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Kang J, Kim H, Kim J, Choi S, Jung SY, Jang EJ, Cho SK, Sung YK. Risk of malignancy in Korean patients with primary Sjögren's syndrome. Int J Rheum Dis 2020; 23:1240-1247. [PMID: 32841507 DOI: 10.1111/1756-185x.13927] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 06/29/2020] [Accepted: 07/09/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To evaluate the risks of overall and site-specific malignancies in Korean patients with primary Sjögren's syndrome (pSS). METHODS Using the Korean nationwide healthcare claims database, we constructed a retrospective cohort for prevalent pSS aged over 50 years. After enrollment between January 2012 and December 2014, patients were followed until the development of any malignancy, or until December 2015. Crude incidence rates of malignancies of pSS patients were calculated, and their standardized incidence ratios (SIRs) for malignancies were calculated compared to those in knee osteoarthritis (OA) patients. RESULTS A total of 6,359 pSS and 5,476,302 knee OA patients were included in this study. During follow-up (19,474 person-years [PYs]), 310 cases of solid malignancy (158.8/10,000 PYs) and 47 cases of hematologic malignancies (23.5/10,000 PYs) were observed in pSS patients. The risks of overall (SIR 1.30, 95% CI 1.16-1.43), solid (SIR 1.16, 95% CI 1.03-1.29), and hematologic malignancies (SIR 4.80, 95% CI 3.43-6.17) were increased in pSS patients. There was an elevated risk of site-specific malignancy in non-Hodgkin's lymphoma (NHL, SIR 6.45, 95% CI 4.05-8.83), multiple myeloma (SIR 4.88, 95% CI 2.00-7.76), and oropharynx (SIR 4.16, 95% CI 1.90-6.42). The risk of lung cancer was increased only in male pSS patients (2.50, 95% CI 1.02-3.99), while the risk of thyroid cancer was increased in female patients (1.44, 95% CI 1.04, 1.84). CONCLUSION In patients with pSS over age 50, the risk of solid cancers such as oropharynx, thyroid, and lung cancers is also increased in addition to NHL.
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Affiliation(s)
- Juyeon Kang
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, South Korea
| | - Hyoungyoung Kim
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, South Korea
| | - Jinwook Kim
- Department of Statistics, Kyungpook National University, Deagu, South Korea
| | - Seongmi Choi
- Health Insurance Policy Research Institute, National Health Insurance Service, Wonju, South Korea
| | - Sun-Young Jung
- College of Pharmacy, Chung-Ang University, Seoul, South Korea
| | - Eun Jin Jang
- Department of Information Statistics, Andong National University, Andong, South Korea
| | - Soo-Kyung Cho
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, South Korea
| | - Yoon-Kyoung Sung
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, South Korea
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AIUM practice guideline for the performance of ultrasound examinations of the head and neck. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2014; 33:366-382. [PMID: 24449746 DOI: 10.7863/ultra.33.2.366] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Abstract
This article reviews current understanding of the clinical manifestations, diagnosis and treatment of Sjögren's syndrome. Sjögren's syndrome is a chronic inflammatory disorder of the exocrine glands with multiple nonexocrine features. It is found predominantly in middle-aged women but exists throughout the population. The diagnosis of Sjögren's syndrome can be challenging because the cardinal sicca symptoms may be subclinical or attributed to other causes, such as medications or aging. Differential diagnosis of Sjögren's syndrome can be confounded by the multiple exocrine manifestations in the mouth, eyes, ears, nose, skin, vagina, and respiratory and gastrointestinal tracts, as well as seemingly unrelated nonexocrine involvement in the thyroid, liver, kidneys and the musculoskeletal, vascular and nervous systems. This article concludes that early diagnosis of Sjögren's syndrome is crucial to prevent and/or minimize potentially life-threatening complications. Periodic follow-up of patients' status and collaboration between the primary-care physician and the rheumatologist, dentist, ophthalmologist and other specialists are indispensable.
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Affiliation(s)
- Ibtisam Al-Hashimi
- Baylor College of Dentistry, Salivary Dysfunction Clinic, Department of Periodontics, 3302 Gaston Avenue, Dallas, TX 75246, USA and University of Texas Southwestern Medical Centre, Faculty of Surgery, Division of Oral Surgery, Dallas, TX, USA.
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Toh AS, Broomfield SJ, Teh LS, Aslam MB, Duncan G, Morar P. Bilateral multicystic parotid masses in primary Sjögren syndrome. EAR, NOSE & THROAT JOURNAL 2012; 90:E20-2. [PMID: 22033967 DOI: 10.1177/014556131109001021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We report the case of a 48-year-old woman who presented with bilateral parotid gland enlargement as the initial manifestation of primary Sjögren syndrome. Magnetic resonance imaging demonstrated multiple areas of low-intensity signal mixed with foci of high-intensity signal, a finding suggestive of Sjögren syndrome. Autoimmune blood tests for Sjögren syndrome were positive, and a sublabial biopsy confirmed the diagnosis. Investigations for other conditions, including human immunodeficiency virus infection, were negative. After 5 years of follow-up, the parotid swellings remained essentially unchanged. We discuss the etiology of multicystic parotid gland pathology, its involvement in Sjögren syndrome, and the risk of lymphoma.
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Affiliation(s)
- Alex S Toh
- Department of Otolaryngology, Royal Blackburn Hospital, Blackburn, UK.
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Abstract
Xerostomia is a common symptom in the elderly population. Studies have suggested that the underlying cause of approximately 40% of xerostomia in the elderly is Sjögren's syndrome. Although it is highly prevalent among middle-aged individuals, elderly patients account for up to 20% of Sjögren's syndrome cases. Sjögren's syndrome is a multisystem exocrinopathy characterised by dry mouth and dry eyes with wide-ranging extraglandular involvement. The exocrine manifestations of Sjögren's syndrome affect the mouth, eyes, nose, ears, skin, vagina and the entire respiratory and gastrointestinal systems. The nonexocrine involvement may include the joints, thyroid gland, liver, kidneys and the musculoskeletal, vascular and central nervous systems. Currently, the mechanism(s) of development and progression of Sjögren's syndrome is/are not clear. Inflammation and lymphocytic infiltration of the exocrine glands is a classical feature of Sjögren's syndrome. During the progression of the disease, the acinar cells of the exocrine glands are replaced by fibrosis, rendering the glands nonfunctional. Sjögren's syndrome remains one of the most underdiagnosed conditions, particularly in the elderly population, because the cardinal sicca symptoms, which are the hallmark of the disease, are frequently attributed to aging and/or medications, which consequently delays the diagnosis. This delay in diagnosis imposes significant physical, psychological and economic burdens on elderly patients. The diagnosis of Sjögren's syndrome requires evaluation of both the exocrine and nonexocrine components of the disease. Management of Sjögren's syndrome requires collaboration by the primary-care physician, rheumatologist, ophthalmologist and dentist. This article reviews current understanding of the clinical manifestations, diagnosis and treatment of Sjögren's syndrome with special emphasis on the oral component of the disease.
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Affiliation(s)
- Ibtisam Al-Hashimi
- Department of Periodontics, Salivary Dysfunction Clinic, Baylor College of Dentistry, Dallas, TX 75246, USA.
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Abstract
The incidence, aetiology and optimal treatment of CNS Sjögren's syndrome, including myelopathy associated with Sjögren's syndrome, are unknown at the present time. CNS Sjögren's syndrome is thought to be the result of an autoimmune vasculitis, but other mechanisms may be important. Spinal cord involvement in CNS Sjögren's syndrome may present as acute transverse myelitis, progressive myelitis, Brown-Séquard syndrome, neurogenic bladder or lower motor neurone disease. Optic nerve pathology frequently accompanies spinal cord involvement. Acute transverse myelitis has a high mortality and appears to be the most frequent form of spinal cord involvement in CNS Sjögren's syndrome, occurring in about 1% of all patients with Sjögren's syndrome. The patient's symptomatology and clinical course dictate current treatment of myelopathy. First-line treatment appears to be corticosteroid therapy. However, when the patient's condition fails to improve or deteriorates a nonsteroidal immunosuppressant agent should be considered. Agents used to treat myelopathy include cyclophosphamide, chlorambucil, azathioprine, ciclosporin (cyclosporin) and methotrexate in conjunction with corticosteroids. Most data exist as anecdotal reports. The agent of first choice, based on adverse effect profile and efficacy, appears to be cyclophosphamide given intravenously in pulse doses. Other nonsteroidal immunosuppressant agents should be considered, especially when lack of efficacy of, or intolerance to, cyclophosphamide exists in the patient's history. Glandular and other extraglandular symptoms may benefit concomitantly from the immunosuppressant treatment. In addition, when acute relief of symptomatology is needed, the patient may benefit from a trial of plasmapheresis or intravenous immunoglobulin. Infliximab (anti-tumour necrosis factor-alpha antibodies) has not been used as a treatment modality for myelopathy, but has shown some usefulness in the treatment of extraglandular symptoms, as well as peripheral nervous system manifestations of Sjögren's syndrome. This agent might be considered when all other treatment modalities have failed given the presumed importance of tumour necrosis factor in the pathogenesis of Sjögren's syndrome.
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Affiliation(s)
- Susan J Rogers
- University of Texas Health Sciences Center at San Antonio, San Antonio, Texas 78229-3900, USA.
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Shah GV, Fischbein NJ, Patel R, Mukherji SK. Newer MR imaging techniques for head and neck. Magn Reson Imaging Clin N Am 2003; 11:449-69, vi. [PMID: 14768729 DOI: 10.1016/s1064-9689(03)00069-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Dynamic and functional imaging techniques are being developed to improve the evaluation of various pathologic processes of the head and neck region. These techniques include dynamic contrast-enhanced MR imaging for evaluating soft tissue masses and cervical lymph nodes, the use of ultrasmall superparamagnetic iron oxide contrast agent, and functional techniques such as in vivo and in vitro MR spectroscopy of head and neck cancer and lymph nodes and apparent diffusion coefficient mapping of parotid glands. These techniques can help to differentiate nonmalignant tissue from malignant tumors and lymph nodes and can aid in differentiating residual malignancies from postradiation changes. From methodological development, they are making the critical transition to preclinical and clinical validating methods and eventually to widespread clinical tools.
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Affiliation(s)
- Gaurang V Shah
- Department of Radiology, University of Michigan Medical Center, 1500 East Medical Center Drive, Room B1 G308, Ann Arbor, MI 48109, USA.
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Cermak JM, Papas AS, Sullivan RM, Dana MR, Sullivan DA. Nutrient intake in women with primary and secondary Sjögren's syndrome. Eur J Clin Nutr 2003; 57:328-34. [PMID: 12571668 DOI: 10.1038/sj.ejcn.1601543] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2001] [Revised: 05/27/2002] [Accepted: 05/28/2002] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Recently, it has been proposed that dietary factors may contribute to the etiology and progression of Sjögren's syndrome, and that nutritional intervention may modify the severity of pathological abnormalities. The objective of this study was to determine whether the nutrient intake of women with primary (1 degrees SS) or secondary (2 degrees SS; ie with systemic lupus erythematosus (2 degrees SS/SLE) or rheumatoid arthritis (2 degrees SS/RA) Sjögren's syndrome is significantly different than that of age- and gender-matched controls. DESIGN Women with Sjögren's syndrome were asked to complete the 97 General Purpose Semi-Quantitative Food Frequency Questionnaire, which consists of a list of 147 separate food items that represent the major sources of multiple nutrients. Nutritional data were evaluated in terms of absolute and energy-adjusted nutrient amounts and analyzed by ANOVA. RESULTS Our results showed: (a) greater intake of energy, glutamate, carbohydrates, lactose, phosphorus, caffeine and unsupplemental thiamin and riboflavin in 1 degrees SS, as well as supplemental calcium in 2 degrees SS/SLE, compared with controls; (b) greater nutrient intake of energy, protein, glutamate, methionine, tryptophan, carbohydrates, lactose, supplemental calcium and phosphorus, sodium, caffeine and unsupplemental calcium, riboflavin and thiamin in 2 degrees SS/RA, relative to 1 degrees SS and/or 2 degrees SS/SLE; (c) higher energy-adjusted values for supplemental calcium in 2 degrees SS/SLE, and for vitamin A and supplemental iron and zinc in 2 degrees SS/RA, compared with other groups; and (d) higher energy-adjusted intake of supplemental calcium, and a lower energy-adjusted intake of unsupplemental vitamin C, polyunsaturated fat, linoleic acid, omega-3 fatty acid, and specific other unsaturated fatty acids, in the Sjögren's syndrome group as a whole, relative to controls. CONCLUSIONS Our findings demonstrate that nutrient intake is altered in Sjögren's syndrome.
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Affiliation(s)
- J M Cermak
- Schepens Eye Research Institute, Boston, Massachusetts 02114, USA
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Abstract
BACKGROUND Sjögren's syndrome, or SS, is a multisystem inflammatory disorder of the exocrine glands with a wide range of extraglandular involvement. Symptoms of dry eyes and xerostomia, although not invariably present, are characteristic features of SS. An increased risk of oral and dental diseases is a prominent consequence of SS. TYPES OF STUDIES REVIEWED The author reviewed recent medical and dental studies that have advanced our understanding of the causes and treatment of SS. She particularly focused on studies addressing the diagnosis and treatment of the oral component of the disease. RESULTS Sjögren's syndrome is a widely underdiagnosed disease. A delay in the diagnosis of SS may have a significant physical, psychological and economic impact on the affected person. The pathogenesis of SS appears to involve a number of factors: immunological, genetic, hormonal and possibly infectious. Successful management of SS requires a multidisciplinary approach, and the dentist plays an essential role in the diagnosis and treatment of the disease. ORAL IMPLICATIONS: Impairment of salivary function in SS increases the risk of developing oral diseases. Effective management of oral health comprises enhancement of salivary output (cholinergic agonist drugs such as pilocarpine or cevimeline) and prevention and treatment of dental caries, oral candidiasis and allergic mucositis. Finally, periodic evaluation of various clinical and laboratory parameters is needed to monitor disease status.
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Affiliation(s)
- I al-Hashimi
- Salivary Dysfunction Clinic, Baylor College of Dentistry, Department of Periodontology, 3302 Gastom Ave., Dallas, Texas 75246, USA.
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Ching AS, Ahuja AT, King AD, Tse GM, Metreweli C. Comparison of the sonographic features of acalculous and calculous submandibular sialadenitis. JOURNAL OF CLINICAL ULTRASOUND : JCU 2001; 29:332-338. [PMID: 11424098 DOI: 10.1002/jcu.1044] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
OBJECTIVE The purpose of this study was to compare the sonographic features of acalculous and calculous sialadenitis of the submandibular gland. METHODS A retrospective review of sonograms of the neck was performed in 25 patients with submandibular sialadenitis: 8 with acalculous and 17 with calculous disease. The submandibular glands were assessed for size, shape, border, and echogenicity; presence of dilated ducts or other intraglandular lesions; inflammatory changes in adjacent tissues; lymphadenopathy; and involvement of other salivary glands. RESULTS In the group with acalculous sialadenitis, 4 (50%) of the 8 patients had unilateral disease, and 11 (92%) of 12 glands were rounded. In all cases (100%), multiple hypoechoic lesions were diffusely distributed throughout the submandibular glands against a heterogeneous parenchymal background. The lesions ranged from 3 to 15 mm and were oval or round. Confluent lesions were noted in 2 glands (17%). There was no sonographic evidence of duct dilatation, calculi, or abnormal lymph nodes. All patients with calculous sialadenitis had unilateral disease; 9 had a main duct calculus (53%), 7 had intraglandular calculi (41%), and 1 had both (6%). In 14 (82%) of 17 glands, normal shape was maintained, and 11 (65%) of 17 had duct dilatation. CONCLUSIONS Acalculous submandibular sialadenitis differs from the calculous form of the disease. The former has characteristic sonographic features, including a round gland with numerous hypoechoic lesions in a heterogeneous parenchymal background. Sonographic imaging in conjunction with fine-needle aspiration is useful for detection of this disorder.
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Affiliation(s)
- A S Ching
- Department of Diagnostic Radiology and Organ Imaging, Prince of Wales Hospital, 30-32 Ngan Shing Street, Shatin, New Territories, Hong Kong
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Abstract
Sjogren's syndrome is a chronic progressive autoimmune disorder manifested predominately by xerostomia (dry mouth) and keratoconjunctivitis sicca (dry eyes). It can also affect many body systems. Up to 5% of people over the age of 60 years have primary Sjogren's syndrome, and approximately one third of patients present with extraglandular (systemic) manifestations. This disease is seen mostly in middle-aged women, with a small but significant proportion of these women developing lymphoid neoplasia. The exact etiology is still unknown. This autoimmune disorder is characterized by B-cell activation, the production of numerous auto-antibodies, and the loss of immune tolerance. Salivary gland biopsy remains the most helpful diagnostic test. Treatment is aimed at moisture replacement, which alleviates the discomfort and slows the destructive process. Because of its prevalence in older women, the obstetrician-gynecologist must be aware of the diagnostic and therapeutic approach to Sjogren's syndrome.
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Affiliation(s)
- N Fleming Cole
- Obstetrics & Gynecology Residency Training Program, St Joseph Hospital/CTMF Brackenridge Hospital-Austin, Houston, Texas, USA
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Nguyen KH, Brayer J, Cha S, Diggs S, Yasunari U, Hilal G, Peck AB, Humphreys-Beher MG. Evidence for antimuscarinic acetylcholine receptor antibody-mediated secretory dysfunction in nod mice. ARTHRITIS AND RHEUMATISM 2000; 43:2297-306. [PMID: 11037890 DOI: 10.1002/1529-0131(200010)43:10<2297::aid-anr18>3.0.co;2-x] [Citation(s) in RCA: 105] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Antibodies directed against general and specific target-organ autoantigens are present in the sera of human patients and animal models with autoimmune disease. The relevance of these autoantibodies to the disease process remains ambiguous in most cases. In autoimmune exocrinopathy (Sjögren's syndrome), autoantibodies to the intracellular nuclear proteins SSA/Ro and SSB/La, as well as the cell surface muscarinic cholinergic receptor (M3) are observed. To evaluate the potential role of these factors in the loss of secretory function of exocrine tissues, a panel of monoclonal and polyclonal antibodies was developed for passive transfer into the NOD animal model. METHODS Monoclonal antibodies to mouse SSB/La, rat M3 receptor, and a rabbit polyclonal antiparotid secretory protein antibody were obtained for this study. These antibody reagents were subsequently infused into NOD-scid mice. Saliva flow rates were subsequently monitored over a 72-hour period. Submandibular gland lysates were examined by Western blotting for alteration of the distribution of the water channel protein aquaporin (AQP). RESULTS Evaluation of the secretory response indicated that only antibodies directed toward the extracellular domains of the M3 receptor were capable of mediating the exocrine dysfunction aspect of the clinical pathology of the autoimmune disease. In vitro stimulation with a muscarinic agonist of submandibular gland cells isolated from mice treated with anti-M3 antibody, but not saline or the isotype control, failed to translocate AQP to the plasma membrane. CONCLUSION These findings define a clear role for the humoral immune response and the targeting of the cell surface M3 signal transduction receptor as primary events in the development of clinical symptoms of autoimmune exocrinopathy. Furthermore, the anti-M3 receptor activity may negatively affect the secretory response through perturbation of normal signal transduction events, leading to translocation of the epithelial cell water channel.
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Affiliation(s)
- K H Nguyen
- Kaiser Permanente, San Jose, California, USA
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