Faut-il encore effectuer des biopsies des glandes salivaires accessoires ?

[Salivary gland ultrasound or biopsy? : Comparison of methods based on case examples]

BACKGROUND

Ultrasound examination of the salivary glands (SG) is a quick and noninvasive method to detect and semiquantitatively estimate typical changes in the large SG in Sjögren's syndrome (SS). The differential diagnosis of SS is difficult because several diseases and adverse effects of treatment have a similar clinical picture as SS with sicca syndrome and can even induce alterations in the SG (mimic diseases). Hence, for a long time an SG biopsy was regarded as the diagnostic procedure of choice, especially in SS‑A negative patients, whereas the significance of SD sonography is still controversially discussed.

OBJECTIVE

Comparison of typical and atypical changes for SS in the salivary glands in ultrasound and associated histological sections.

MATERIAL AND METHODS

This article describes six patient cases with antibody positive or negative SS with and without typical SS ultrasound patterns, SS-associated lymphoma, sarcoidosis and IgG4-associated disease. The findings of the sonographic examination of the parotid glands and the associated histology of the SD are explained and put into context.

RESULTS

The SSA antibody positive patients with SS show a typical sonographic pattern with hypoechoic foci, especially if the disease has been present for a long time. This pattern can help support the diagnosis of SS. The ultrasound patterns of the mimic diseases sometimes differ significantly from the typical patterns of pSS. The histological examination of the SG helps to corroborate the diagnosis but low histological focus scores, in particular, require a critical synopsis of the clinical, serological and imaging findings.

CONCLUSION

Both salivary gland ultrasound and the histological examination of SG biopsies are justified in the diagnostics and differential diagnosis of SS and sicca syndrome.

[Echo-guided splenic biopsy: An effective diagnostic tool in sarcoidosis?]

BACKGROUND

Histological diagnosis of systemic granulomatosis may be difficult. The question of the best histological target remains unanswered.

CASE

We report here the observation of a patient admitted in intensive care unit for severe hypercalcemia in the context of polylymphadenopathy and constitutional symptoms. Assessment of this hypercalcemia was suggestive of systemic granulomatosis. The CT (computed tomodensitometry) revealed lymphadenopathies of the mediastinum and the hepatic hilus, hepatomegaly and heterogeneous splenomegaly. At this stage, our main hypotheses were: lymphoid hematopathy, sarcoidosis, tuberculosis. An echo-guided biopsy of the spleen allowed the histological diagnosis of systemic granulomatosis suggestive of sarcoidosis, without significant complication in the course.

CONCLUSION

This observation illustrates the efficiency and safety of spleen biopsy for the histological diagnosis of systemic granulomatosis.

Noninvasive Score in Classification Diagnosis of Sjögren's Syndrome

Background:

To develop simple, practical classification criteria for Sjögren's Syndrome (SS) without Labial Salivary Gland Biopsy (LSGB).

Methods:

In the new criteria (noninvasive score, NIS) set, classification as “definite SS” is based on the ocular and oral symptoms and signs, autoantibodies and the existence of autoimmune thyroid disease, which were calculated. Patients with a score ≥5 were classified as having definite SS and patients with a score <4 were supposed to be excluded from SS. For the patients with a score of 4, LSGB was suggested.

Result:

76 patients with suspected SS were recruited between April 2013 and September 2014, 42 of which were definitive diagnosis of SS and 34 were excluded from SS. Sensitivity and specificity for the NIS criteria in the diagnosis of SS were 97.6% and 94.1%, respectively. The Negative Predictive Value (NPV) and Positive Predictive Value (PPV) to detect SS were 97.0% and 95.3% respectively, and the diagnostic accuracy was 96.1%. The area under the ROC curves (AUC; 95% CI) for NIS criteria was 0.959 (0.905-1.000), which performed better than the American-European Consensus Group’s (AECG) criteria and LSGB in the diagnosis of SS (P < 0.05).

Conclusion:

The NIS criteria are an alternative to the AECG criteria in classification diagnosis of SS, which are with high diagnostic efficiency. We recommend using a score <4 and ≥5 to rule out or to diagnose SS respectively. For the patients with a score of 4, LSGB is necessary and able to diagnose SS.

Clinical and laboratory profiles of primary Sjogren's syndrome in a Chinese population: A retrospective analysis of 315 patients

AIM

To assess the clinical and laboratory features of primary Sjogren's syndrome (pSS) in a large teaching hospital in China.

METHODS

Three hundred and fifteen pSS patients diagnosed according to American-European Classification Criteria and consecutively admitted to Anhui Provincial Hospital from 1 January 1999 to 30 September 2012 were retrospectively selected in this study.

RESULTS

The median age was 46.8 ± 14.4 years (range 13-83 years) and the majority of patients were female (96.5%). The common clinical features at initial presentations were dry mouth (50.2%), dry eyes (31.4%) and joint pain (24.8%); 92.6% of patients had positive anti-SSA antibody and 49.2% patients had positive anti-SSB antibody. One hundred and eighteen patients underwent labial salivary gland biopsy. According to Chisholm grading criteria, grade 3 to 4 was present in 58.5% of the patients. The frequency of interstitial lung disease (ILD) occurred (20.9%) in the patients with systemic extraglandular manifestations. The patients with ILD were frequently associated with positive anti-SSA (P = 0.005) and low levels of C3. The most common impairment of lung function was small airway function abnormalities. Sixty-six pSS patients with ILD (pSS-ILD) were diagnosed with high-resolution computed tomography and treated with corticosteroids and/or immunosuppressants, in which 18 patients had improved pulmonary function.

CONCLUSION

Labial salivary gland biopsy and anti-nuclear antibodies spectrum were important to the diagnosis of pSS. The pSS patients had high percentage of ILD, especially small airway function abnormalities. The combination of corticosteroids and immunosuppressants appears to be effective in treatment of pSS patients with ILD.

The role of a labial salivary gland biopsy in the diagnostic procedure for Sjögren's syndrome; a study of 94 cases

Objectives: The purpose of the present study is to examine the role of the outcome of the labial salivary gland biopsy (LSGB) in the diagnostic procedure of patients suspected of suffering from Sjögren’s syndrome (SS). Material and Methods: In a retrospective study the result of histopathological assessment of 94 consecutively taken labial salivary gland biopsies has been examined. For the diagnosis of SS the American-European Consensus Group classification (AECG, 2002) have been used. The outcome of the assessment has been discussed in relation to a recently reported classification provided by the American College of Rheumatology (ACR, 2012). Results: In the 94 LSGBs support for a diagnosis of SS has been encountered in 24 out of 26 patients with SS. In the 68 patients with a negative diagnosis of SS only six positive LSGBs were observed. The sensitivity of the labial biopsy amounted 0.92; the specificity was 0.91, while the positive predictive value and the negative predictive value amounted 0.80 and 0.97 respectively. LSGBs taken by or on the request of the departments of Rheumatology or Internal Medicine had a significant higher yield compared to LSGBs taken in other clinical departments. Conclusions: The LSGB may play a role in the diagnostic procedure of Sjögren’s syndrome when using either the AECG classification or the ACR classification. A LSGB should preferably taken after counseling for the possible presence of SS by a department of Rheumatology or Internal Medicine since the yield of such biopsies is much higher than in patients who have not been counseled by these departments prior to the taking of a LSGB. When using the ACR classification, a positive serologic result and a positive ocular test make the taking of a LSGB redundant. Only in case of a negative serologic outcome or a negative result of the ocular test a LSGB is indicated. Since both the serologic test and the ocular test carry hardly any morbidity, these tests should, indeed, be performed first before considering to take a LSGB.

Key words:Labial salivary gland biopsy, Sjögren’s syndrome.

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.

Quantitative assessment of oral mucosa and labial minor salivary glands in patients with Sjögren's syndrome using swept source OCT

Three-dimensional imaging of the mucosa of the lower lip and labial minor salivary glands is demonstrated in vivo using swept source optical coherence tomography (OCT) system at 1310 nm with modified interface. Volumetric data sets of the inner surface of the lower lip covering ~230 mm(2) field are obtained from patients with Sjögren's syndrome and a control group. OCT enables high-resolution visualization of mucosal architecture using cross-sectional images as well as en-face projection images. Comprehensive morphometry of the labial minor salivary glands is performed, and statistical significance is assessed. Statistically significant differences in morphometric parameters are found when subgroups of patients with Sjögren's syndrome are analyzed.

[Maxillary bone sarcoidosis]

INTRODUCTION

Sarcoidosis is an unexplained systemic granulomatosis. Bone localizations of the disease are rare. We report a maxillary localization.

CASE

A 35-year-old patient consulted for facial dysmorphia first observed 2 years before. This swelling was associated to nodular panniculitis lesions and xerostomia. The facial asymmetry was due to maxillary gingival and alveolar swelling. It was associated with scarring in the legs and a purple nodular facial lesion. Lip and jaw biopsies revealed epithelioid and giant cell granulomas without caseous necrosis. The panoramic dental X-ray showed diffuse horizontal alveolar ridge lysis and CT scan revealed an osteolytic lesion of the right maxilla associated to a bone-condensing lesion of the left hemi-mandible.

DISCUSSION

The diagnosis of sarcoidosis is made in case of epithelioid and giant cell granulomas without caseous necrosis and the ruling out of other possible diagnoses, including tuberculosis. Bone involvement is rare; face and maxillary localization are extremely rare. The recommended treatment is corticosteroids. Facial remodeling surgery is not recommended.