Safety and usefulness of minor salivary gland biopsy: Retrospective analysis of 502 procedures performed at a single center

The Value of Labial Gland Biopsies as a Diagnostic Test for Sjögren's Syndrome

PURPOSE

There are a number of diagnostic criteria that can be used to support a diagnosis of Sjögren's syndrome (SS), a chronic autoimmune condition often characterised by xerostomia and xerophthalmia. Of the available investigations, the most invasive is the labial gland biopsy (LGB) for histopathology, which is associated with a risk of long-term altered sensation to the lip. A positive histological diagnosis is currently considered to be one of the most objective criteria, however there is debate about the interobserver agreement between pathologists, as well as the sensitivity and specificity of this test. We aim to determine if the diagnostic value of the LGB is significant enough to warrant the surgical procedure and its associated risks.

METHODS

This study involved assessing the degree of agreement between members of a pathology team for a cohort of 50 LGBs taken for the purpose of confirming or excluding SS. The Tarpley system was used, which involves the allocation of a 'focus score'. Additionally, the histological diagnoses were compared to the relevant serological findings where available.

RESULTS

All cases within the cohort had adequate tissue for assessment. 84% agreement (Cohen's Kappa = 0.585) was seen between the current team's consensus and the original reporting pathologist on whether the appearance was supportive of SS. However, only 58% agreement was seen for focus scores (Weighted Kappa = 0.496). The agreement between the serology result and whether the histology was supportive of SS was 79% (Cohen's Kappa = 0.493).

CONCLUSION

The findings raise the possibility that undue emphasis is placed on the value of a histological SS diagnosis. The current system for assessing and grading these biopsies is ambiguous in nature, with a low threshold considered indicative of SS. Due to the risk of complications associated with a LGB, alternative minimally invasive investigations should always be considered. The histological findings in isolation, particularly when a low focus score is seen, may not be predictive of a diagnosis of SS.

Prognostic significance of lymphocytic foci composition in minor salivary gland biopsies for severe disease flare and severity in Sjögren's syndrome: a 3-year follow-up cohort study

Introduction

This was an ambispective cohort study evaluating the prognostic significance of lymphocytic foci and its lymphoid composition in minor salivary gland biopsy (MSGB) for short-term disease flare and severity in Sjögren's syndrome (SS).

Methods

The inclusion criteria comprised individuals meeting the ACR/EULAR 2016 criteria who underwent MSGB with an infiltration of more than 50 lymphocytes and received clinical diagnosis between September 2017 and December 2018. Patients with inadequate biopsy samples were excluded. The number of lymphocytic foci and their lymphoid composition in MSGB were assessed using immunofluorescence staining. Major organ damage and improvements in the EULAR Sjögren's Syndrome Disease Activity Index (ESSDAI) were measured. Statistical analyses, including Cox and linear regressions, were conducted.

Results

A total of 78 patients with at least one lymphocytic focus were included in the study. The presence of higher T-cell counts in lymphocytic foci in MSGB was associated with severe disease flare, and a logarithmic transformation of T-cell count indicated increased risk (HR 1.96, 95% CI 0.91-4.21). Improvements in the ESSDAI were associated with higher total lymphocyte count and T- and B-cell numbers in the lymphoid composition of the lymphocytic foci. Seropositive patients exhibited higher T CD4+ cell numbers. Correlation analysis showed negative associations between age and lymphocytic foci and the T-cell count. Positive correlations were observed between antinuclear antibody (ANA) titers and total lymphocyte numbers.

Discussion

Patients with a higher number of T cells in the lymphocytic infiltrates of lymphocytic foci may have a two-fold risk of severe disease flare. The number of B cells and T CD4+ cells in the lymphocytic infiltrates of lymphocytic foci showed a weak but positive relation with the ESSDAI improvement during follow-up. Age and seropositivity appeared to influence the lymphoid composition of the lymphocytic foci.

CXCL9 may serve as a potential biomarker for primary Sjögren's syndrome with extra-glandular manifestations

BACKGROUND

Primary Sjögren's syndrome (pSS) is an autoimmune condition that causes harm to exocrine glands and also has extra-glandular manifestations (EGM). pSS patients with EGM have a worse prognosis than those with only sicca symptoms. Previous studies have shown that the minor salivary glands (MSG) of pSS patients exhibit a unique profile of cytokines and chemokines compared to healthy controls. However, there is a lack of research comparing pSS with EGM (pSS-EGM) and pSS without EGM (pSS-non-EGM). This study aims to explore potential biomarkers associated with pSS, particularly pSS with EGM.

METHODS

By utilizing RNA sequencing, we conducted an analysis on the gene expression profiles of MSG in 63 patients diagnosed with pSS, as well as 12 non-pSS individuals. Furthermore, we also investigated the MSG of pSS patients, both with and without EGM. Through bioinformatics analysis, we identified genes with differential expression (DEGs) and determined the core hub genes using PPI network. We then analyzed the top 20 DEGs and their correlation with the patients' clinical characteristics, and validated our findings using peripheral blood plasma.

RESULTS

A total of 725 differentially expressed genes (DEGs) were identified in the comparison between pSS and non-pSS groups, and 727 DEGs were observed between pSS-EGM and pSS-non-EGM. It is noteworthy that the expression levels of CXCL9 were higher in both pSS patients and pSS-EGM when compared to the control group. Taking into consideration the significance of the top 20 DEGs in relation to clinical parameters and the central hub genes, we ultimately chose CXCL9. In comparison to the non-pSS group, pSS patients exhibited notably greater expression of the CXCL9 gene in the MSG, as well as higher levels of CXCL9 protein in their plasma (p < 0.001). Furthermore, the expression of the CXCL9 gene and levels of CXCL9 protein were notably higher in pSS patients accompanied by EGM and those with SSA antibodies. Additionally, a correlation was found between the expression of the CXCL9 gene and the EULAR Sjogren's Syndrome Disease Activity Index (ESSDAI), as well as with immunoglobulin G (IgG) levels and erythrocyte sedimentation rate (ESR). Meanwhile, the protein levels of CXCL9 were found to be correlated with IgG levels and ESSDAI.

CONCLUSION

CXCL9 proves to be a valuable biomarker in pSS, specifically due to its strong ability to differentiate between pSS patients with EGM and those without EGM. There is a significant correlation between CXCL9 and various clinical parameters both at the gene and protein level. Therefore, CXCL9 could be a potential target for future treatment of pSS.

A single-center study of clinical features of pediatric Sjögren's syndrome

OBJECTIVE

Sjögren's syndrome (SS) is a rare disease with unclear diagnostic criteria among the children and adolescents. The purpose of this study is to describe the clinical features of pediatric Sjögren's syndrome and validate with Japanese diagnostic guidelines criteria of 2018.

METHODS

We conducted a retrospective analysis of the clinical data of a cohort of 54 patients with pediatric Sjögren's syndrome admitted to our hospital over a total of 10 years from September 2013 to September 2022.

RESULTS

The ratio of females to males was 49:5 among the 54 children (34 cases of primary SS and 20 cases of secondary SS), the average age of onset of symptoms for the first time was 9.9 years, and the average age at diagnosis was 10.2 years. In terms of subjective symptoms, 7 cases (13.0%) presented with dry mouth and 5 cases (9.3%) reported dry eyes. The positive rates were 9.3% for Schirmer I test, 70.4% for salivary gland function test, and 55.6% for salivary gland ultrasonography. The positive rates were 94.4% for Anti-Ro/SSA antibodies, 66.7% for Anti-La/SSB antibodies, 88.9% for ANA, 59.3% for RF, and the elevation rate of IgG was 63.0%. Among the EULAR Sjögren's syndrome disease activity index (ESSDAI) domains, the biological, constitutional, glandular, cutaneous, and lymphadenopathy domains were most involved. Treatment consisted of glucocorticoids in 88.9% of the patients in our study and hydroxychloroquine in 92.6%. As per the Japanese version of the clinical practice guidance for Sjögren's Syndrome in pediatric patients (2018), 5 cases were identified as Definite SS, 35 cases as Probable SS, and 14 cases as Possible SS. With respect to primary and secondary SS, there was essentially no significant difference between the groups in any of the above aspects.

CONCLUSIONS

Patients with pediatric SS presented with a wide spectrum of clinical features, a low prevalence of reported symptoms of dry mouth and dry eyes, and various clinical manifestations with multi-system involvement. These are similar to other pediatric study cohorts in terms of epidemiology, auxiliary investigation results, disease activity scores, and treatment. The coincidence between our study and the Japanese version of the clinical practice guidance for Sjögren's Syndrome in pediatric patients (2018) is good for the diagnosis of pediatric SS.

Bedside labial salivary gland biopsy (LSGBx: Lip biopsy): An update for rheumatologists

Retrieval of minor salivary glands from a labial submucosal site through a minimally invasive bedside procedure was first described nearly 60 years ago and remains an attractive alternative to more invasive surgical procedures to obtain salivary gland tissue for pathologic examination. Examination of glands for features of Sjögren's has constituted the primary use of this procedure but other systemic disorders can affect minor salivary glands and their diagnoses can be supported by biopsy. Performance of the procedure does not require specialized training in head and neck surgery or dentistry, only simple wound closure skills. Skill in performing the procedure enables the clinician to acquire potentially diagnostic material without the need for referral while offering immediate expert feedback to the patient being biopsied. Material obtained at biopsy can also be the focus of research investigations.

Complications after minor salivary gland biopsy: a retrospective study of 630 patients from two Swedish centres

OBJECTIVES

The aims of the study were to investigate the prevalence of impaired sensation after minor salivary gland biopsy (MSGB) in two Swedish centres [Karolinska University Hospital (KUH) and Skåne University Hospital (SUH)] and to assess its impact on quality of life (QoL) and associated risk factors.

METHOD

A questionnaire including questions regarding the presence of impaired sensation, impact on QoL, and impact on everyday life was sent to patients who had undergone MSGB between 2007 and 2016, and their medical notes were scrutinized.

RESULTS

The study included 630 patients (505 from KUH and 125 from SUH). In KUH the biopsies were performed by rheumatologists and in SUH by dentists or oral and maxillofacial surgeons (OMSs). Long-standing, probably permanent, impaired sensation after MSGB was reported by 21% of patients, and was associated with lower age and absence of anti-SSA antibodies. Patients with long-standing impaired sensation reported the inconvenience (1-10) of impaired sensation as 4.0 (2.0-7.0) [median (interquartile range)], and 32% reported an influence on their QoL, the reported influence (1-10) on everyday life being 3.0 (1.0-5.0). When comparing the outcomes from KUH and SUH, patients from SUH reported a significantly lower frequency of long-standing impaired sensation (14% vs 23%; p = 0.02).

CONCLUSION

A high frequency of long-standing impaired sensation after MSGB was found among patients who had undergone MSGB, although it had a low impact on everyday life. The complication frequency was less pronounced when a dentist or an OMS had performed the biopsy.

Diagnostic value of the saliva immunoglobulin free light chains concentrations measured in primary Sjцgren's syndrome

Proliferation and hyperactivation of B-lymphocytes in the salivary glands is a feature of primary Sjцgren's syndrome (pSS). Detection in saliva of proteins synthesized by B-lymphocytes may be important in the diagnosis of this disease.Objective: to evaluate the diagnostic value of measuring the concentration of immunoglobulin free light chains (FLC) in saliva in patients with pSS.Material and methods. The cross-sectional study included 24 patients with pSS over the age of 18 years. PSS was diagnosed according to the 2016 ACR/EULAR classification criteria. The control group consisted of 11 healthy volunteers. Blood-salivary glands histohematic barrier permeability ratio for albumin, FLC was measured. Quantitative determination of FLC and in blood and saliva was performed by enzyme immunoassay. An immunohistochemical study of biopsies of minor salivary glands (MSG) was carried out with a quantitative assessment of CD3+, CD4+, CD8+, CD20+, CD21+, CD68+, CD138+ cells. The Mann–Whitney U-test was used to compare quantitative traits. Identification of diagnostic thresholds for the concentration of FLC in saliva for the diagnosis of pSS was carried out using the ROC analysis method. An operating characteristic curve was plotted, the area under the curve, indicators of diagnostic specificity, diagnostic sensitivity, and diagnostic accuracy were calculated.Results and discussion. The obtained values corresponded to the low permeability of the histohematic barrier of the salivary glands for albumin and FLC in patients with pSS and healthy individuals. The median concentrations of FLC ê and ë in the saliva of patients with pSS and healthy volunteers were 1.08 [0.58; 1.91], 1.038 [0.55; 2.03] mg/l and 0.36 [0.32; 0.54], 0.35 [0.21; 0.52] mg/l, respectively. The concentration of FLC in the saliva of patients with pSS was statistically significantly higher than in the control group (p<0.01). The amount of FLC ê and ë in saliva correlated with the rate of unstimulated saliva flow: rs=-0.483 (p=0.02), rs=-0.491 (p=0.017), respectively.A relationship was found between the concentration of ê-chains in saliva and the specific number of CD138+ cells: rs=0.733 (p=0.025). Statistically significant correlations between the concentration of ë-chains and the number of mononuclear cells in the MSG have not been established.Based on the results of ROC analysis, diagnostic thresholds for FLC concentrations in the saliva of patients with pSS were determined. Concentrations of ê- and ë-type FLC in saliva of 0.56 and 0.68 mg/l correspond to area under the curve values of 0.84 (95% confidence interval, CI 0.69–0.98) and 0.83 (95% CI 0.71–0.97), sensitivity 79.2% (95% CI 59.5–90.8) and 75% (95% CI 55.1–88), specificity 81.8% (95% CI 52.3–96.8) and 90.9% (95% CI 62.3–99.5), respectively.Salivary FLC concentrations were compared in patients with pSS receiving and not receiving glucocorticoids (GC). The groups did not differ in a statistically significant way in terms of clinical and laboratory parameters. The median daily dose of GC was 10 [5; 10] mg in prednisolone equivalent. There were no significant differences between the concentrations of saliva FLC in patients of these groups.Conclusion. Salivary-fixed FLCs are most likely produced by cells localized in the stroma of the salivary glands. Determination of the concentration of FLC in saliva can be proposed as a diagnostic test for the pSS. The concentration of free ê-chains in saliva can be considered as a surrogate marker of benign B-cell proliferation in the MSG. Therapy with low and medium doses of GC in pSS does not affect the concentration of FLC in saliva.

Sicca syndrome in systemic sclerosis: a narrative review on a neglected issue

SSc is an auto-immune disease characterized by life-threatening manifestations such as lung fibrosis or pulmonary arterial hypertension. Symptoms with a detrimental impact on quality of life are also reported and sicca syndrome (xerostomia, xeropthalmia) is present in up to 80% of patients with SSc. Sicca syndrome can occur in the absence of overlap with Sjögren's disease and recent studies highlight that fibrosis of minor and major salivary glands, directly linked to the pathogenesis of SSc, could be a major contributor of xerostomia in SSc. This narrative review provides an overview of the clinical presentation, diagnostic strategies, management and future perspectives on sicca syndrome in patients with SSc.

Diagnostic utility of a second minor salivary gland biopsy in patients with suspected Sjögren's syndrome: A retrospective cohort study

OBJECTIVE

To determine whether repeated minor salivary gland biopsy (MSGB) has a clinical diagnostic utility in patients with suspicion of Sjögren's syndrome (SS).

METHODS

Clinical, biological, pathological data and physician's diagnosis after each MSGB from patients with suspected primary or secondary SS who had benefited from 2 MSGB at Brest University Hospital between January 1st, 1990 and January 14th, 2015, were retrospectively collected. We compared the characteristics of patients with and without first positive MSGB, concordance between the MSGB, and analyzed the modifications of diagnosis after the second MSGB.

RESULTS

Ninety-three patients were included, first MSGB was positive for 23 and negative for 70. Patients with first positive MSGB had more often renal involvement (P<0.05) and hypergammaglobulinemia (P=0.01), anti-SSA antibodies (P<0.05) and positive second biopsy with focus score ≥ 1 or Chisholm>2 (P<0.01). The mean time between the 2 MSGB was 5.7±4.3 years. The concordance between the results of the 2 biopsies was low (κ = 0.34). MSGB influenced diagnostic's change in 10 cases where the second MSGB was always guided by new specific clinical manifestations.

CONCLUSION

We observed a low concordance between 2 MSGB in patients with suspected pSS in our study. Despite this variability, performing a second MSGB changed the initial diagnosis in only a minority of the patients and was particularly useful when clinical manifestations had deeply evolved.

Characteristics of Patients with Primary Sjögren's Syndrome and Non-specific Chronic Sialadenitis: A Subtype in Elderly Patients

Introduction

Non-specific chronic sialadenitis (NSCS) is a common pathology of labial salivary glands (LSGs), and NSCS with positive anti-SSA/SSB antibodies is common in clinical practice. Previous studies have evaluated the associations of high focus score (FS) with clinical manifestations in primary Sjögren’s syndrome (pSS) patients extensively, but the characteristics of pSS with NSCS have seldom been investigated. We here analyzed the characteristics of pSS patients with NSCS.

Methods

Among 425 patients who underwent LSG biopsies, 217 had pSS and 37 non-SS sicca patients had NSCS without other diseases (i.e., sicca controls). We categorized these 217 pSS patients into three groups based on the pathology of LSGs: FS ≥ 1 (n = 104), 0 ≤ FS < 1 (n = 76), and NSCS (n = 37). We then compared the three groups while focusing on the NSCS group. Multivariate logistic regression analysis was performed to identify variables that influenced NSCS.

Results

The mean age of pSS patients with NSCS (58.3 ± 11.0 years) was significantly higher than those with FS ≥ 1 (48.5 ± 14.9 years) and 0 ≤ FS < 1 (45.3 ± 13.7 years), but other clinical characteristics were similar. NSCS had a significant positive correlation with age (OR = 7.282, 95% CI 2.085–25.44 and OR = 13.130, 95% CI 3.368–51.189 for patients aged 45–64 years and > 65 years, respectively). Significantly higher levels of lymphocytic infiltration were found in the pSS NSCS group than in the sicca NSCS controls (48.6 vs. 10.8%, respectively).

Conclusions

The pSS patients with NSCS were older than corresponding non-NSCS pSS individuals, but they had similar clinical features. NSCS is associated with age and seldom occurred below the age of 45 years, regardless of the presence or absence of pSS. NSCS may be a subtype of pSS in elderly patients.

The role of minor salivary glands' biopsy in the diagnosis of Sjögren's syndrome and other systemic diseases

BACKGROUND

The minor salivary glands' biopsy is a minimally invasive procedure used for the diagnosis of Sjögren's syndrome. Its significance has also been reported in other inflammatory/infiltrative diseases. The objectives are to investigate its use in the diagnosis of Sjögren's syndrome, as well as to evaluate its role in the diagnosis of amyloidosis and sarcoidosis.

METHODS

A retrospective analysis was carried out on patients who underwent minor salivary glands' biopsies between April of 2014 and December of 2017.

RESULTS

A total of 173 patients were identified. Of the patients with suspected Sjögren's syndrome, in 40% of the cases there was evidence of lymphocytic sialadenitis. The antibodies against SSA, antinuclear antibodies and the Rheumatoid Factor correlated significantly with the presence of lymphocytic sialadenitis. The result of the minor salivary glands' biopsies allowed an increase of 12.4% of patients who met the criteria defined by the American - European Consensus Group. Of the patients with suspected amyloidosis (25%), the biopsies were positive in 4 patients.

CONCLUSION

The minor salivary glands' biopsy is a simple procedure with effectiveness in the diagnosis of Sjögren's syndrome and amyloidosis. In this study, its use increased the number of patients who met the Sjögren's syndrome classification criteria. It also appears to be useful in the diagnosis of amyloidosis.

Adverse post-operative events of salivary gland biopsies: A systematic review and meta-analysis

OBJECTIVES

The study aimed to perform a systematic review and meta-analysis of the complications following major and minor salivary gland biopsy.

MATERIALS AND METHODS

Observational studies assessing postoperative complications of minor salivary gland biopsy and indexed at Medline/PubMed, EMBASE, Cinahl, LILACS, or Scopus were selected. This review was registered under the protocol number: CRD42020211169. The level of significance considered was 0.05, and the R software (The R Foundation) was used for the meta-analysis.

RESULTS

Twenty-seven studies reporting 3208 patients were included in this review. The combined prevalence of postsurgical complications was 11% (95% CI, 8 to 13%, p = 0.01). The percentage of the combined prevalence of neurological complications was 3% (95% CI, 1-6%, p = 0.01). The surgical technique did not influence the frequency of overall and neurological complications.

CONCLUSION

Minor salivary gland biopsies are a safe and predictable procedure that should be performed on the lower lip. Postoperative complications are more common than previously reported, but permanent complaints are uncommon.

The accuracy of dry surgical field sublabial biopsy in the diagnosis of sicca syndrome

BACKGROUND

Sublabial gland biopsy is the 'gold standard' in establishing the diagnosis of primary Sjögren's syndrome. Bleeding and nerve damage are complications. Our centre has adopted the use of the chalazion clamp to provide a dry surgical field to address these challenges. This study aimed to assess the accuracy of minor salivary gland harvest rate using this technique.

METHOD

A retrospective review of all minor salivary gland biopsies was carried out in a single tertiary referral centre over a five-year period.

RESULTS

Forty-one biopsy patients were identified, with a mean age of 56.1 years. There was 100 per cent accuracy in harvest rate in our series. Twelve patients (29 per cent) were positive for primary Sjögren's syndrome. No patients had a complication immediately or at one month follow up.

CONCLUSION

Dry surgical field sublabial gland biopsy is a safe and highly effective technique in the diagnosis of primary Sjögren's syndrome. Initial results indicate it may provide a higher harvest rate with fewer complications than traditional non-ischaemic techniques.

Two cases of secondary AA amyloidosis involving the skin and chronic kidney infection with a nephrotic syndrome in a high-income country

We present two French cases of amyloid-associated (AA) amyloidosis secondary to chronic infections. Patient 1, a 51-year-old heroin addict, was hospitalised for chest pain and anasarca. During hospitalisation, a nephrotic syndrome with an inflammatory condition was discovered along with a chronic skin ulcer on his arm. Salivary gland and kidney biopsies confirmed the diagnosis of AA amyloidosis. Renal function quickly declined and haemodialysis was initiated 6 months later. Patient 2, a 55-year-old woman, was hospitalised for obstructive pyelonephritis secondary to coraliform lithiasis. Renal insufficiency with an impure nephrotic syndrome was found. After nephrectomy due to chronic pyelonephritis and an atrophic cortex on the abdominal scan, the histology revealed AA amyloidosis. Despite treatment with ACE inhibitors and control of inflammation, the nephrotic syndrome persisted with rapid decline of the kidney function.

CXCR2 May Serve as a Useful Index of Disease Activity in Interstitial Lung Disease Associated With Primary Sjögren's Syndrome

Background: Primary Sjögren's syndrome (pSS) is a chronic systemic autoimmune disease characterized by typical autoantibody production and lymphocytic-mediated exocrine gland damage. Interstitial lung disease (ILD) is a common complication of pSS and can be associated with a poor prognosis. However, the pathogenesis of ILD in pSS is still unclear. Methods: In this study, we used RNA sequencing to investigate the gene-expression profile of the minor salivary glands (MSGs) from 36 patients with ILD-pSS and 128 patients with non-ILD-pSS. Results: In the remarkably enriched chemokine-mediated signaling pathway, C-X-C motif chemokine receptor 2 (CXCR2), a receptor for interleukin-8, which participates in the activation of neutrophils, was found to be significantly elevated in both MSG and plasma from pSS patients with vs. without ILD (p < 0.001). Furthermore, the CXCR2 expression level in MSG and plasma was significantly associated with the diffusing capacity of the lungs for carbon monoxide, erythrocyte sedimentation rate, and EULAR Sjögren's Syndrome disease Activity Index in ILD-pSS. Conclusion: Therefore, with its potential role in ILD progression in patients with pSS and its strong association with clinical manifestations of the disease, CXCR2 may serve as a useful index for disease activity in ILD associated with pSS.

Occult primary Sjögren Syndrome in patients with interstitial pneumonia with autoimmune features

INTRODUCTION/OBJECTIVES

To define the performance of Minor Salivary Gland Biopsy (MSGB) and Dry Eye Tests (DET) to detect occult Sjögren Syndrome (SS) among Interstitial Pneumonia with Autoimmune Features (IPAF) patients.

METHODS

Prospective study. Interstitial Lung Disease (ILD) patients without defined Connective Tissue Disease and one or more IPAF classification domains or xerophthalmia were included. MSGB, Schirmer's test (ST) and Ocular Staining Score (OSS) were performed in a blinded manner by experienced specialists. MSGB with ≥1 focus of lymphocytes and Dry Eye Test (DET) with OSS ≥ 5 and/or ST < 5 s were considered positive. SS was diagnosed according to the ACR 2016 criteria.

RESULTS

534 patients on the first consult were screened. 67 patients had at least one IPAF criteria, 53 (79.1%) female, mean age (SD) 64.2 years old (10.8). Positive ST in 36 (53.7%), positive OSS in 29 (43.3%) and positive MSGB in 36 (53.7%) were found. Finally, 27 (40.3%) met SS diagnostic criteria. 25 (37.3%) and 18 (26.8%) of them did not report dry eyes or dry mouth, respectively. 53 (79.1%) had negative anti SSA/Ro, 57 (85.1%) had negative anti LA/SSB, 30 (44.7%) had negative ANA, and 52 (77.6%) had negative RF, respectively. A significantly higher proportion of ANA (+), anti-SSA/Ro (+), anti-SSB/La (+), positive DET and positive MSGB were found in the SS population.

CONCLUSIONS

A significant proportion of patients with occult SS were found in our study. MSGB and DET may be considered in the evaluation of IPAF patients.

Clinical and laboratory features of patients with focal lymphocytic sialadenitis on minor salivary gland biopsy for sicca symptoms: A single-center experience

Minor salivary gland biopsy (MSGB) is often used in patients lacking specific autoantibodies (seronegative patients) to confirm the presence of focal lymphocytic sialadenitis (FLS), which would suggest a diagnosis of Sjogren syndrome. There are no current guidelines indicating when to refer patients for MSGB. The objective of our study was to ascertain distinguishing clinical and laboratory features among individuals with sicca symptoms based on their serologic and histopathologic status, and to identify factors associated with FLS.Using a cross-sectional study design, patients ages 18 years or older with sicca symptoms who had MSGB performed at the University of Iowa from January 2000 to December 2016 were selected for chart reviews. The clinical and laboratory features of patients with and without FLS were analyzed using exact univariate and multivariable logistic regression, with Bonferroni correction for multiple comparisons.We identified 177 patients who had MSGB performed and available clinical data. A total of 133 patients had FLS, 37 (27.8%) were seropositive (positive-anti-Sjogren syndrome type A [SSA] and/or anti-Sjogren syndrome type B) and 96 (72.2%) were seronegative. Dry eyes (unadjusted odds ratio [OR]: 5.17, 95% confidence interval [CI]: 1.16-26.30; adjusted odds ratio [aOR]: 12.58, 95% CI: 1.70-167.77) and the presence of anti-SSA (OR: 7.16, 95% CI: 1.70-64.24; aOR: 8.82, 95% CI: 1.73-93.93) were associated with FLS. Smoking (aOR 0.27, 95% CI: 0.11-0.63) and antihistamine use (aOR 0.23, 95% CI: 0.08-0.63) were associated with lower odds of FLS.Our study suggests that dry eyes and anti-SSA positivity are associated with FLS. Smoking and antihistamine use were associated with lower odds of FLS. In the appropriate clinical context, seronegative patients with sicca symptoms and no smoking history could be considered for MSGB. A thorough medication and smoking history should be performed in all patients before referral for MSGB.

Ultra-high frequency ultrasonography (UHFUS)-guided minor salivary gland biopsy: A promising procedure to optimize labial salivary gland biopsy in Sjögren's syndrome

BACKGROUND

Sjögren's syndrome (SS) is an autoimmune disease characterized by an inflammatory infiltrate of exocrine salivary and lachrymal glands. Diagnosis is complex, and minor salivary gland biopsy and subsequent focus score (FS) calculation appear of extreme importance in the diagnostic work-up of the disease. Ultra-high frequency ultrasonography (UHFUS) is a recently introduced diagnostic technique, which is gaining an increasingly important role in intraoral imaging. This study aims at exploring the usefulness of UHFUS for obtaining valuable labial salivary gland samples to assess the histopathological features of SS patients.

METHODS

Patients with clinical suspect of SS and eligible for minor salivary gland biopsy were enrolled. UHFUS scan of the lower lip was performed. Glandular echostructure was classified according to Outcome Measures in Rheumatology (OMERACT) scoring system. The glands to be sampled were selected on the basis of UHFUS evaluation and biopsied. The areas of the samples were recorded and compared with those obtained without UHFUS guidance. The correlation between UHFUS grade and labial gland FS was also assessed.

RESULTS

The areas of the samples obtained with UHFUS guidance were significantly higher (7.25 ± 3.98 mm² ) than those obtained by conventional procedures (5.79 ± 3.49 mm² , P = .02). UHFUS correlated significantly with the salivary gland FS (r = .532, P = .001).

CONCLUSION

UHFUS seems a promising tool in SS diagnostic algorithm, being able to provide a valuable support to the biopsy procedure. Further studies are mandatory to confirm the role of UHFUS in SS.

Local complications associated with labial salivary gland biopsy for diagnosis of Sjögren's Syndrome: A retrospective cohort study

Background

To describe local or systemic complications related to the labial salivary glands biopsy (LSGB) used as diagnostic tool for the diagnosis of Sjögren’s Syndrome (SS).

Material and Methods

Clinical databases from a cohort of patients, who underwent LSGB with provisional clinical diagnosis of Sjögren’s Syndrome, were retrospectively reviewed. Pain, assessed by registering the intake of analgesic drugs in the first week following the biopsy, and any further relevant clinical information regarding complications after biopsy were recorded.

Results

50 patients received LSGB. 10 of them (9 women and 1 man) showed histopathological findings compatible with SS. Ten patient (20%) receiving labial biopsy developed local complications: three of them (6%) reported a sensory defect at the surgical site that lasted at most few weeks; three patients (6%) reported pain sensation needing the assumption of analgesic drugs, while one patient (2%) described a transient local burning sensation, which resolved in few days. Three patients (6%) showed cutaneous haematoma in the surgical area and two patients (4%) showed mild mucosal inflammation at the biopsy site.

Conclusions

LSGB is associated with to few and mild complications and it is a useful tool in the diagnosis of SS. The complications usually resolved in few weeks after the biopsy.

Key words:Sjögren’s syndrome, labial salivary glands biopsy, adverse events, diagnosis.

Dry surgical field minor salivary gland harvest using a chalazion clamp for sicca syndrome

Background

Sjögren's syndrome is a rheumatological condition. Diagnosing Sjögren's syndrome can be challenging given the overlapping nature of clinical presentations. Currently, minor salivary gland biopsy is considered the definitive test for diagnosing Sjögren's syndrome. Various surgical techniques have been described, targeting biopsy of minor salivary glands from the lower lip. Identification of minor salivary glands is often difficult because of bleeding. One common complication of minor salivary gland biopsy is lip paraesthesia from iatrogenic sensory nerve injury.

Objectives

To describe a minor salivary gland biopsy technique in a bloodless operative field using a chalazion ophthalmic clamp under local anaesthesia, and to report our clinical outcomes.

Methods

A prospective study was performed on patients who underwent minor salivary gland biopsy using a chalazion ophthalmic clamp between July 2017 and April 2018.

Results

The study included 23 patients. The histopathological reports positively identified minor salivary glands for all patients. In nine cases, the histological findings were positive for Sjögren's syndrome. No lip paraesthesia complications were reported post-operatively.

Conclusion

This technique facilitates a superior yield, ensures adequate sampling of appropriate glands for histopathological analysis, and minimises the complications associated with traditional techniques.

Nitrated alpha-synuclein in minor salivary gland biopsies in Parkinson's disease

Alpha-synuclein (α-SYN) is found in peripheral autonomic neuronal network apart from brain in Parkinson's disease (PD). Nitrated α-SYN is an undesirable modification associated with oxidative and nitrative damage and has been found extensively in brain, gastrointestinal(GI) tract and blood cells in PD. We aim to investigate the presence of nitrated α-SYN in minor salivary gland biopsy in PD. Patients with PD and age-matched controls underwent minor salivary gland biopsy. Motor impairment was assessed by Hoehn-Yahr (H-Y) stage and Unified Parkinson's Disease Rating Scale (UPDRS) Part III in off-state. 11C-methyl-N-2b-carbomethoxy-3b-(4-fluorophenyl) tropane (11C-CFT) DAT-PET scan was performed in all subjects. Immunohistochemical staining for nitrated α-SYN was performed in the minor salivary gland tissues. The minor salivary gland tissues of 8 PD cases and 7 controls with early stage (H-Y stage 1-2) were detected. All PD patients showed asymmetrical and reduction of ¹¹C-CFT uptake in the caudate, anterior and posterior putamen, while all control subjects showed normal DAT-PET scan. Positive nitrated α-SYN immunostaining was observed in all PD patients (8/8,100%) but not in control subjects (0/7). The results were consistent well with that of DAT-PET. These nitrated alpha-synuclein positive structures were mainly located in the periacinar stroma in PD patients. Our result suggests that nitrated α-SYN exists in the early stage and is probably a promising biomarker for PD. Minor salivary gland is an ideal site for α-SYN nitration detection. Despite of the small number of subjects, attention should be given to α-SYN nitration in PD and more investigations on nitrated α-SYN in different sites and large sample using should be explored in future.

Role of oral examination in newly diagnosed multiple myeloma patients: A safe and simple way to detect light chain amyloidosis

OBJECTIVE

Up to 30% of multiple myeloma (MM) patients have subclinical amyloid deposits. These patients are under-recognized and are more susceptible to drug toxicity, bleeding and death. Early diagnosis and adjustment of treatment are crucial. Biopsies of oral mucosa might be a potentially useful diagnostic tool. The objective of this study was to assess the prevalence and characteristics at presentation of oral amyloidosis in a large cohort of MM patients.

METHODS

The prevalence and characteristics of oral amyloidosis in a large cohort of MM patients who were referred for oral evaluation before and during bisphosphonate therapy were assessed, retrospectively.

RESULTS

Among 212 patients analysed, 13 (6%) were diagnosed with concomitant light chain (AL) amyloidosis. In 54% (n = 7), lesions in the oral cavity compatible with amyloid deposition were detected by examination.

CONCLUSIONS

The salient feature of this study is the high prevalence of oral manifestations among MM patients with amyloidosis. These results highlight the value of routine oral cavity examination and biopsy as a safe and simple method for detecting light chain amyloidosis.

Minor Salivary Gland Biopsy-An Important Contributor to the Diagnosis of Sjögren Syndrome

PURPOSE

Sjögren syndrome (SS), although commonly associated with xerostomia and xerophthalmia, can present with extraglandular manifestations that make definitive diagnosis difficult. The 2 leading diagnostic classification systems include a positive minor salivary gland biopsy (MSGB) result as a major inclusion criterion. The purpose of this study was to better define the role of the MSGB in establishing a diagnosis of SS in a cohort of referred patients.

MATERIALS AND METHODS

This is a retrospective cohort study of patients referred to the Massachusetts General Hospital Department of Oral and Maxillofacial Surgery (Boston, MA) over a 5-year period to establish a diagnosis of SS. Inclusion criteria were complete information regarding presenting symptoms, reason for referral, and findings at MSGB. Incomplete records and referral for reasons other than presumptive SS resulted in exclusion. The MSGB and its role in definitive diagnosis based on accepted classification systems were evaluated for sensitivity, specificity, and positive and negative predictive values. Other variables of interest (demographics, pattern of referral, and symptomology) are described for the cohort.

RESULTS

Eighty-seven patients met the inclusion criteria. The mean age was 48.3 years (range, 19 to 74 yr) and 75 were women (86.2%). Fifteen MSGB results (17.2%) were positive based on the focus score histologic criteria. In 12 of 15 cases, the positive MSGB result allowed for a definitive diagnosis (80%). In 3 cases, other criteria allowed diagnosis without the contribution of the MSGB (sensitivity of MSGB, 80.0%; specificity, 87.5%; positive predictive value, 57.1%; negative predictive value, 95.5%).

CONCLUSION

The MSGB is an important contributor to a diagnosis of SS. When serology was negative, the MSGB often was the criterion that allowed the diagnosis to be established. It is the most frequently positive of the major criteria used by the 2 classification systems in current use.

Epidemiology of Sjögren's Syndrome-from an Oral Perspective

Oral symptoms are among the most distressing manifestations for patients with Sjögren's syndrome (SS). The feeling of dry mouth is unpleasant, and hyposalivation may contribute to difficulty in speaking, chewing and swallowing and reduced quality of life. Reduced salivary flow increases the risk for dental caries and problems with prosthetic replacement. It seems that SS is not as frequently occurring as previously anticipated. Population-based prevalence studies on primary SS in Europe, conducted on large background populations and in accordance with the AECG criteria, reported of a prevalence of 1-9 cases per 10,000 people. This gives a combined prevalence of nearly 39/100,000 (~0.04 %). The cause of Sjögren's syndrome is even now not fully understood, and the treatment of oral symptoms is still mostly palliative. Hopefully, useful information will appear from the new methods that are now available for genome wide association studies, epigenetics, DNA methylation studies, and proteomics. Similarly, this is anticipated for the immunological side of the story. The interferon signature, the interferon γ/interferon α mRNA ratio, and CXCL13 are among the proposed biomarkers of active disease. In this review, we provide an update on oral aspects of Sjögren's syndrome with emphasis on the latest publications on these topics.

Managing xerostomia and salivary gland hypofunction: executive summary of a report from the American Dental Association Council on Scientific Affairs

BACKGROUND AND OVERVIEW

Xerostomia, also known as "dry mouth," is a common but frequently overlooked condition that is typically associated with salivary gland hypofunction, which is the objective measurement of reduced salivary flow. Patients with dry mouth exhibit symptoms of variable severity that are commonly attributed to medication use, chronic disease and medical treatment, such as radiotherapy to the head and neck region. Chronic xerostomia significantly increases the risk of experiencing dental caries, demineralization, tooth sensitivity, candidiasis and other oral diseases that may affect quality of life negatively. This article presents a multidisciplinary approach to the clinical management of xerostomia, consistent with the findings of published systematic reviews on this key clinical issue.

CONCLUSIONS AND PRACTICE IMPLICATIONS

Initial evaluation of patients with dry mouth should include a detailed health history to facilitate early detection and identify underlying causes. Comprehensive evaluation, diagnostic testing and periodic assessment of salivary flow, followed by corrective actions, may help prevent significant oral disease. A systematic approach to xerostomia management can facilitate interdisciplinary patient care, including collaboration with physicians regarding systemic conditions and medication use. Comprehensive management of xerostomia and hyposalivation should emphasize patient education and lifestyle modifications. It also should focus on various palliative and preventive measures, including pharmacological treatment with salivary stimulants, topical fluoride interventions and the use of sugar-free chewing gum to relieve dry-mouth symptoms and improve the patient's quality of life.

Can we use peripheral tissue biopsies to diagnose Parkinson's disease? A review of the literature

Phosphorylated α-synuclein (phosαSYN) containing inclusions in neurons (Lewy bodies, LB) and nerve terminals (Lewy neurites, LN), the pathological hallmark of Parkinson's disease (PD), are not confined to the central nervous system, but have also been reported in peripheral tissues. However, the usefulness of αSYN/phosαSYN detection in tissues accessible to biopsies as a reliable biomarker for prodromal PD remains unclear. A systematic review of studies using biopsies of skin, olfactory and gastrointestinal (GI) tissues was conducted to evaluate the sensitivity and specificity of both αSYN and phosαSYN staining in PD patients. Data analysis was hampered by the diversity of the methods used, e.g. choice of biopsy sites, tissue processing, staining protocols and evaluation of the findings. Tissue obtained from GI tract/salivary glands (13 post-mortem, 13 in vivo studies) yielded the highest overall sensitivity and specificity compared to skin (three post-mortem, eight in vivo studies) and olfactory mucosa/bulb (six post-mortem studies, one in vivo study). In contrast to phosαSYN, αSYN was more consistently detectable in peripheral tissues of healthy controls. GI tract/salivary glands appear to be the most promising candidate tissue for peripheral biopsy-taking. phosαSYN is considered as the marker of choice to delineate pathological aggregates from normal αSYN regularly found in peripheral neural tissues. However, the sensitivity and specificity of phosαSYN are not yet acceptable for using phosαSYN as a reliable peripheral biomarker for PD in clinical routine. Further refinement regarding the interpretation of the peripheral αSYN/phosαSYN burden and the phenotypical definition of peripheral LB/LN is needed to optimize screening methods for prodromal PD.

A review of salivary gland histopathology in primary Sjögren's syndrome with a focus on its potential as a clinical trials biomarker

Salivary gland changes, characterised by a focal lymphocytic sialadenitits, play an important role in the diagnosis of primary Sjögren's syndrome (PSS) and were first described over 40 years ago. Recent evidence suggests that minor salivary gland biopsy may also provide information useful for prognostication and stratification, yet difficulties may arise in the histopathological interpretation and scoring, and evidence exists that reporting is variable. With the increasing number of actual and proposed clinical trials in PSS, we review the evidence that might support the role of histopathology as a biomarker for stratification and response to therapy and highlight areas where further validation work is required.

Clinical characteristics and biopsy accuracy in suspected cases of Sjögren's syndrome referred to labial salivary gland biopsy

BACKGROUND

Labial salivary gland biopsy (LSGB) is the most important diagnostic tool for the diagnosis of Sjögren's syndrome (SS), but its diagnostic value is rarely studied. This study assessed the sensibility and specificity of LSGB, and the clinical profiles of patients who were referred for biopsy.

METHODS

Retrospective analysis of the histopathological reports from LSGB and medical report data from patients who underwent LSGB between 2008 and 2011 was conducted.

RESULTS

About 290 biopsies were performed and 74 were excluded due to insufficient clinical data. Of the 216 patients, 0.46% was carrier of hepatitis C virus, 30.1% had primary SS (pSS), and 8.8% had secondary SS (sSS). Of the samples, 94.3% presented dryness symptoms, 51.6% experienced dryness only, 42.7% had systemic manifestations, and 66.9% presented low unstimulated salivary flow and/or Schirmer's test. LSGB was necessary in 67.6% to confirm the presence of SS based on the American-European Consensus Group 2002 criteria (AECG). Based on specialist's opinion, sensibility level was 86.57%, and specificity was 97.43%. Positive predictive value (PPV) was 95%, and negative predictive value (NPV) was 92.6%. Determined accuracy was 93.3%. Concordance (kappa coefficient) of LSGB and specialist's opinion was 0.851, and LSGB with AECG criteria was 0.806. Of the 98 patients referred with fibromyalgia and dryness, 36.7% had SS and LSBG focus score of ≥ 1. Patients with SS were older, and showed more severe lachrymal and salivary dysfunctions, greater frequency of fibromyalgia, anti-nuclear antibodies (ANA), anti-SSA-Ro, and anti-SSB-La.

CONCLUSIONS

Labial salivary gland biopsy has high sensibility, specificity, positive and negative predictive values for diagnosis of pSS. In the clinical practice, it is useful, especially for those patients with glandular dysfunctions and negative antibodies.

Salivary gland disorders

Patients with salivary gland disease present with certain objective and/or subjective signs. An accurate diagnosis for these patients requires a range of techniques that includes the organized integration of information derived from their history, clinical examination, imaging, serology, and histopathology. This article highlights the signs and symptoms of the salivary gland disorders seen in the Salivary Gland Center, and emphasizes the methodology used to achieve a definitive diagnosis and therapy.

Systemic AA amyloidosis: epidemiology, diagnosis, and management

The term “amyloidosis” encompasses the heterogeneous group of diseases caused by the extracellular deposition of autologous fibrillar proteins. The global incidence of amyloidosis is estimated at five to nine cases per million patient-years. While amyloid light-chain (AL) amyloidosis is more frequent in developed countries, amyloid A (AA) amyloidosis is more common in some European regions and in developing countries. The spectrum of AA amyloidosis has changed in recent decades owing to: an increase in the median age at diagnosis; a percent increase in the frequency of primary AL amyloidosis with respect to the AA type; and a substantial change in the epidemiology of the underlying diseases. Diagnosis of amyloidosis is based on clinical organ involvement and histological evidence of amyloid deposits. Among the many tinctorial characteristics of amyloid deposits, avidity for Congo red and metachromatic birefringence under unidirectional polarized light remain the gold standard. Once the initial diagnosis has been made, the amyloid subtype must be identified and systemic organ involvement evaluated. In this sense, the ¹²³I-labeled serum amyloid P component scintigraphy is a safe and noninvasive technique that has revolutionized the diagnosis and monitoring of treatment in systemic amyloidosis. It can successfully identify anatomical patterns of amyloid deposition throughout the body and enables not only an initial estimation of prognosis, but also the monitoring of the course of the disease and the response to treatment. Given the etiologic diversity of AA amyloidosis, common therapeutic strategies are scarce. All treatment options should be based upon a greater control of the underlying disease, adequate organ support, and treatment of symptoms. Nevertheless, novel therapeutic strategies targeting the formation of amyloid fibrils and amyloid deposition may generate new expectations for patients with AA amyloidosis.

Clinical and laboratorial profile and histological features on minor salivary glands from patients under investigation for Sjögren's syndrome

Diagnosis of Sjögren’s syndrome (SS) is complex and the usefulness of labial minor salivary glands biopsy in this process remains controversial. Objectives: to evaluate the clinical and laboratorial profile and histological features on labial minor salivary glands from patients under investigation of SS. Study Design: clinical charts from 38 patients under suspicion of SS and submitted to labial minor salivary glands biopsies were reviewed. Clinical and laboratorial data were retrieved from the clinical files and the HE-stained histological slides were reviewed under light microscopy. Results: mean age of the patients was 56.5 years and 97% were females; histological analysis showed that 42% of the cases showed ductal dilatation, lymphocytic foci were found in 52.6% and, from this group, 80% of the cases presented a foci/lobules ratio above 0.8. Acinar/ductal ratio was considered diminished in 39.5% of the samples. Thirty six (95%) and 32 (84%) patients, respectively, complained about xerostomia and xerophthalmia. A study of the time interval of the symptoms that led to SS investigation showed a mean of 116 months. Moreover, sixty-six percent of the patients had already been submitted to immunosuppressive therapy prior to the labial minor salivary gland biopsy. Age of the patients, scintigraphic alterations on salivary function, antinuclear factor (ANF), anti-Ro and anti-La did not show statistical significant association with the histological features. Lobules/foci ratio above 0.8 was the only histological parameter statistically associated with Sjögren’s syndrome diagnosis (p<0.0001). Conclusions: in the studied sample, lymphocytic foci on salivary glands were the only histological parameter associated to the diagnosis of SS. Early indication of labial minor salivary gland biopsy to patients under investigation of SS could limit the effects of immunosuppressive therapy on the histological features associated with the evolution of salivary gland involvement in SS.

Key words:Sjögren syndrome, minor salivary glands, biopsy, lymphocytic foci.

Neurological adverse events related to lip biopsy in patients suspicious for Sjögren's syndrome: a systematic review and prevalence meta-analysis

OBJECTIVE

The aim of this study was to compare the prevalence of neurological complications related to lip biopsy for SS diagnosis using conventional vs minimally invasive techniques.

METHODS

We performed a systematic review and prevalence meta-analysis using the search strategy [(salivary gland biopsy OR labial biopsy OR lip biopsy) AND (Sjögren)] in the MEDLINE, EMBASE and Web of Science Conference Proceedings Citation Index databases. Studies were selected if they included original data for minor salivary gland biopsy, sample size, exposure of interest (technique description), number of complications and number of affected patients. The prevalence of total and permanent neurological adverse effects was calculated. Both fixed-effects and random-effects pooled estimates were assessed. Heterogeneity was calculated using an adaptation of the DerSimonian and Laird Q test.

RESULTS

Sixteen articles were selected for the study. In the minimally invasive group (n = 3), the pooled prevalence of total adverse events is almost four times higher than that in the linear incision group (n = 12) (4.73% vs. 1.20%). In contrast, the pooled prevalence of the permanent or potentially permanent neurological adverse events is 8.5 times lower in the minimally invasive technique group than in the studies using linear incisions (0.17% vs. 1.45%).

CONCLUSION

With the limitations intrinsic to the potential biases in the studies included in this meta-analysis, we conclude that the minimally invasive lip biopsy technique for SS diagnosis induces fewer permanent neurological complications than conventional approaches with large linear incisions in the lower lip.

Minimally invasive minor salivary gland biopsy for the diagnosis of amyloidosis in a rheumatology clinic

Background. Systemic amyloidosis is a potentially fatal condition, unless diagnosed and treated before development of irreversible organ damage. Demonstration of amyloid deposits within tissue biopsies is only definitive diagnostic method, which makes appropriate selection of biopsy site essential. Herein, we evaluated efficacy of minimally invasive minor salivary gland biopsy (MSGB) for the diagnosis of amyloidosis. Methods. We analyzed 37 biopsies taken from 35 patients. Suggestive findings for amyloidosis were significant proteinuria, renal impairment, refractory diarrhea, neuropathy, and restrictive cardiomyopathy. Minor salivary gland was the initial biopsy site in all subjects. When MSGB was negative but there was a high suspicion for amyloidosis, a kidney, duodenum, or rectal biopsy was performed for further investigation. Results. Mean age of patients was 45.4 and 21 were female. In 11 patients amyloidosis was diagnosed with MSGB. In overall 18 patients were diagnosed with amyloidosis. Sixteen of them were identified as being of AA type and two were AL type amyloidosis. The sensitivity of minimally invasive MSGB is 61.1% for diagnosing amyloidosis in this study. Conclusion. MSGB is a safe and simple method for the diagnosis of amyloidosis which can be performed in an outpatient setting. We suggest extensive use of this minimally invasive method.

[Normal skin biopsy as a tool for extra-cutaneous disorders]

Biopsies of apparently healthy skin can contribute to the diagnosis of an internal disorder in a patient or in the detection of a potential disease carrier. Herein, we review those diseases for which dermatologists may be asked to perform a biopsy on normal skin where analysis by optical microscopy, immunofluorescence or electronic microscopy may result in diagnosis of an "internal" disease. Diseases for which biopsies are required for cell cultures (e.g. fibroblasts cultures), clonality testing or chromosomal analysis are not discussed here.

Minor salivary gland biopsy in Sjögren's syndrome: a review and introduction of a new tool to ease the procedure

Objectives: To review the existing techniques for minor salivary gland biopsy (MSGB) in the lip and to suggest a new approach to ease the procedure and reduce post-operative complications. Study Design: A comprehensive literature review and a descriptive study of a new surgical technique. Results: Diverse incisions have been suggested for MSGB with different designs (ellipse, circular, linear), different directions (parallel, oblique, vertical) and a wide range of lengths (from 1 mm up to 3 cm), but no comparative studies supporting the advantages of a particular type of incision over the others could be retrieved. A variety of features of the existing techniques for MSGB are linked to undesired events and surgical complications which could be minimized by modifying certain aspects of these procedures. The technique described, together with the use of the S forceps, represents a significant improvement over the already described chalazion forceps because it allows for a better access and positioning of the lower lip, improves the ergonomic conditions of the assistant, and facilitates the identification of lip areas with more superficial gland lobules. Conclusions: The suggested approach for lip MSGB includes a specifically designed instrument whose performance during lip biopsy may contribute to minimize post-operative complications.

Key words:Sjögren’s syndrome, diagnosis, minor salivary gland biopsy, surgical technique, lower lip.

Comparison of two different labial salivary gland biopsy incision techniques: a randomized clinical trial

Objectives: To compare the reliability of two different labial salivary gland biopsy (LSGB) incision techniques (vertical versus horizontal incision techniques) and to report the related complications and discomfort. Study Design: 163 patients who underwent LSGB were included in this study. Patients were randomly divided as vertical incision group (n=81) and horizontal incision group (n=82). Demographic and clinical information of each patient were recorded. A questionnaire was prepared and applied together with Visual Analog Scale (VAS) on the subjects verbally at the 7th day, postoperatively. Intraoperative, short- term and delayed complications were evaluated. Results: The mean age of patients (117 female, 46 male) was 47.3 years (range 19-79 years). Vertical incision technique was associated with less pain (p<0.001), less swelling (p<0.05), less scar formation (p<0.05) and less difficulty in eating (p<0.05) when compared with horizontal incision technique. No statistically significant differences were observed between the 2 groups in terms of hematoma, parasthesia and speech difficulty (p>0.05). Additionally, two subjects in the horizontal incision group revealed permanent paresthesia during the follow-up period of two years. Conclusions: This prospective study demonstrated that the subjects in the vertical incision group had less complication rates and discomfort after labial salivary gland procedure than those in the horizontal incision group.

Key words:Salivary gland, biopsy, incision.

Diagnostic value of minor salivary glands biopsy for the detection of Lewy pathology

The recent demonstration of the presence of Lewy pathology in the submandibular glands of Parkinson's disease (PD) patients prompted us to evaluate the diagnostic performance of minor salivary gland biopsy for PD. Minor salivary glands were examined for Lewy pathology using phosphorylated alpha-synuclein antibody in 16 patients with clinically diagnosed PD and 11 control subjects with other neurological disorders. Abnormal accumulation of alpha-synuclein was found in 3 out of 16 PD patients. Two control subjects exhibited weak phosphorylated alpha-synuclein immunoreactivity. Our results do not support the use of minor salivary glands biopsy for the detection of Lewy pathology in living subjects.