Approach to Pulmonary Nodules in Connective Tissue Disease

The assessment of pulmonary nodules is a common and often challenging clinical scenario. This evaluation becomes even more complex in patients with connective tissue diseases (CTDs), as a range of disease-related factors must also be taken into account. These diseases are characterized by immune-mediated chronic inflammation, leading to tissue damage, collagen deposition, and subsequent organ dysfunction. A thorough examination of nodule features in these patients is required, incorporating anatomic and functional information, along with patient demographics, clinical factors, and disease-specific knowledge. This integrated approach is vital for effective risk stratification and precise diagnosis. This review article addresses specific CTD-related factors that should be taken into account when evaluating pulmonary nodules in this patient group.

PET/CT in Inflammatory and Auto-immune Disorders: Focus on Several Key Molecular Concepts, FDG, and Radiolabeled Probe Perspectives

Chronic immune diseases mainly include autoimmune and inflammatory diseases. Managing chronic inflammatory and autoimmune diseases has become a significant public health concern, and therapeutic advancements over the past 50 years have been substantial. As therapeutic tools continue to multiply, the challenge now lies in providing each patient with personalized care tailored to the specifics of their condition, ushering in the era of personalized medicine. Precise and holistic imaging is essential in this context to comprehensively map the inflammatory processes in each patient, identify prognostic factors, and monitor treatment responses and complications. Imaging of patients with inflammatory and autoimmune diseases must provide a comprehensive view of the body, enabling the whole-body mapping of systemic involvement. It should identify key cellular players in the pathology, involving both innate immunity (dendritic cells, macrophages), adaptive immunity (lymphocytes), and microenvironmental cells (stromal cells, tissue cells). As a highly sensitive imaging tool with vectorized molecular probe capabilities, PET/CT can be of high relevance in the management of numerous inflammatory and autoimmune diseases. Relying on key molecular concepts of immunity, the clinical usefulness of FDG-PET/CT in several relevant inflammatory and immune-inflammatory conditions, validated or emerging, will be discussed in this review, together with radiolabeled probe perspectives.

Expert Perspective: Challenges in Sjögren's Disease

The management of Sjögren's disease is challenging because of several factors. Indeed, the clinical presentations are heterogeneous, and one must be able to identify prognostic markers to adapt the follow-up. In addition, there is no validated treatment. Nevertheless, international experts have been working for several years to establish recommendations to guide management. Since research in this field is extremely active, we anticipate the development of effective treatments for our patients in the near future.

FDG-PET/CT discriminates between patients with and without lymphomas in primary Sjögren's syndrome

OBJECTIVES

To assess the usefulness of [18F]-fluorodeoxyglucose (FDG)-PET/CT (i) to discriminate between primary SS (pSS) patients with and without lymphomas and (ii) to evaluate systemic disease activity in pSS.

METHODS

ACR-EULAR-positive pSS patients who underwent FDG-PET/CT were included. Scans were visually evaluated and quantitative analysis was performed by measuring standardized uptake values (SUV) of salivary and lacrimal glands and systemic regions. Receiver operating characteristic curve analyses were performed to find SUV cut-off values to discriminate between lymphoma and non-lymphoma.

RESULTS

Of the 70 included patients, 26 were diagnosed with a pSS-associated lymphoma, mostly of the mucosa-associated lymphoid tissue type (23/26). Lymphoma patients showed higher FDG uptake in the parotid and submandibular glands, and more frequently showed presence of nodular lung lesions, compared with non-lymphoma patients. The accuracy of the maximum SUV (SUVmax) in the parotid and submandibular gland to predict lymphoma diagnosis was good, with optimal cut-off points of 3.1 and 2.9. After combining these three visual and quantitative findings (nodular lung lesions, parotid SUVmax > 3.1 and submandibular SUVmax > 2.9), sensitivity was 92% when at least one of the three features were present, and specificity was 91% in case at least two features were present. Furthermore, FDG-PET/CT was able to detect systemic manifestations in pSS patients, mostly involving lymph nodes, entheses and lungs.

CONCLUSIONS

FDG-PET/CT can assist in excluding pSS-associated lymphomas in patients without PET abnormalities, possibly leading to a decrease of invasive biopsies in suspected lymphoma patients. Furthermore, FDG-PET/CT is able to detect systemic manifestations in pSS and can guide to the best biopsy location.

Predisposing Factors, Clinical Picture, and Outcome of B-Cell Non-Hodgkin’s Lymphoma in Sjögren’s Syndrome

Among other systemic autoimmune diseases, primary Sjögren syndrome (pSS) bears the highest risk for lymphoma development. In pSS, chronic antigenic stimulation gradually drives the evolution from polyclonal B-cell expansion to oligoclonal/monoclonal B-cell predominance to malignant B-cell transformation. Thus, most pSS-related lymphomas are B-cell non-Hodgkin lymphomas (NHLs), with mucosa-associated lymphoid tissue (MALT) lymphomas predominating, followed by diffuse large B-cell lymphomas (DLBCLs) and nodal marginal zone lymphomas (NMZLs). Since lymphomagenesis is one of the most serious complications of pSS, affecting patients’ survival, a plethora of possible predisposing factors has been studied over the years, ranging from classical clinical, serological, hematological, and histological, to the more recently proposed genetic and molecular, allowing clinicians to timely detect and to closely follow-up the subgroup of pSS patients with increased risk for lymphoma development. Overall predisposing factors for pSS-related lymphomagenesis reflect the status of B-cell hyperactivity. Different clinical features have been described for each of the distinct pSS-related B-cell NHL subtypes. While generally pSS patients developing B-cell NHLs display a fairly good prognosis, outcomes in terms of treatment response and survival rates seem to differ depending on the lymphoma subtype, with MALT lymphomas being characterized by a rather indolent course and DLBCLs gravely affecting patients’ survival.

Sjögren Syndrome: New Insights in the Pathogenesis and Role of Nuclear Medicine

In the last years, new insights into the molecular basis of rheumatic conditions have been described, which have generated particular interest in understanding the pathophysiology of these diseases, in which lies the explanation of the diversity of clinical presentation and the difficulty in diagnostic and therapeutic approaches. In this review, we focus on the new pathophysiological findings for Sjögren syndrome and on the derived new SPECT and PET radiopharmaceuticals to detect inflammation of immunological origin, focusing on their role in diagnosis, prognosis, and the evaluation of therapeutic efficacy.

The role of PET/CT in connective tissue disorders: systemic sclerosis, Sjögren's syndrome and systemic lupus erythematosus

Advanced imaging techniques are needed to help clinicians in the diagnosis, in the choice of the right time for therapeutic interventions or for modifications and monitoring of treatment response in patients with autoimmune connective tissue diseases. Nuclear medicine imaging, especially PET/CT and PET/MRI, may play an important role in detecting disease activity, assessing early treatment response as well as in clarifying the complex mechanisms underlying systemic sclerosis, Sjögren's syndrome or systemic lupus erythematosus. In addition, [¹⁸F]FDG PET/CT may help in excluding or detecting coexisting malignancies. Other more specific radiopharmaceuticals are being developed and investigated, targeting specific cells and molecules involved in connective tissue diseases. Further larger studies with standardized imaging protocol and image interpretation are strongly required before including PET/CT in the diagnostic work-up of subsets of patients with autoimmune connective tissue diseases.

Features of non-Hodgkin’s lymphoma diagnosed in minor salivary gland biopsies from primary Sjögren’s syndrome patients

Objective

To evaluate the contribution of minor salivary gland biopsy (mSGB) histology to diagnosing primary Sjögren’s syndrome (pSS)-associated non-Hodgkin B cell lymphoma (NHL).

Methods

pSS patients with mSGB at NHL diagnosis were included.

Results

Among the 24 patients (92.3% female; mean age: 61.3 years) with an mSGB at NHL diagnosis, 13 (54.2%) had mSGB-histology–revealed NHL (mSGB+); it was the only site enabling NHL diagnosis in 10/13 (76.9%) patients. Mucosa-associated lymphoid tissue (MALT) lymphoma was found in 23/24 (95.8%) patients; 100% of mSGB+ identified MALT lymphomas. pSS and lymphoma characteristics were comparable for mSGB+ and mSGB– patients. Eight (61.5%) of the 13 mSGB+ patients and all 11 mSGB– patients were treated for lymphoma. Between diagnosis and 1 year of follow-up, ESSDAI without the NHL item remained stable (7.4 vs 5.0; p = 0.33) for the five untreated patients, while it decreased significantly for the 19 treated patients (15.8 vs 5.1; p = 0.004).

Conclusion

For pSS patients with suspected NHL, mSGB histology enabled NHL diagnosis in half of them, MALT was found in 95.8% and all mSGBs+ were MALT lymphomas, thereby avoiding more invasive biopsy. Our results suggest that mSGB should be obtained at pSS diagnosis and repeated during follow-up, when NHL is suspected.

Pulmonary involvement in Sjögren's syndrome

Sjögren's syndrome is an autoimmune disease that involves exocrine glands. The most characteristic symptoms consist of the sicca syndrome (including xerostomia and dry eye - xerophtalmia), but can involve multiple organs. The extraglandular involvement determines the prognosis. It is typically associated with the presence of antinuclear antibodies, including Ro-60 antibodies. Pulmonary involvement appears as bronchiectasis and/or interstitial pneumonia. Considering its high prevalence, it must be ruled out in all patients with respiratory symptoms by performing pulmonary function tests and high-resolution computed tomography of the chest. Evaluation can be completed with a transbronchial biopsy if diagnostic doubts persist. Treatment includes steroid therapy, inmunosupressive or antifibrotic drugs, or biological therapy. In selected cases pulmonary transplantation must be considered.

Advanced imaging for quantification of abnormalities in the salivary glands of patients with primary Sjögren's syndrome

Objectives

To assess non-invasive imaging for detection and quantification of gland structure, inflammation and function in patients with primary Sjogren's syndrome (pSS) using PET-CT with ¹¹C-Methionine (¹¹C-MET; radiolabelled amino acid), and ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG; glucose uptake marker), to assess protein synthesis and inflammation, respectively; multiparametric MRI evaluated salivary gland structural and physiological changes.

Methods

In this imaging/clinical/histology comparative study (GSK study 203818; NCT02899377) patients with pSS and age- and sex-matched healthy volunteers underwent MRI of the salivary glands and ¹¹C-MET PET-CT. Patients also underwent ¹⁸F-FDG PET-CT and labial salivary gland biopsies. Clinical and biomarker assessments were performed. Primary endpoints were semi-quantitative parameters of ¹¹C-MET and ¹⁸F-FDG uptake in submandibular and parotid salivary glands and quantitative MRI measures of structure and inflammation. Clinical and minor salivary gland histological parameter correlations were explored.

Results

Twelve patients with pSS and 13 healthy volunteers were included. Lower ¹¹C-MET uptake in parotid, submandibular and lacrimal glands, lower submandibular gland volume, higher MRI fat fraction, and lower pure diffusion in parotid and submandibular glands were observed in patients vs healthy volunteer, consistent with reduced synthetic function. Disease duration correlated positively with fat fraction and negatively with ¹¹C-MET and ¹⁸F-FDG uptake, consistent with impaired function, inflammation and fatty replacement over time. Lacrimal gland ¹¹C-MET uptake positively correlated with tear flow in patients, and parotid gland ¹⁸F-FDG uptake positively correlated with salivary gland CD20+ B-cell infiltration.

Conclusion

Molecular imaging and MRI may be useful tools to non-invasively assess loss of glandular function, increased glandular inflammation and fat accumulation in pSS.

Ultrasound and Bioptic Investigation of Patients with Primary Sjögren's Syndrome

Primary Sjögren's syndrome (pSS) is a chronic and heterogeneous disorder characterized by a wide spectrum of glandular and extra-glandular features. The hallmark of pSS is considered to be the immune-mediated involvement of the exocrine glands and B-cell hyperactivation. This leads pSS patients to an increased risk of developing lymphoproliferative diseases, and persistent (>2 months) major salivary gland enlargement is a well-known clinical sign of possible involvement by B cell lymphoma. Better stratification of the patients may improve understanding of the mechanism underlying the risk of lymphoproliferative disorder. Here, we summarize the role of different imaging techniques and a bioptic approach in pSS patients, focusing mainly on the role of salivary gland ultrasonography (SGUS) and a US-guided core needle biopsy (Us-guided CNB) as diagnostic and prognostic tools in pSS patients with persistent parotid swelling.

Pulmonary nodules in patients with primary Sjögren's syndrome: Causes, clinico-radiologic features, and outcomes

BACKGROUND

Primary Sjögren's Syndrome (pSS) is characterized by an immune-mediated lymphoplasmacytic infiltration of the salivary and lacrimal glands. Pulmonary nodules are not uncommonly encountered in these patients.

METHODS

We conducted a retrospective computer-assisted search for patients with pSS who were encountered at our institution between 1999 and 2018 and had histologically characterized pulmonary nodule(s)/mass (es) (PNs).

RESULTS

Of 41 patients with pSS and PNs, median age was 67 years (IQR, 56-74), 94% were women, and 39% had a smoking history. The PNs proved to be non-Hodgkin lymphoma (NHL) in 16 patients (39%), lung carcinoma in 11 patients (27%), other malignancies in 2 patients (5%), and benign diseases in remaining 12 patients (29%), including 7 with amyloidomas. Patients with NHL were younger (p = 0.006) while smoking exposure was more prevalent in patients with lung carcinoma (p = 0.022). Patients with NHL had a higher number of PNs and more often manifested random distribution, cysts, ground-glass changes and consolidations. Upper and/or mid-lung location, spiculated borders, solitary nodule, increasing size, and higher SUV_mean on FDG-PET scan were associated with lung carcinoma. At the end of follow-up (median 5.9 years), 8 patients (20%) had died and included 5 patients with lung carcinoma; no deaths were observed in the NHL group.

CONCLUSIONS

The majority of biopsied PNs in patients with pSS were malignant, most commonly lymphomas. Smoking exposure, solitary nodule, and high FDG avidity were more frequently associated with lung carcinoma. The clinical context, CT and ¹⁸FDG-PET are complementary in the evaluation and management of PNs in patients with pSS.

Consensus Guidelines for Evaluation and Management of Pulmonary Disease in Sjögren's

Background

Pulmonary disease is a potentially serious yet underdiagnosed complication of Sjögren’s syndrome, the second most common autoimmune rheumatic disease. Approximately 16% of patients with Sjögren’s demonstrate pulmonary involvement with higher mortality and lower quality of life.

Research Question

Clinical practice guidelines for pulmonary manifestations of Sjögren’s were developed by the Sjögren’s Foundation after identifying a critical need for early diagnosis and improved quality and consistency of care.

Study Design and Methods

A rigorous and transparent methodology was followed according to American College of Rheumatology guidelines. The Pulmonary Topic Review Group (TRG) developed clinical questions in the PICO (Patient, Intervention, Comparison, Outcome) format and selected literature search parameters. Each article was reviewed by a minimum of two TRG members for eligibility and assessment of quality of evidence and strength of recommendation. Guidelines were then drafted based on available evidence, expert opinion, and clinical importance. Draft recommendations with a clinical rationale and data extraction tables were submitted to a Consensus Expert Panel for consideration and approval, with at least 75% agreement required for individual recommendations to be included in the final version.

Results

The literature search revealed 1,192 articles, of which 150 qualified for consideration in guideline development. Of the original 85 PICO questions posed by the TRG, 52 recommendations were generated. These were then reviewed by the Consensus Expert Panel and 52 recommendations were finalized, with a mean agreement of 97.71% (range, 79%-100%). The recommendations span topics of evaluating Sjögren’s patients for pulmonary manifestations and assessing, managing, and treating upper and lower airway disease, interstitial lung disease, and lymphoproliferative disease.

Interpretation

Clinical practice guidelines for pulmonary manifestations in Sjögren’s will improve early identification, evaluation, and uniformity of care by primary care physicians, rheumatologists, and pulmonologists. Additionally, opportunities for future research are identified.

Current status of imaging of Sjogren's syndrome

Primary Sjögren's syndrome (pSS) is an autoimmune disease, which involves salivary glands (SG) and extra glandular organs. Today, Sjögren's patients' diagnosis is based on classification criteria taking into account five objective tests, including histology, immunology, two ophthalmological tests, and salivary flow evaluation. To date, the challenge is to find the right imaging tool for diagnosis, follow up, and prognosis of pSS. The objective of this review is to describe as to what are these imaging modalities and particularly the place and validity of salivary glands ultrasonography (SGUS) in the diagnosis and follow-up strategy of patients with suspected pSS. Moreover, new noninvasive tools are emerging, including elastography, a new ultrasonography technique that provides an estimate of tissue elasticity, MRI, MR sialography, and ¹⁸ fluorodeoxyglucose-positron emission tomography. Although new imaging opportunities are available, SGUS should be the first-line choice in pSS because of its accessibility, feasibility over time, and sensitivity to change.

Imaging in Primary Sjögren's Syndrome

Primary Sjögren's syndrome (pSS) is a systemic autoimmune disease characterized by dysfunction and lymphocytic infiltration of the salivary and lacrimal glands. Besides the characteristic sicca complaints, pSS patients can present a spectrum of signs and symptoms, which challenges the diagnostic process. Various imaging techniques can be used to assist in the diagnostic work-up and follow-up of pSS patients. Developments in imaging techniques provide new opportunities and perspectives. In this descriptive review, we discuss imaging techniques that are used in pSS with a focus on the salivary glands. The emphasis is on the contribution of these techniques to the diagnosis of pSS, their potential in assessing disease activity and disease progression in pSS, and their contribution to diagnosing and staging of pSS-associated lymphomas. Imaging findings of the salivary glands will be linked to histopathological changes in the salivary glands of pSS patients.

Relevance on the diagnosis of malignant lymphoma of the salivary gland

Malignant lymphoma originates from the lymphohematopoietic system. It can occur in any lymphoid tissue. Malignant lymphoma of the salivary gland is rare, but its incidence has increased in recent years. Its clinical- presentations are non-specific, and it is often manifested as a painless mass in a salivary gland, which can be accompanied by multiple swollen cervical lymph nodes. Confirmation of the diagnosis before an invasive procedure is difficult. Clinically, malignant lymphoma of the salivary gland tends to be misdiagnosed, leading to an inappropriate treatment plan and the ultimate delay in the optimal treatment of the disease. This article reviews the pathogenesis, clinical features, imaging findings, diagnosis, treatment and prognosis of malignant lymphoma of the salivary gland.

[Sjögren's syndrome update: Clinical and therapeutic aspects]

Sjögren's syndrome (SS) is a systemic orphan disease. It is characterized by the involvement of epithelial tissues leading to the term of autoimmune epithelitis. New classification criteria have been developed in 2016. New scores have also been developed: a patient-reported outcome called ESSPRI and a score assessing systemic activity of the disease called ESSDAI. These new tools are very helpful to better stratify patients and to customize the management of this very heterogeneous disease. Among the autoimmune diseases, SS is associated with the highest risk of lymphoma. Five to ten percent of the patients will have a B cell lymphoma mostly a low-grade lymphoma developing from mucosa-associated lymphoid tissue (MALT). Major advances have been made in this field: pathogeny is better understood, new predictors are available and progresses have been made in the management of this severe complication. Research in the field of SS is very dynamic as illustrated by the high number of therapeutic trials. There is hope that these innovations, reviewed in the present article, will have potential significant repercussions for the patients in the next few years.

Lymphomas complicating primary Sjögren's syndrome: from autoimmunity to lymphoma

Lymphoma development is the most serious complication of SS and the main factor impacting on mortality rate in patients with this condition. Lymphomas in SS are most commonly extranodal non-Hodgkin B-cell lymphomas of the mucosa-associated lymphoid tissue and frequently arise in salivary glands that are the target of a chronic inflammatory autoimmune process. Extensive work on lymphomagenesis in SS has established that the progression towards B-cell lymphoma is a multistep process related to local chronic antigenic stimulation of B cells. These neoplastic B cells in SS frequently derived from autoreactive clones, most commonly RF-producing B cells, which undergo uncontrolled proliferation and malignant escape. In this review, we highlight the most important recent findings that have enhanced our understanding of lymphoma development in SS, with particular reference to the close link between autoimmunity and lymphomagenesis. We also discuss how the identification of key factors involved in B-cell malignancies may impact on our ability to identify at early stages patients at increased risk of lymphoma with potential significant repercussions for the clinical management of SS patients. Finally, we identified the most promising areas of current and further research with the potential to provide novel basic and translational discoveries in the field. The questions of finding new biomarkers, developing a validated score for predicting lymphoma occurrence and assessing if a better control of disease activity will decrease the risk of lymphoma in primary SS will be the enthralling questions of the next few years.