Familial Sjögren's syndrome with associated primary salivary gland lymphoma

MALT Lymphoma of the Tongue in a Patient with Sjögren's Syndrome: A Case Report and Literature Review

Sjögren’s syndrome (SS) is a systemic chronic autoimmune disorder characterized by lymphocytic infiltration of the exocrine glands, as well as oral and ocular dryness. Among the late complications, malignant lymphoma is the most serious complication of SS. The risk of lymphoma in patients with SS has been estimated to be approximately 7–19 times higher than that in a generally healthy population. Although various histologic subtypes of lymphoma can occur in patients with SS, mucosa-associated lymphoid tissue (MALT) lymphoma accounts for 48–75% of malignant lymphomas that are frequently located in the parotid gland. However, MALT lymphoma affecting the tongue in patients with SS is extremely rare. Here, we share our experience with a unique case of MALT lymphoma of the tongue, originating from the minor salivary gland tissue in a patient with SS. Through this case report, we emphasize that MALT lymphoma should be considered in the differential diagnosis of a tongue mass in patients with SS.

Contribution of Genetic Factors to Sjögren's Syndrome and Sjögren's Syndrome Related Lymphomagenesis

We aimed to summarize the current evidence related to the contributory role of genetic factors in the pathogenesis of Sjögren's syndrome (SS) and SS-related lymphoma. Genes within the major histocompatibility complex (MHC) locus previously considered conferring increased susceptibility to SS development have been also revealed as important contributors in recent genome wide association studies. Moreover, genetic variations outside the MHC locus involving genes in type I interferon pathway, NF-κB signaling, B- and T-cell function and methylation processes have been shown to be associated with both SS and SS-related lymphoma development. Appreciating the functional implications of SS-related genetic variants could provide further insights into our understanding of SS heterogeneity, allowing the design of tailored therapeutic interventions.

Familial Risk of Sjögren's Syndrome and Co-aggregation of Autoimmune Diseases in Affected Families: A Nationwide Population Study

Objective

To investigate familial aggregation of Sjögren's syndrome (SS) and the relative risks (RRs) of other autoimmune disease in relatives of patients with SS.

Methods

We identified 23,658,577 beneficiaries enrolled in the Taiwan National Health Insurance system in 2010, of whom 12,754 had SS. We identified 21,009,551 parent–child relationships and 17,168,340 pairs of full siblings. The familial risks of SS and other autoimmune diseases, tetrachoric correlation, and familial transmission were estimated.

Results

We identified 105 patients with SS who had an affected first‐degree relative. The RR of SS was 18.99 (95% confidence interval [95% CI] 9.76–36.93) in siblings of patients with SS, 11.31 (95% CI 8.34–15.33) in offspring, and 12.46 (95% CI 9.34–16.62) in parents. Tetrachoric correlation coefficients were 0.53 (95% CI 0.41–0.65) for cotwins of affected individuals and 0.21 (95% CI 0.16–0.26) for full siblings. The familial transmission (heritability plus shared environmental contribution) was 0.54 (95% CI 0.44–0.77). In first‐degree relatives of patients with SS, the RRs were 2.95 (95% CI 2.33–3.73) for rheumatoid arthritis, 6.25 (95% CI 5.15–7.58) for systemic lupus erythematosus, 2.39 (95% CI 0.77–7.41) for systemic sclerosis, 0.71 (95% CI 0.10–5.07) for idiopathic inflammatory myopathy, 1.97 (95% CI 1.29–3.02) for type 1 diabetes mellitus, 3.38 (95% CI 1.26–9.05) for multiple sclerosis, 1.67 (95% CI 0.83–3.33) for myasthenia gravis, 1.25 (95% CI 1.04–1.50) for psoriasis, 1.21 (95% CI 0.39–3.76) for inflammatory bowel disease, and 2.29 (95% CI 1.19–4.40) for vasculitis.

Conclusion

The risk of SS and other autoimmune diseases is increased in relatives of patients with SS, and more than one‐half of phenotypic variance in SS can be explained by familial factors.

Primary Sjögren's syndrome and occupational risk factors: A case-control study

OBJECTIVES

A case-control study was carried out to investigate the relation between primary Sjögren's syndrome (pSS) and occupational exposure.

METHODS

One hundred seventy five cases of pSS followed up into the internal medicine departments of three French university hospitals from 2010 to 2013 were included. For each case, two age and gender matched controls were selected during the same period in the same departments. Occupational exposure was assessed retrospectively by industrial hygienists and occupational practitioners. Exposure to occupational factors such as organic solvents or silica was investigated using semiquantitative estimates of exposure. An exposure score was calculated for each subject based on probability, intensity, daily frequency, and duration of exposure for each period of employment. The final cumulative exposure score was obtained, taking into account all periods of employment.

RESULTS

Significant associations with pSS were observed for dichloromethane (OR 9.28, 95%CI 2.60-33.03), perchlorethylene (OR 2.64, 95%CI 1.20-5.77) chlorinated solvents (OR 2.95, 95%CI 1.77-4.93), benzene (OR 3.30, 95%CI 1.07-10.26), toluene (OR 4.18 95%CI 1.41-12.43), white spirit (OR 3.60, 95%CI 1.39-9.33), aromatic solvents (OR 3.03, 95%CI 1.41-6.50) and any types of solvents (OR 2.76, 95%CI 1.70-4.47). Risk of pSS was significantly associated with a high cumulative exposure score of occupational exposure to toluene (OR 4.69, 95%CI 1.42-15.45), white spirit (OR 3.30, 95%CI 1.07-10.26), aromatic solvents (OR 2.50, 95%CI 1.06-5.91) and any types of solvents (OR 2.25, 95%CI 1.20-4.22).

CONCLUSION

This work suggests the influence of occupational risk factors in the occurrence of pSS.

Sjögren Syndrome-associated lymphomas: an update on pathogenesis and management

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.

Renal tubular acidosis in Sjögren's syndrome: a case series

BACKGROUND

The exact frequency of distal and proximal renal tubular acidosis (RTA) in Sjögren's syndrome is unknown. Other features of Sjögren's syndrome like polyuria, glomerular manifestations, familial occurrence and pregnancy are not widely reported. The aim was to prospectively study the clinical features and outcome of distal and proximal RTA in Sjögren's syndrome and also report on other renal manifestations of Sjögren's syndrome.

METHODS

The present study is a prospective consecutive case series of patients who presented with a history suggestive of RTA and Sjögren's syndrome. All patients were followed for 1 year. The diagnosis of RTA was by fractional excretion of bicarbonate. The diagnosis of Sjögren's syndrome was according to the American-European classification system [modified by Tzioufas and Voulgarelis: Best Pract Res Clin Rheumatol 2007;21:989-1010].

RESULTS

The total number of RTA patients diagnosed during this period was 149. Sjögren's syndrome accounted for 34.8% (52 of 149) of RTA patients. The important symptoms and laboratory parameters were oral and ocular symptoms in 23 (44.2%), dental caries in 12 (23%), body pains in 47 (90.3%), mean serum pH 7.202 ± 0.03, mean serum bicarbonate, 14.03 ± 1.66 mmol/l, and mean urine pH, 7.125 ± 0.54. There were 30 (57.6%) patients with distal RTA and 22 (42.3%) patients with proximal RTA.

CONCLUSIONS

The clinical implication of the present study is that RTA is a common feature of Sjögren's syndrome. It may be missed if the presentation is not due to oral and ocular symptoms. The present study is also the only one with a 1-year follow-up.

Familial Idiopathic Interstitial Pneumonia: Histopathology and Survival in 30 Patients

Context.—Familial idiopathic interstitial pneumonia (F-IIP) describes the unexplained occurrence of diffuse parenchymal lung disease in related individuals. Prevailing wisdom suggests that the histopathology of F-IIP is indistinguishable from that of idiopathic pulmonary fibrosis, namely, usual interstitial pneumonia (UIP).

Objective.—To define the histopathology of F-IIP in lung tissue samples.

Design.—Tissue sections from 30 patients with F-IIP, enrolled in a national research program, were evaluated by 3 pulmonary pathologists using 15 predefined histopathologic features. Each feature was recorded independently before a final diagnosis was chosen from a limited list dichotomized between UIP or “not UIP.” These 2 groups were then compared to survival.

Results.—The consensus diagnosis for the F-IIP cohort was an unclassifiable parenchymal fibrosis (60%), with a high incidence of histopathologic honeycombing, fibroblast foci, and smooth muscle in fibrosis. Usual interstitial pneumonia, strictly defined, was identified in less than half of the F-IIP cases (range, 23%–50%). Interobserver agreement was fair (κ  =  0.37) for 2 observers for the overall diagnosis of UIP. Findings unexpected in UIP were prevalent. The survival for the entire F-IIP cohort was poor, with an estimated mortality of 93% and a median age at death of 60.9 years. Subjects with UIP had a shorter survival and younger age at death.

Conclusions.—Pulmonary fibrosis was the dominant histopathology identified in our patients, but diagnostic features of UIP were seen in less than 50% of the samples. Overall survival was poor, with mortality accelerated apparently by the presence of a UIP pattern of disease.

Influence of STAT4 polymorphism in primary Sjögren's syndrome

OBJECTIVE

To examine the influence of STAT4 rs7574865 gene polymorphism on patients with primary Sjögren's syndrome (SS).

METHODS

Two different cohorts were studied: 69 patients with primary SS and 296 controls from Colombia and 108 patients with primary SS and 227 controls from Germany. Samples were genotyped for the STAT4 rs7574865 single-nucleotide polymorphism with a predesigned TaqMan single-nucleotide polymorphism genotyping assay. We carried out a metaanalysis of our results combined with data published to date.

RESULTS

Although no significant differences were observed in the allele frequencies of STAT4 rs7574865 gene polymorphism between patients and controls in Colombians (p = 0.28, OR 1.24, 95% CI 0.82-1.87) and Germans (p = 0.08, OR 1.40, 95% CI 0.96-2.02), the metaanalysis disclosed a significant effect of the T allele on disease (p = 4.7 x 10(-6), OR 1.40, 95% CI 1.21-1.62).

CONCLUSION

These data reinforce the influence of STAT4 gene on primary SS and as a general autoimmune gene.

Genes and Sjögren's syndrome

The evidence for a strong genetic component conferring susceptibility to primary Sjögren's syndrome (SS) is mounting. Several associations with SS have been reported and provide evidence that the HLA region harbors important susceptibility loci and that multiple genes outside the HLA region play a role. Genetic discovery lags behind success observed in related autoimmune diseases. Identifying genetic factors that cause SS will allow more precise definition of pathogenic mechanisms leading to the overall SS phenotype and clinically heterogeneous subsets of patients. Critical opportunities are certain to follow for translation into improved diagnosis and therapies for SS and its spectrum diseases.

Cell biology of membrane trafficking in human disease

Understanding the molecular and cellular mechanisms underlying membrane traffic pathways is crucial to the treatment and cure of human disease. Various human diseases caused by changes in cellular homeostasis arise through a single gene mutation(s) resulting in compromised membrane trafficking. Many pathogenic agents such as viruses, bacteria, or parasites have evolved mechanisms to subvert the host cell response to infection, or have hijacked cellular mechanisms to proliferate and ensure pathogen survival. Understanding the consequence of genetic mutations or pathogenic infection on membrane traffic has also enabled greater understanding of the interactions between organisms and the surrounding environment. This review focuses on human genetic defects and molecular mechanisms that underlie eukaryote exocytosis and endocytosis and current and future prospects for alleviation of a variety of human diseases.

Genetic aspects of Sjögren's syndrome

Sjögren's syndrome is a multisystem inflammatory rheumatic disease that is classified into primary and secondary forms, with cardinal features in the eye (keratoconjunctivitis sicca) and mouth (xerostomia). The aetiology behind this autoimmune exocrinopathy is probably multifactorial and influenced by genetic as well as by environmental factors that are as yet unknown. A genetic predisposition to Sjögren's syndrome has been suggested on the basis of familial aggregation, animal models and candidate gene association studies. Recent advances in molecular and genetic methodologies should further our understanding of this complex disease. The present review synthesizes the current state of genetics in Sjögren's syndrome.

Primary parotid lymphoma: the effect of International Prognostic Index on outcome

Since the reported survival and failure-free survival (FFS) of adults with primary parotid non-Hodgkin's lymphoma (NHL) is variable, we reviewed our experience of untreated adults with primary parotid NHL. Patients were eligible if they presented to the University of Texas M. D. Anderson Cancer Center Cancer between 1980 and 1995 with parotid enlargement and if the diagnosis of lymphoma was verified according the Working Formulation. Medical records were reviewed to determine Ann Arbor Stage (AAS), the International Prognostic Index (IPI) score, response to therapy, relapse, FFS, and survival. We identified 39 untreated adults with primary parotid NHL representing 1% of all lymphomas and 8.6% of all untreated parotid neoplasms. Three patients were excluded because of suboptimal therapy, leaving 36 patients eligible for outcome analysis. Of the 18 patients with low-grade NHL, two were treated with radiotherapy, eight with chemotherapy and radiotherapy, seven with chemotherapy only, and one with antibiotics. The complete remission (CR) rate was 94%, and with a median follow-up of 36 months for surviving patients the survival and failure-free survival (FFS) at 5 years were 94% and 78%, respectively. The 5-year FFS were not statistically different between patients with early (I or II) or advanced (III or IV) AAS (83% and 74%, respectively; p > 0.05) and favorable (0 or 1) or unfavorable (> 1) IPI scores (73% and 100%, respectively; p > 0.05). All 18 patients with intermediate-grade NHL were treated with doxorubicin-based chemotherapy which was followed by radiotherapy in six. The CR rate was 89%, and with a median follow-up of 51 months for surviving patients the survival and FFS at 10 years were 80% and 72%, respectively. In this group 10-year FFS was better in early than in advanced AAS (100% vs 0%, respectively; p = 0.01) and in favorable (0 or 1) than in unfavorable (> 1) IPI scores (86% vs 20%, respectively; p < 0.01). We conclude the the FFS of patients with low-grade NHL is 78% and not affected by AAS or IPI score. The FFS of patients with intermediate-grade NHL appears comparable with that of NHLs of other primary sites, being 86% for those with IPI < or = 1 and 20% for those with IPI 1. Patients with IPI > 1 should be entered on investigational protocols aiming to increase FFS.

Genetics of Hodgkin's and non-Hodgkin's lymphoma: a review

Host susceptibility factors have been documented in both HD and NHL wherein a subset of pedigrees provide evidence for an autosomal dominantly inherited factor. Families with both HD and NHL occurring in genetically informative patients provide evidence in support of a possible common pathogenetic pathway for these diseases, as does recent cytogenetic and molecular genetic evidence. AIDS as an unmasking factor for familial predisposition to lymphoma and other cancers may be a powerful tool for identifying lymphoma- and cancer-prone families, but to date has not been employed. In concert with ecogenetic research, it will be important that lymphoma-prone families be subjected to multidisciplined research involving experimental designs developed by geneticists and epidemiologists in concert with pathologists, immunologists, and molecular geneticists.

Chronic bilateral dacryo-adenitis in identical twins: a possible incomplete form of Sjögren syndrome

We report an unusual case of chronic bilateral dacryo-adenitis in 10-year-old identical twin sisters. Both girls presented with bilateral lacrimal gland enlargement and developed moderate xerophthalmia and keratitis. Both the lacrimal and minor salivary gland biopsies showed a non-granulomatous inflammatory infiltration of mono-nuclear cells. All granulomatous diseases and neoplasms could therefore be ruled out and only Sjögren syndrome and very few other forms of chronic dacryo-adenitis remained as possible diagnoses. Both patients and their parents were evaluated for auto-antibodies. Very low titres of smooth muscle antibodies were found in one, antinuclear antibodies in two and anti-dsDNA antibodies in all four members of the family. Even though the titres of antinuclear and anti-dsDNA antibodies increased in one of the sisters, both patients did not develop any sign or symptom of a systemic connective tissue disease. During the 6 years' follow up, both patients showed persistent tarsal gland enlargement but no other symptoms apart from a moderate xerophthalmia and occasional mild keratitis.

Two patients illustrating lymphoma transition and response to therapy in Sjögren's syndrome

Two patients with Sjögren's syndrome (SS) who subsequently developed malignant B-cell lymphomas are reported in detail. The first patient had both benign- and malignant-appearing lymphoid infiltrates on the same submandibular gland specimen and was successfully treated with combined chemotherapy and irradiation. The second patient developed cutaneous lymphoid infiltrates difficult to diagnose by light microscopy but containing a monoclonal IgM-Kappa population revealed by immunoperoxidase staining and immunoglobulin gene rearrangement studies. Her lesions resolved rapidly and completely on cyclophosphamide, recurred rapidly when this drug was discontinued, and resolved again on a second course of cyclophosphamide which is currently maintained at 50 mg daily. Both patients are doing well without recurrence two and three years after initial treatment. This clinical experience is presented to emphasize: (1) the clinical use of molecular biologic techniques to define the earliest appearance of malignant transformation in Sjögren's syndrome, and (2) the successful outcome that can be achieved with prompt institution of appropriate treatment. The phenomenon of lymphoma development in SS is discussed with regard to immunoregulatory abnormalities predisposing to malignancy in the setting of autoimmune disease.

Cancer in offspring of long-term survivors of childhood and adolescent cancer

A multicentre retrospective cohort study of long-term survivors of childhood and adolescent cancer identified 7 cases of cancer among 2308 offspring (0.30%) of 2283 case-survivors and 11 cases among 4719 offspring (0.23%) of 3604 controls. Overall, the observed numbers of cases were not significantly different from those expected in the general population. Among offspring of case-survivors observed for the first 5 years of life, the group with the most person-years of follow-up, 5 cancers were reported (3 confirmed), compared with 1.7 expected, a significant excess due mostly to boys whose mothers survived cancer. Some offspring with cancer had known single-gene traits; others resembled previously recognised patterns of family cancer. The remainder may represent chance occurrences or new cancer family syndromes, such as an association with malignant melanoma. The study had an overall 79% power to detect a 3-fold excess of cancer among offspring of case-survivors, but no excess was observed. The number person-years of follow-up in the second decade of life, when most cases of cancer developed, was small.

Lymphomas of salivary glands

Primary lymphomas arising in salivary glands are very uncommon. The histologic classification of 40 cases of lymphomas in salivary gland tissue submitted to the British Salivary Gland Tumour Panel is reported, and, for 30 of the patients for whom adequate information was available, the clinical presentation, management, and outcome have been analyzed. Lymphomas in salivary glands represented 1.7% of all reported salivary neoplasms. The majority developed in the parotid glands of patients aged between 50 and 70 years. Only four cases gave a premorbid history compatible with sicca syndrome. In this series, non-Hodgkin's lymphomas predominated; 23 were Grade I, and 13 were Grade II. Treatment regimens were not uniform, but are outlined. Survival ranged from 5 to 111 months. Median survival for the group was 49 months. Prognosis was not influenced by the clinical stage of disease at presentation. Four cases of lymphoma arising in benign lymphoepithelial lesions are included. None had clinical symptoms of sicca complex. Prognosis for this group was found to be as favorable as the others.

Benign lymphoepithelial lesion: a less than benign disease

The precise clinical correlate of the benign lymphoepithelial lesion is unclear. Thirty-six cases of benign lymphoepithelial lesions (BLL), reported to the British Salivary Gland Tumour Panel between 1971 and 1984, have been reviewed. Eighty per cent arose in the parotid gland and 20% were bilateral; 83% were in females and the mean age at presentation was 55.26 years. Only 50% presented with, or developed, symptoms of sicca complex, Sjogren's syndrome or related autoimmune disease. Two cases of BLL had, or went on to develop, extra salivary lymphomas and 5 cases of BLL had lymphomatous change in the initial biopsy. A further case had carcinoma within the benign lymphoepithelial lesion. None of those who developed lymphoma had sicca or Sjogren's syndrome but 3 of them had rheumatoid arthritis. The incidence of lymphomas (salivary or extra-salivary) in this series is very much higher than that reported in Sjogren's patients and amounted to 20% overall.

Primary Sjogren's syndrome and autoimmune hemolytic anemia in sisters. A family study

Familial primary Sjogren's syndrome is infrequently reported despite a strong association with a genetically determined factor, HLA-DR3. Although autoimmune hemolytic anemia occurring with secondary Sjogren's syndrome has been well-documented, its association with primary Sjogren's syndrome has not previously been well-recognized. Thus, the unique occurrence of primary Sjogren's syndrome and autoimmune hemolytic anemia in two sisters prompted investigation of other family members for autoimmune diseases and serologic phenomena and their relationships to HLA genotypes. Serologic analysis (antinuclear antibodies, anti-single-stranded DNA, biologic false-positive result for syphilis, and rheumatoid factor) and HLA-A, B, C, and DR typing were performed in 19 relatives in the kindred. Although HLA-DR3 occurred in those affected with Sjogren's syndrome and thyroid disease, there was no consistent segregation of HLA haplotype with serologic abnormalities in other relatives. These data suggest that there are other, non-HLA-linked, factors contributing to the autoimmune diseases in this family.