly similar VH, DH, and JH gene segments. We identified one SjS subject with a large expanded B-cell clone that was present prior to therapy and persisted after therapy. Somatic mutations in the clone were numerous but did not increase in frequency over the course of the 1-year follow-up, suggesting that the clone had been present for a long period of time. Intriguingly, a majority of the somatic mutations in the clone were silent, suggesting that the clone was under chronic negative selection. Conclusions For some subjects with primary SjS, these data show that (a) expanded B-cell clones are readily identified in the peripheral blood, (b) some clones are not eliminated by rituximab, and (c) persistent clones may be under chronic negative selection or may not be antigen-driven. The analysis of sequence variation among members of an expanded clone may provide a novel means of measuring the chronicity and selection of expanded B-cell populations in humans.
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113
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Cornec D, Saraux A, Devauchelle-Pensec V, Clodic C, Pers JO. The future of B cell-targeted therapies in Sjögren's syndrome. Immunotherapy 2014; 5:639-46. [PMID: 23725286 DOI: 10.2217/imt.13.49] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Primary Sjögren's syndrome is a systemic autoimmune disease characterized by progressive exocrine gland destruction, resulting clinically in eyes and mouth dryness. To date, no treatment has been proven effective to modify the course of this slow-evolving disease. B cells are now considered to play a central role in the pathogenesis of primary Sjögren's syndrome because their functions are not restrained to antibody production. Thus, several B-cell targeting therapies are under clinical investigation. Rituximab, a monoclonal antibody directed to CD20 and leading to transient blood B-cell depletion, has shown partial improvements in subjective and objective sicca symptoms in small studies. However, the results of two large controlled trials are awaited before considering its use in large populations of patients. Several other therapeutic strategies are being studied, targeting other B-cell surface proteins (epratuzumab and anti-CD22) or major cytokines of B-cell homeostasis (e.g., BAFF, IL-6 and lymphotoxin-β). Although great hope is generated by the trials of these specific therapies, another challenge for clinical researchers is the development of reliable tools to assess the activity of Sjögren's syndrome and its response to treatment.
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Affiliation(s)
- Divi Cornec
- Department of Rheumatology, CHRU la Cavale Blanche, Brest, France
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114
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Baldini C, Pepe P, Quartuccio L, Priori R, Bartoloni E, Alunno A, Gattamelata A, Maset M, Modesti M, Tavoni A, De Vita S, Gerli R, Valesini G, Bombardieri S. Primary Sjögren’s syndrome as a multi-organ disease: impact of the serological profile on the clinical presentation of the disease in a large cohort of Italian patients. Rheumatology (Oxford) 2013; 53:839-44. [DOI: 10.1093/rheumatology/ket427] [Citation(s) in RCA: 145] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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115
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Baecklund E, Smedby KE, Sutton LA, Askling J, Rosenquist R. Lymphoma development in patients with autoimmune and inflammatory disorders--what are the driving forces? Semin Cancer Biol 2013; 24:61-70. [PMID: 24333759 DOI: 10.1016/j.semcancer.2013.12.001] [Citation(s) in RCA: 136] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Accepted: 12/03/2013] [Indexed: 12/27/2022]
Abstract
For decades, it has been known that patients with certain autoimmune and inflammatory disorders, such as rheumatoid arthritis (RA) and primary Sjögren's syndrome (pSS), have an increased risk of developing malignant lymphoma. Although the clinico-biological reasons for this association remain largely unknown, our knowledge has improved and new insights have been obtained. First, the direct link between autoimmunity and lymphomagenesis has been strengthened by large epidemiological studies showing a consistent risk increase of lymphoma associated with certain autoimmune/inflammatory conditions in independent cohorts from different countries. Second, a number of local and systemic disease-related risk factors in these diseases have been repeatedly linked to lymphoma development, with the prime examples being disease severity and the degree of inflammatory activity. Considering the key role of B- and T-cell activation in the pathogenesis of both autoimmunity and lymphoma, it is perhaps not surprising that longstanding chronic inflammation and/or antigen stimulation have emerged as major predisposing factors of lymphoma in patients with active autoimmune disease. Finally, increasing evidence suggests that lymphomas associated with autoimmunity constitute a different spectrum of entities compared to lymphomas arising in patients without any known autoimmune or inflammatory conditions, pointing to a different pathobiology. In this review, we summarize the recent literature that supports a direct or indirect link between immune-mediated disease and lymphoma and describe the characteristics of lymphomas developing in the different diseases. We also discuss molecular, genetic and microenvironmental factors that may come into play in the pathobiology of these disorders.
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Affiliation(s)
- Eva Baecklund
- Unit of Rheumatology, Department of Medical Sciences, Uppsala University, Uppsala, Sweden.
| | - Karin E Smedby
- Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
| | - Lesley-Ann Sutton
- Department of Immunology, Genetics and Pathology, Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Johan Askling
- Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden; Rheumatology Unit, Department of Medicine Solna, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
| | - Richard Rosenquist
- Department of Immunology, Genetics and Pathology, Science for Life Laboratory, Uppsala University, Uppsala, Sweden
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116
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Absence of somatic MYD88 L265P mutations in patients with primary Sjogren's syndrome. Genes Immun 2013; 15:54-6. [PMID: 24153350 DOI: 10.1038/gene.2013.54] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Revised: 08/23/2013] [Accepted: 08/26/2013] [Indexed: 01/22/2023]
Abstract
Sjogren's syndrome (SS) is a chronic autoimmune disorder with the highest risk for lymphoma development among all autoimmune diseases. In order to evaluate whether the presence of the recently described MYD88 L265P mutation in patients with Waldenström's macroglobulinemia (WM) is contributory to SS-associated lymphomagenesis, a quantitative allele-specific PCR method was performed in peripheral blood derived from 90 SS patients as well as in minor salivary gland tissues derived from 12 primary SS patients with or without lymphoma. MYD88 L265P was not detected in either of the samples tested. Although the absence of the MyD88 L265P somatic mutation in our SS cohort does not exclude a common germline susceptibility gene in SS, it might suggest a distinct operating pathogenetic mechanism in SS-related lymphoma compared with WM and other hematological malignancies.
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117
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Mavragani CP, Moutsopoulos HM. Sjögren's syndrome. ANNUAL REVIEW OF PATHOLOGY-MECHANISMS OF DISEASE 2013; 9:273-85. [PMID: 24050623 DOI: 10.1146/annurev-pathol-012513-104728] [Citation(s) in RCA: 150] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Sjögren's syndrome (SS) is a chronic autoimmune disorder that typically affects exocrine glands--mainly labial and lacrimal--leading to complaints of dry mouth and eyes. Given that periepithelial mononuclear cell infiltrates, both in exocrine glands and in other parenchymal organs (kidney, lung, and liver), are the histopathological disease hallmark, the term autoimmune epithelitis has been proposed. B cell hyperactivity is another cardinal SS feature manifested by the presence of autoantibodies and hypergammaglobulinemia, as well as clinical/serological phenotypes mediated by immune complexes, such as peripheral neuropathy, vasculitic lesions, and hypocomplementemia. These have been designated adverse predictors for lymphoma development in approximately 5% to 10% of patients. Activation of the type I interferon/B cell-activating factor axis in SS has recently attracted particular attention. Inappropriate overexpression of endogenous nucleic acids in a genetically susceptible individual might provide a plausible scenario for the immune activation observed in SS.
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Affiliation(s)
- Clio P Mavragani
- Department of Physiology, University of Athens, Athens, 11527 Greece;
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118
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Cohen C, Mekinian A, Uzunhan Y, Fauchais AL, Dhote R, Pop G, Eder V, Nunes H, Brillet PY, Valeyre D, Fain O, Soussan M. 18F-fluorodeoxyglucose positron emission tomography/computer tomography as an objective tool for assessing disease activity in Sjögren's syndrome. Autoimmun Rev 2013; 12:1109-14. [DOI: 10.1016/j.autrev.2013.06.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2013] [Accepted: 06/11/2013] [Indexed: 02/03/2023]
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119
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Mian M, Capello D, Ventre MB, Grazio D, Svaldi M, Rossi A, Tsang R, Gospodarowicz MK, Oldani E, Federico M, Luminari S, Marcheselli L, Pogliani EM, Rossini F, Cabrera ME, Martelli M, Gutierrez-Garcia G, Busetto M, Visco C, Fiegl M, Rossi D, Gaidano G, Cavalli F, Zucca E, Rambaldi A, Cortelazzo S. Early-stage diffuse large B cell lymphoma of the head and neck: clinico-biological characterization and 18 year follow-up of 488 patients (IELSG 23 study). Ann Hematol 2013; 93:221-231. [PMID: 23959436 DOI: 10.1007/s00277-013-1856-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2013] [Accepted: 07/18/2013] [Indexed: 11/30/2022]
Abstract
It is known that extranodal head and neck diffuse large B cell lymphomas (eHN-DLBCL) can affect various anatomical structures what is not well-known, however, is whether they differ in terms of clinical presentation and outcome. Clinical data of the multi-institutional series, the largest of its kind as yet, has been analysed with the aim of answering these open questions and providing long-term follow-up information. Data from 488 patients affected by stage I/II eHN-DLBCL was collected: 300 of the Waldeyer's Ring (WR), 38 of the parotid and salivary glands (PSG), 48 of the thyroid gland (TG), 53 of the nasal cavity and paranasal sinuses (NPS), 24 of the palate and oral cavity (POC) and 25 with more than one involved site. Different eHN-DLBCL arising have distinct characteristics at presentation. The intermediate high risk-modified IPI was 67 % in TG, 44 % in WR, 38 % in PSG and POC and 20 % in MS. The worst 5-year survival rate had TG-DLBCL (61 %) due to the 61 % of patients with a mIPI >1. The addition of radiotherapy (cRT) to remitters did not translate into a survival advantage (5-year disease-free survival of 67 % in the cRT group vs. 70 % in the other). Three of four central nervous system recurrences occurred in NPS-DLBCL. Survival of HN-DLBCL was inferior to nodal DLBCL. This study showed that eHN-DLBCL remitters have an inferior survival when compared to nodal DLBCL, and that the addition of cRT does not provide a survival advantage. Since the standard of care nowadays is chemo-immunotherapy, survival of these patients might have been improved.
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Affiliation(s)
- M Mian
- Division of Hematology, Azienda Ospedaliera S. Maurizio, Bolzano/Bozen, Italy,
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Abstract
The connective tissue disorders comprise a number of related conditions that include systemic lupus erythematosus (SLE) and the antiphospholipid (Hughes) syndrome, scleroderma, myositis and Sjögren's syndrome. They are characterized by autoantibody production and other immune-mediated dysfunction. There are common clinical and serological features with some patients having multiple overlapping connective tissue disorders. The latest advances include new approaches to therapy, including more focused utilization of existing therapies and the introduction of biological therapies in SLE, more precise protocols for assessment of severe disease manifestations such as in interstitial lung disease and pulmonary artery hypertension in scleroderma, new antibodies for disease characterization in myositis and new approaches to patient assessment in Sjögren's syndrome. B cells have a critical role in most, if not all of these disorders such that B-cell depletion or suppression of B-cell activating cytokines improves disease in many patients. In particular, the introduction of rituximab, a monoclonal antibody targeting the CD20 molecule on B cells, into clinical practice for rheumatoid arthritis and B-cell lymphoma has been a key driver of experimental approaches to therapy in connective tissue disorders. Genetic studies also suggest a role for the innate immune system in disease pathogenesis, suggesting further future targets for biological therapies over the next few years.
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Affiliation(s)
- Vijay Rao
- Rheumatology Department, Queen Elizabeth Hospital Birmingham, Birmingham, UK
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Moerman RV, Bootsma H, Kroese FGM, Vissink A. Sjögren's syndrome in older patients: aetiology, diagnosis and management. Drugs Aging 2013; 30:137-53. [PMID: 23341116 DOI: 10.1007/s40266-013-0050-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Sjögren's syndrome (SS) is a systemic autoimmune disease, characterized by chronic inflammation of exocrine glands that results in development of xerostomia and keratoconjunctivitis sicca. The disease activity of SS is not restricted to exocrine glands, and many other organs and organ systems can be involved. Diagnosis of SS in the elderly population can be challenging because xerostomia, dry eyes, symptoms of fatigue, weight loss and muscle pain are also common features of old age. Delay between clinical onset and diagnosis of SS in the elderly may be due to the shared features of SS and old age. The 2002 revised American-European Consensus Group (AECG) classification criteria for SS are the preferred tool used to confirm diagnosis of SS, but recently alternative criteria have been put forward by the American College of Rheumatology (ACR). The AECG criteria set combines subjective symptoms of dry eyes and dry mouth with objective signs of keratoconjunctivitis sicca, salivary gland dysfunction and histopathological (salivary gland biopsy) and serological (autoantibodies against SSA/Ro and SSB/La antigens) features. Treatment of SS in the elderly does not differ from that in younger patients. The aims of the treatment of SS are to control glandular and extraglandular manifestations, to prevent damage to organ systems and loss of function, and to decrease morbidity and mortality. Treatment of the elderly can be complicated by co-morbidities, an increased rate of adverse events related to therapeutic agents, and polypharmacy. Therefore, careful follow-up of the treatment is required.
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Affiliation(s)
- Rada V Moerman
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Nocturne G, Mariette X. Advances in understanding the pathogenesis of primary Sjögren's syndrome. Nat Rev Rheumatol 2013; 9:544-56. [PMID: 23857130 DOI: 10.1038/nrrheum.2013.110] [Citation(s) in RCA: 263] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Primary Sjögren's syndrome (pSS) is a prototypic autoimmune disorder, management of which has long suffered from a lack of knowledge of the underlying pathophysiological mechanisms; however, over the past decade major advances have been made in understanding the pathogenesis of pSS. The innate immune system has been demonstrated to have an important role at the early stage of the disease, notably through activation of the type I interferon (IFN) system. In addition, mechanisms of B-cell activation in pSS have become clearer, particularly owing to recognition of the involvement of the TNF family cytokine B-cell-activating factor, production of which is highly dependent on expression of type I and type II IFNs. Moreover, key inroads have been made in understanding lymphomagenesis, the most severe complication of pSS. IL-12 production and subsequent T-cell activation, mainly IFN-γ-secreting type 1 T-helper cells, have also been implicated in disease pathogenesis. Furthermore, evidence implicates neuroendocrine system dysfunction in pSS pathogenesis. These pathophysiological advances open new avenues of investigation. Indeed, the increased understanding of pSS pathogenesis has already led to the development of promising novel therapeutic strategies. This article summarizes recent findings regarding the pathogenic mechanisms involved in pSS and their implications.
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Affiliation(s)
- Gaëtane Nocturne
- Service de Rhumatologie, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris-Sud, INSERM U1012, 78 rue du Général Leclerc, Le Kremlin Bicêtre, France
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Malignant lymphoma in primary Sjögren's syndrome: an update on the pathogenesis and treatment. Semin Arthritis Rheum 2013; 43:178-86. [PMID: 23816048 DOI: 10.1016/j.semarthrit.2013.04.004] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Revised: 03/27/2013] [Accepted: 04/11/2013] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Sjögren's syndrome (SS), a chronic autoimmune disorder, particularly compromises the function of exocrine glands. Its association with lymphoma is well documented. Our aim was to systematically review the molecular, clinical, histopathologic, and therapeutic aspects of these SS-related malignant lymphoproliferations. METHODS The literature was searched for original articles published between 1968 and 2012 focusing on the risk factors for lymphoma development in Sjögren's syndrome using MEDLINE and PubMed. The search terms we used were "Sjögren's syndrome," "lymphoma," and "risk factors." All papers identified were English-language, full-text papers. RESULTS A low-grade marginal-zone lymphoma related to mucosa-associated lymphoid tissue is the commonest lymphoid neoplasia in SS. The majority of SS-associated lymphomas are characterized by localized stage, indolent clinical course, and recurrence in other extranodal sites. Although the transition from a chronic inflammatory condition to malignant lymphoma is a multistep process that is yet poorly understood, there is increasing evidence that chronic antigenic stimulation by an exoantigen or autoantigens plays an essential role in the development of SS-associated lymphoproliferation. CONCLUSIONS This review discusses the pathogenetic aspects of lymphomagenesis in SS. Recent advances in the treatment of lymphoma in SS are also stated.
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Nakamura H, Iwamoto N, Horai Y, Takagi Y, Ichinose K, Kawashiri SY, Taguchi J, Hayashi T, Nakamura T, Kawakami A. A case of adult T-cell leukemia presenting primary Sjögren's syndrome-like symptoms. Int J Rheum Dis 2013; 16:489-92. [PMID: 23992276 DOI: 10.1111/1756-185x.12127] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Tarella C, Gueli A, Ruella M, Cignetti A. Lymphocyte transformation and autoimmune disorders. Autoimmun Rev 2013; 12:802-13. [DOI: 10.1016/j.autrev.2012.11.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Keszler A, Adler LI, Gandolfo MS, Masquijo Bisio PA, Smith AC, Vollenweider CF, Heidenreich AM, de Stefano G, Kambo MV, Cox DP, Narbaitz M, Lanfranchi HE. MALT lymphoma in labial salivary gland biopsy from Sjögren syndrome: importance of follow-up in early detection. Oral Surg Oral Med Oral Pathol Oral Radiol 2013; 115:e28-33. [PMID: 23157989 PMCID: PMC3593994 DOI: 10.1016/j.oooo.2012.07.481] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2012] [Revised: 06/27/2012] [Accepted: 07/24/2012] [Indexed: 02/07/2023]
Abstract
Mucosa-associated lymphoid tissue (MALT) lymphomas are known to occur in Sjögren syndrome (SS) patients, but reported cases in labial salivary glands (LSG) are rare. We report a case of 60-year-old female patient with SS who developed MALT lymphoma in the labial salivary glands during a 2-year time interval when she was participating in the Sjögren's International Clinical Collaborative Alliance, an ongoing longitudinal multisite observational study funded by the National Institutes of Health of the United States. At follow-up exam, LSG biopsy showed atypical diffuse infiltration by mononuclear cells of variable size and atypical nuclei affecting the whole specimen with destruction of glandular architecture, leading to a diagnosis of B-cell MALT lymphoma. Computerized tomography and bone marrow biopsy failed to show additional evidence of disease. Clinical, serologic, ocular, histologic and immunohistochemical findings are presented. A "watch and wait" policy was adopted with regular examinations.
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Affiliation(s)
- A Keszler
- Department of Oral Pathology, School of Dentistry, University of Buenos Aires, Buenos Aires, Argentina.
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Brito-Zerón P, Sisó-Almirall A, Bové A, Kostov BA, Ramos-Casals M. Primary Sjögren syndrome: an update on current pharmacotherapy options and future directions. Expert Opin Pharmacother 2013; 14:279-89. [DOI: 10.1517/14656566.2013.767333] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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PATEL SHEETAL, KRAMER NEIL, COHEN ALICEJ, ROSENSTEIN ELLIOTD. Renal Lymphoma: Unusual Lymphoproliferative Manifestation of Sjögren’s Syndrome. J Rheumatol 2013; 40:102-3. [DOI: 10.3899/jrheum.120869] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Bowman S, Barone F. Biologic treatments in Sjögren's syndrome. Presse Med 2012; 41:e495-509. [PMID: 22836195 DOI: 10.1016/j.lpm.2012.05.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Accepted: 05/11/2012] [Indexed: 02/08/2023] Open
Abstract
Primary Sjögren's Syndrome (pSS) is characterized by focal lymphocytic infiltration of secretory exocrine glands associated with severe dryness of eyes and mouth in particular. Systemic features such as disabling fatigue, cutaneous vasculitis, lung, neurological, haematological or other systemic involvement also occur. Conventional immunosuppressive therapies such as corticosteroids or disease-modifying drugs, have been used in some patients with these systemic features with variable benefit. Current therapy for dryness is principally symptomatic although medications to stimulate residual glandular secretion can be helpful for appropriate individuals. As the pathogenesis of the condition becomes better understood, particularly, in recent years, the role of systemic B-cell activation, biologic therapies specifically targeted against molecules involved in disease pathogenesis represent a more targeted approach to therapeutic intervention. The greatest experience in pSS is with rituximab, an anti-CD20 (expressed on a subset of B-cells) monoclonal antibody already in use for the treatment of some B-cell lymphomas and rheumatoid arthritis. Randomised placebo-controlled studies in pSS are currently underway. This review discusses the rationale for using biologic therapies in pSS, the current data on rituximab and the potential use of other biologic therapies in pSS in the future.
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Affiliation(s)
- Simon Bowman
- Queen Elizabeth Hospital, Rheumatology Department, Edgbaston, Birmingham B15 2TH, United Kingdom.
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