Ultrasonography of major salivary glands could be an alternative tool to sialoscintigraphy in the American-European classification criteria for primary Sjogren's syndrome

Operational characteristics of ultrasound in the diagnosis of Sjögren's syndrome

BACKGROUND AND OBJECTIVE

To determine the operational characteristics of salivary gland ultrasound (SGU) in the diagnosis of Sjögren's syndrome (SS) in a population of colombian patients with dry symptoms.

MATERIALS AND METHODS

Study of diagnostic tests in patients with dry symptoms who consecutively attended the rheumatology consultation (2018-2020). Sociodemographic and clinical data were obtained through a survey, paraclinical and ophthalmological tests, minor salivary gland biopsy, unstimulated salivary flow and SGU (score 0-6 based on De Vita) were done. Sensitivity, specificity, positive (PPV) and negative (NPV) predictive values (Stata 15®) were calculated. The receiver operating characteristics (ROC) curve was developed.

RESULTS

102 patients were included (34 SS and 68 non-SS), mean age 55.69 (±11.93) years, 94% women. Positive ultrasound (score of 2 or more) was more frequent in the SS group, (70.6% vs. 22.1%, P<0.0001). The sensitivity was the same for grade 2 and 3 (70.59%), with a higher specificity (89.71%) for grade 3 (PPV 77.42% NPV 85.92). The ROC curve from the sum of the glands by means of ultrasound was better than those of the independent glands. The ROC curve of the ultrasound presented a greater area under the curve (0.72 [0.61-0.82]) than that of the histological analysis (focus score) (0.68 [0.59-0.78]), P=0.0252.

CONCLUSION

Salivary gland ultrasound is a useful and reliable method for the classification of SS. Its use could be considered in the future within the SS classification criteria.

Lacrimal gland ultrasonography and elastography as a diagnostic and activity tool for primary Sjögren's syndrome

OBJECTIVE

To investigate the effectiveness of 2-dimensional shear wave elastography (2D-SWE) in the assessment of lacrimal gland involvement in primary Sjögren's syndrome (pSS) and to determine the association between ultrasonographic findings and clinical activity measures.

METHOD

Forty-six patients who fulfilled the 2016 American College of Rheumatology/European League Against Rheumatism (EULAR) classification criteria of pSS and 23 age and gender-matched healthy control subjects were enrolled. Clinical, laboratory and labial biopsy histopathologic characteristics of patients were recorded. Disease activity of pSS and severity of ocular dryness were evaluated with EULAR Sjögren's Syndrome Patient Reported Index (ESSPRI) and Ocular Surface Disease Index (OSDI), respectively. Parotid and lacrimal gland architectures were assessed by B-mode ultrasound and 2D-SWE techniques.

RESULTS

Mean shear wave elastography measurements, reflecting loss of elasticity, were remarkably higher in pSS patients compared to healthy subjects both in the lacrimal and parotid glands (8.99 ± 3.45 vs 3.68 ± 1.76 in lacrimal glands and 14.14 ± 4.39 vs 7.83 ± 1.69 in parotid glands, all P < 0.001). Shear wave elasticity of lacrimal glands was correlated with OSDI and ESSPRI scores (r = 0.69; P = 0.001 and r = 0.58; P = 0.001, respectively). A cut-off value of 4.6 kPa in the lacrimal gland elasticity discriminated pSS patients from healthy subjects with a sensitivity of 94% and specificity of 87%.

CONCLUSION

Results of our study suggest that lacrimal glands lose elasticity in patients with pSS and the assessment of elasticity with 2D-SWE might help to classify patients as having pSS. Further studies are needed to validate the diagnostic utility of lacrimal 2D-SWE by including diseases other than pSS.

Quantitative Texture Analysis of Parotid Gland Ultrasound Images Yield Higher Correlation with Scintigraphy than Semiquantitative Scoring in Primary Sjögren's Syndrome Patients

Background

Ultrasound (US) can detect salivary gland abnormalities in primary Sjögren's syndrome (SS). This study aimed to compare the correlation among the semiquantitative US scores, texture features, and the quantitative salivary gland scintigraphy (SGS) results.

Methods

This retrospective study included 11 patients who were diagnosed with primary SS and underwent US examinations of the parotid glands and SGS simultaneously. We evaluated SGS quantitatively based on the calculation of maximum accumulation ratio (MAR) and stimulated excretion fraction (EF). The US findings were accessed through the semiquantitative Outcome Measures in Rheumatology scoring system and by gray-level co-occurrence matrix (GLCM) texture analysis. Spearman's rank correlation tests were performed.

Results

A significant moderate negative correlation was noted between the semiquantitative US score and MAR (rho = -0.57, P = 0.006), but not with EF (rho = -0.11, P = 0.613). The GLCM texture metrics, including contrast, dissimilarity, and homogeneity, were all determined to be significantly associated with both MAR and EF. The GLCM contrast correlated moderately to MAR (rho = -0.66, P = 0.001). The GLCM homogeneity highly correlated to EF (rho = 0.74, P < 0.001). The contrast and homogeneity can still discriminate the changes in MAR and EF in the subgroups with the same semiquantitative US scores.

Conclusion

US findings on parotid gland can correlate with SGS results when analyzed based on GLCM texture features. With the GLCM texture metrics, US appears to be an excellent imaging tool for the assessment of the parotid glands in primary SS patients.

Indications for diagnostic use of nuclear medicine in rheumatology: A mini-review

Nuclear medicine techniques allow important insights not only into oncologic, neurologic, and infectious conditions, but also for the assessment of rheumatic diseases. This review provides a brief, update on the potential role of nuclear imaging in rheumatology, especially on ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography for the diagnosis of giant cell arteritis and other large vessel arteritis according to international recommendations. Besides, the potential role of this and other nuclear imaging techniques for the rheumatologic practice are summarized. With ¹⁸F-fluoride as tracer for positron emission tomography, a new option for bone scintigraphy comes up, whereas the use of a semiquantitative sialoscintigraphy is no more supported for classification of Sjögren's syndrome according to current recommendations. Other techniques are used for different organ manifestations in systemic rheumatic diseases like for myocardial infarction and apoplectic insult.

The sialodynamic test: A preliminary porcine head study

Objectives

To provide a concept of measuring pressure changes under constant fluid infusion for the diagnosis of sialolithiasis, termed the sialodynamic test, in a porcine head model.

Methods

Using a porcine head model, a constant infusion of water into the submandibular gland of the two groups over 30 s was performed and the outlet pressure was measured. Metal beads were inserted into the salivary duct for obstruction simulation after the normal submandibular gland sialodynamic measurements were completed. Statistical analyses were performed to evaluate the differences between the measured individuals and the experimental group (n = 3).

Results

The results showed no significant difference between individuals in the control group, but intergroup variation was noted in the simulated sialolithiasis group. The volume-dependent linear increase in pressure was exacerbated in the simulated sialolithiasis group compared with the control.

Conclusion

This study indicated that evaluating the relationship between pressure and volume changes can help to determine whether stones are present in the submandibular gland. The sialodynamic test might serve as a potential diagnostic method for salivary diseases.

Correlations between salivary gland scintigraphy and histopathologic data of salivary glands in patients with primary Sjogren's syndrome

OBJECTIVES

Our aim was to evaluate the association between salivary gland scintigraphy and the clinical parameters, including histological characteristics of salivary glands, in patients with primary Sjogren's syndrome (pSS).

METHODS

Forty-one pSS patients were included in the study. The patients who had received salivary gland scintigraphy and minor salivary gland biopsy were retrospectively analyzed. Salivary gland scintigraphy was interpreted via semi-quantitative methods obtained by calculating the peak uptake and washout of each gland using regions of interest. All specimens were examined by pathologists for focus scores and leukocyte common antigen (LCA) to determine the degree of inflammatory infiltration.

RESULTS

The mean age of pSS patients was 46.4 years, 82.9% were female, and the mean duration of symptoms was 2.5 years. The focus score was negatively correlated to the mean peak uptake (r = ‒0.396; p = 0.019), mean uptake (r = ‒0.388; p = 0.021), and mean percentage washout (r = ‒0.391; p = 0.02). In addition, the focus score and number of LCA positive cells per mm² were correlated with the clinical parameters including erythrocyte sedimentation rate, globulin, rheumatoid factor, unstimulated whole saliva, and stimulated whole saliva flow. The number of LCA positive cells per mm² was negatively correlated to leukocytes and hemoglobin.

CONCLUSION

Although the diagnostic role of salivary gland biopsy is widely accepted and features in the classification criteria of Sjogren's syndrome, salivary gland scintigraphy may be an acceptable alternative method especially if a non-invasive test is required.

Diagnostic value of salivary gland ultrasonography for secondary Sjögren syndrome in patients with systemic lupus erythematosus

BACKGROUND

Salivary gland ultrasound (SGUS) is a reliable technique for assessing the salivary glands in patients with primary Sjögren's syndrome (SS); however, the role of SGUS for diagnosis of secondary SS (sSS) in patients with systemic lupus erythematosus (SLE) was not examined.

OBJECTIVE

To assess the diagnostic value of SGUS for sSS in patients with SLE, and to investigate the relationship between SGUS findings with clinical and laboratory characteristics of patients with SLE.

PATIENTS AND METHODS

This cross-sectional study included 49 patients with SLE. The diagnosis of sSS was confirmed according to the 2016 ACR/EULAR criteria. Salivary gland US was performed for all patients and graded using a validated Hočevar scoring system. A complete clinical and laboratory workup for SLE was assessed. Schirmer's test and the ocular staining were performed.

RESULTS

Of the 49 patients with a mean age of 30.2 ± 9.6 years, 98% were female. 19 (38.8%) had sSS. SGUS changes consistent with sSS (≥17) were found in 29 (59.2%) of the patients. Patients with higher SGUS score had more sicca findings as well as positive anti-Ro, anti-La antibodies, and poorer psychological stress (p < 0.05). The SGUS (≥17) showed a sensitivity of 84.2% and a specificity of 56.7% for sSS diagnosis, with an area under the curve of 0.77 (95% CI: 0.63, 0.91).

CONCLUSION

We propose salivary gland ultrasound as a non-invasive method in the diagnostic workup for sSS in patients with SLE. Further studies to confirm the diagnostic value of SGUS in a larger sample of patients with sSS will be necessary.

Performance Evaluation of Multiple Ultrasonographical Methods for the Detection of Primary Sjögren's Syndrome

Major salivary gland ultrasonography (SGUS) is increasingly being recognized as having critical roles in differentiating primary Sjögren’s syndrome (pSS) from other connective tissue disorders. Contrast-enhanced ultrasonography (CEUS) has been reported to evaluate microvascularity of lesions in different tissues with objective angiographic index, eliminating the observer-dependent defect of ultrasonography. However, there are few relevant studies concentrating on the application of CEUS in the diagnosis and assessment for pSS, and their clinical utility prospect remains uncertain. In this study, a total of 227 eligible patients were enrolled, including 161 pSS and 66 non-pSS patients with comprehensive ultrasonographic evaluation of the parotid and submandibular glands, including grayscale ultrasonography, color Doppler sonography (CDS), and CEUS. Compared with non-pSS, pSS patients had significantly higher grayscale ultrasound (US) scores and CDS blood grades in the parotid gland and significantly higher grayscale US and CEUS scores in the submandibular glands. Diagnostic model combining ultrasonographic signatures, anti-SSA/Ro60, and keratoconjunctivitis sicca (KCS) tests showed a remarkable discrimination [mean area under the curve (AUC)0.963 in submandibular glands and 0.934 in parotid glands] for pSS, and the nomogram provided excellent prediction accuracy and good calibration in individualized prediction of pSS. A combination of multiple ultrasonographical examinations of the major salivary glands (SGs) is a promising technique that may be used as a practical alternative to minor SG biopsy in the detection of pSS.

Ultrasonographic characteristics of major salivary glands in anti-centromere antibody-positive primary Sjögren's syndrome

Purpose

To investigate salivary gland ultrasonography (SGUS) findings in primary Sjögren’s syndrome (pSS) patients positive for the anti-centromere antibody (ACA) and compare these with those in ACA-negative pSS patients.

Methods

We analyzed demographic, clinical, laboratory, and SGUS data of pSS patients who fulfilled the 2002 American-European Consensus Group classification criteria for pSS. SGUS findings of four major salivary glands (bilateral parotid and submandibular glands) were scored in five categories and compared between ACA-positive and ACA-negative pSS patients. Linear regression analysis was performed to elucidate the factors associated with SGUS score.

Results

In total, 121 pSS patients were enrolled (19, ACA-positive). The ACA-positive patients were older (67.0 vs 58.0 years, P = 0.028), whereas anti-Ro/SSA and anti-La/SSB positivity was more prevalent in the ACA-negative group (89.2% vs 21.1%, P < 0.001, and 47.1% vs 10.5%, P = 0.007, respectively). The total SGUS and hypoechoic area scores were lower in ACA-positive patients (16.0 vs 23.0, P = 0.027, and 4.0 vs 7.0, P = 0.004, respectively). In univariate regression analysis, being positive for unstimulated salivary flow rate (USFR < 1.5 ml/15 min), anti-Ro/SSA, and rheumatoid factor were positively associated whereas ACA positivity was negatively associated with the SGUS score. In multivariate regression analysis, being positive for USFR, anti-Ro/SSA, and rheumatoid factor showed significant association with the SGUS score.

Conclusions

ACA-positive pSS patients showed a lower SGUS score than ACA-negative patients, which was especially prominent in the hypoechoic area component.

Application of the OMERACT Grey-scale Ultrasound Scoring System for salivary glands in a single-centre cohort of patients with suspected Sjögren's syndrome

AIM

To describe salivary gland involvement in patients suspected of Sjögren's syndrome (SS) using the OMERACT Ultrasound Scoring System for SS. Next, using different ultrasound cut-offs, to assess the performance of the scoring system for diagnosis and fulfilment of 2016 ACR/EULAR SS classification criteria.

METHODS

All patients referred to our department with a suspicion of SS in a 12-month period were included. All underwent grey-scale ultrasound of the parotid and submandibular glands prior to clinical examination, Schirmer's test, unstimulated salivary flow, blood samples including autoantibody analysis. Labial biopsy was performed according to clinicians' judgement. Images of the four glands were scored 0-3 according to the scoring system and a consensus score was obtained using a developed ultrasound atlas.

RESULTS

Of the 134 patients included in the analysis, 43 were diagnosed with primary SS (pSS) and all fulfilled the 2016 American College of Rheumatology (ACR)/EULAR classification criteria. More patients with pSS compared with non-pSS had score ≥2 in at least one gland (72% vs 13%; p<0.001). In patients with score ≥2 in any gland, significantly more had positive autoantibodies, sialometry, Schirmer's test and positive labial biopsy compared with those with scores ≤1. The best ultrasound cut-off value for diagnosing pSS was ≥1 gland with a score ≥2 (sensitivity=0.72, specificity=0.91).

CONCLUSION

The OMERACT Ultrasound Scoring System showed good sensitivity (0.72) and excellent specificity (0.91) for fulfilling 2016 ACR/EULAR criteria using cut-off score >2 in at least one gland. Our data supports the use of ultrasound for diagnosing pSS and supports incorporation of ultrasound in the classification criteria.

Salivary glands ultrasonography as a diagnostic aid in Sjögren syndrome: A prospective pilot investigation

OBJECTIVE

The aims of this pilot investigation were to calculate the levels of sensitivity and specificity of salivary glands ultrasonography (SGUS) in diagnosing Sjögren syndrome (SS) and to assess the ultrasonographic findings of parotid and submandibular glands.

STUDY DESIGN

Patients diagnosed with SS or dry mouth and healthy controls were enrolled. Bilateral parotid and submandibular glands were assessed for (1) parenchymal inhomogeneity (PIH), (2) median size of the glands, (3) visibility of glandular posterior borders, and (4) size of sialolith, if present.

RESULTS

This study included 34 female patients, of whom 12 had SS (35.3%), 12 had dry mouth (35.3%), and 10 were healthy controls (29.4%). Patients with SS showed higher PIH scores in all glands with the median differences being statistically higher in the right and left parotids and left submandibular glands (P < .001, P = .012, and P < .001, respectively). SGUS, with a PIH cutoff ≥2, showed a sensitivity of 100% and a specificity of 81.6% for detecting SS. The majority of SS had invisible glandular posterior borders (P < .001). Median size of the glands and size of the sialolith did not show any statistically significant differences between groups.

CONCLUSIONS

SGUS is a noninvasive imaging modality with good sensitivity and specificity that might be valuable as a diagnostic aid for SS.

Effectiveness of ultrasonography and shear wave sonoelastography in Sjögren syndrome with salivary gland involvement

Purpose

This study investigated the effectiveness of major salivary gland ultrasonography (MSGUS) using a new grading system and shear wave elastography (SWE) in evaluating the major salivary glands of patients with Sjögren syndrome (SjS).

Methods

This prospectively-designed cross-sectional study included 49 SjS patients and 49 healthy controls. Major salivary glands were examined with gray-scale ultrasonography and SWE. A new grading system for salivary glands was developed using MSGUS findings. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of MSGUS and shear wave velocity (SWV) values were investigated. The MSGUS grading system and SWV values were evaluated together by logistic regression analysis. A cutoff value of SWE for salivary glands was determined.

Results

The sensitivity, specificity, PPV, and NPV of MSGUS were 69.4%, 73.5%, 72.3%, and 70.6% for the submandibular gland and 69.4%, 65.3%, 66.7%, and 68.1% for the parotid gland, respectively. The mean SWV values of the parotid and submandibular glands were significantly higher in SjS patients than in controls (P<0.05). The sensitivity, specificity, PPV, and NPV for the submandibular gland (cutoff, 1.95 m/s) and the parotid gland (cutoff, 2.39 m/s) were 69.4%, 52%, 59.1%, and 63% and 82.7%, 83.7%, 83.5%, and 82.8%, respectively. Adding SWE to the parotid gland grading system increased the sensitivity and specificity (sensitivity, 82.7%; specificity, 83.7%).

Conclusion

Evaluating the salivary glands using MSGUS with a new grading system and SWE may contribute to the diagnosis of SjS. The combination of MSGUS and SWE may be a promising tool for diagnosing SjS.

Narrative review of multiparametric ultrasound in parotid gland evaluation

Disorders affecting parotid gland represent a heterogeneous group comprising congenital, inflammatory and neoplastic diseases which show a focal or diffuse pattern of appearance. The differentiation of neoplastic from non-neoplastic conditions of parotid glands is pivotal for the diagnostic imaging. Frequently there is evidence of overlapping between the clinical and the imaging appearance of the various pathologies. The parotid gland is also often object of study with the combination of different techniques [ultrasound-computed tomography-magnetic resonance imaging (US-CT-MRI), ex.]. Compared to other dominant methods of medical imaging, US has several advantages providing images in real-time at lower cost, and without harmful use of ionizing radiation and of contrast enhancement. B-mode US, and the microvascular pattern color Doppler are usually used as first step evaluation of parotid lesions. Elastography and contrast-enhanced US (CEUS) has opened further possible perspectives to improve the differentiation between benign and malignant parotid lesions. The characterization of the parotid tumors plays a crucial role for their treatment planning and for the prediction of possible surgical complications. We present, here an updated review of the most recurrent pathologies of parotid gland focusing on the diagnostic power of multiparametric US including CEUS and ultrasound elastography (USE); limitations, advantages and the main key-points will be presented.

Are Salivary Gland Ultrasonography Scores Associated with Salivary Flow Rates and Oral Health-related Quality of Life in Sjögren Syndrome?

OBJECTIVE

Major salivary gland ultrasonography (SGUS) is a widely used imaging technique to evaluate salivary gland involvement in primary Sjögren syndrome (pSS). The aim of this study was to evaluate the relationship between SGUS, salivary flow rate (SFR) as an objective measure of the gland function, and oral health-related quality of life (OHRQOL) as a patient-reported outcome measure (PROM) in a pSS cohort.

METHODS

Sixty-six patients with pSS were examined by SGUS according to Hocevar and Milic scoring systems. Patients with inhomogeneity/hypoechoic areas with scores ≥ 2 in parotid and submandibular glands were classified separately as "severe glandular involvement." Further, oral health, SFR, and Oral Health Impact Profile-14 (OHIP-14) for OHRQOL were assessed.

RESULTS

Both total Hocevar and Milic scores were higher in 21 pSS patients with low unstimulated whole salivary flow rate (U-WSFR) than 45 pSS patients without low U-WSFR (P = 0.001 and P < 0.0001, respectively). Increased scores of homogeneity, hypoechoic areas and glandular border visibility were observed in patients with low U-WSFR (P < 0.05). Among these variables, homogeneity score was found to be an independent risk factor for low U-WSFR in pSS according to logistic regression analysis (OR 1.586, P = 0.001). Moreover, a higher OHIP-14 score was observed in severe parotid involvement compared to nonsevere cases (23.26 ± 21.19 vs 8.32 ± 13.82, P = 0.004).

CONCLUSION

High Milic and Hocevar SGUS scores are associated with reduced SFR and poor OHRQOL as a PROM. The inhomogeneity component of the SGUS score is associated with low U-WSFR and is an indicator of severely affected gland function.

Diagnostic accuracy of salivary gland ultrasound in Sjögren's syndrome: A systematic review and meta-analysis

BACKGROUND

To systematically review the diagnostic accuracy of salivary gland ultrasound in primary Sjögren's syndrome (pSS).

METHODS

PubMed, Embase, CINAHL, Cochrane Central and Scopus and ClinicalTrials.gov were searched to identify diagnostic or validation studies in patients with pSS meeting the diagnostic criteria. A diagnostic test meta-analysis was performed using a bivariate model to calculate the pooled sensitivity, specificity, positive/negative likelihood ratios, and the diagnostic odds ratio. Meta-regression analyses were done for several pSS covariates.

RESULTS

Sixty-five studies met our criteria for the qualitative review. Fifty-four studies with a total of 6087 patients were included in the meta-analysis. Pooled sensitivity for salivary gland ultrasound was 80% [95% confidence interval (CI): 77-83%; I 2 = 78%], and specificity was 90% (95% CI: 87-92%; I 2 = 76%). The pooled positive and negative likelihood ratios were 8 (95% CI: 6.4-10) and 0.22 (95% CI: 0.19-0.25), respectively. The corresponding pooled diagnostic odds ratio (DOR) was 37 (95% CI: 28-48). Separate meta-regression models resulted in similar diagnostic estimates: (a) adjusted for mean age: sensitivity 81% (95% CI:77-84%; I 2 = 99%) and specificity 90% (95% CI: 87-93%; I2 = 99%); (b) adjusted for mean disease duration, sensitivity 79% (95% CI:72-84%; I 2 = 99%), and specificity 90% (89-94%; I 2 = 99%). The diagnostic estimates were robust to sensitivity analyses by quality criteria, pSS diagnostic criteria and ultrasound scoring systems.

CONCLUSION

Salivary gland ultrasound is a valuable modality for the diagnosis of Sjögren's syndrome. It is plausible that salivary gland ultrasound can be used as an important criterion for the diagnosis of pSS.

The validity of salivary gland scintigraphy in Sjögren's syndrome diagnosis: comparison of visual and excretion fraction analyses

OBJECTIVES

The diagnostic validity of salivary gland scintigraphy in Sjögren's syndrome (SS) has not been conclusively defined. Whether a quantitative (excretion fraction) interpretation of scintigraphy is superior to a qualitative one (visual analysis) remains a matter of debate. We sought to determine whether the diagnostic discrimination of excretion fraction is higher compared to that obtained by visual analysis.

METHODS

Diagnostic test validity study that encompassed 137 suspected SS subjects who underwent scintigraphy for diagnostic purposes. Patients were diagnosed as SS and non-SS according to the rheumatologist's clinical judgment, and by using the American-European Consensus Group (AECG) and American College of Rheumatology (ACR) classification criteria. Visual analysis (normal vs. abnormal and Schall's classification grade) and excretion fraction scores were calculated. The diagnostic discrimination of these methods was compared through the area under the curve (AUC) analysis. Scintigraphy associations with SS clinical and laboratory features were assessed through multivariable regression analysis.

RESULTS

Schall's classification AUC reached statistical significance in its diagnostic discrimination for SS clinical judgment (0.704 [95%CI 0.597-0.811]) and AECG criteria (0.764 [95%CI 0.641-0.886]). Similarly, submandibular excretion fraction was associated with SS diagnosis based on ACR (0.737 [95%CI 0.546-0.931]) and AECG criteria (0.715 [95%CI 0.597-0.833]). However, AUC comparisons between qualitative and quantitative methods did not yield statistically significant values. Both interpretation modalities were associated with SS serological features. Moreover, excretion fraction was also associated with salivary gland biopsy.

CONCLUSIONS

SS diagnostic discrimination of excretion fraction is not superior to that obtained by qualitative visual analysis. Both qualitative and quantitative scintigraphy methods are associated with SS clinical and laboratory characteristics.

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.

Incorporation of Salivary Gland Ultrasonography Into the American College of Rheumatology/European League Against Rheumatism Criteria for Primary Sjögren's Syndrome

Objective

To assess whether the addition of salivary gland ultrasonography (SGUS) or replacement of current criteria items by SGUS influences the performance of the American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) criteria for primary Sjögren's syndrome.

Methods

Included were consecutive patients with complete data on all ACR/EULAR items (n = 243) who underwent SGUS in our primary Sjögren's syndrome expertise center. Clinical diagnosis by the treating physician was used as the gold standard. Separate analyses were performed for patients who underwent labial or parotid gland biopsies. The average score for hypoechogenic areas in 1 parotid and 1 submandibular gland was determined (range 0–3). Next, performance of the ACR/EULAR criteria was evaluated after addition of SGUS or replacement of current items by SGUS.

Results

Receiver operating characteristic analysis showed an optimal cutoff value of ≥1.5 for SGUS. The optimal weight for SGUS positivity was 1. Cutoff for ACR/EULAR fulfilment remained ≥4. In patients who underwent a labial gland biopsy (n = 124), the original criteria showed an area under the curve (AUC) of 0.965, sensitivity of 95.9%, and specificity of 92.2%. After the addition of SGUS, the AUC was 0.966, with a sensitivity of 97.3% and specificity of 90.2%. In patients who underwent a parotid gland biopsy (n = 198), similar results were found. Sensitivity of the criteria decreased substantially when SGUS replaced salivary gland biopsy or anti‐SSA antibodies, while performance remained equal when SGUS replaced the ocular staining score, Schirmer's test, or unstimulated whole saliva flow.

Conclusion

Validity of the ACR/EULAR criteria remains high after incorporation of SGUS. With SGUS, clinicians are offered a larger array of tests to evaluate fulfillment of the ACR/EULAR criteria.

Sonographic Features of Salivary Glands in Sjögren's Syndrome and its Mimics

PURPOSE OF REVIEW

For 30 years, ultrasound has been investigated as a means to evaluate salivary gland abnormalities in patients with autoimmune disease. We aim to review the test characteristics of ultrasound for diagnosing Sjögren's syndrome, the scoring systems used for this purpose, and the ultrasound similarities and differences between Sjögren's syndrome and some of its potential salivary gland mimics.

RECENT FINDINGS

Hypo/anechoic glandular lesions are the major ultrasound characteristic found in Sjögren's syndrome. Most studies have reported such ultrasound abnormalities to have a sensitivity and specificity in the range of 65-85% and 85-95%, respectively, as well as a positive likelihood ratio between 4 and 12. However, similar findings can also be seen in sarcoidosis, amyloidosis, IgG4-related disease, HIV, and lymphoma. A "nodal" pattern of involvement or the ultrasound artifact of "through transmission" can help distinguish some of these mimics from Sjogren's syndrome. Ultrasound can substantially influence the diagnosis of Sjögren's syndrome.

Salivary gland ultrasound in the diagnostic workup of juvenile Sjögren's syndrome and mixed connective tissue disease

BACKGROUND

Juvenile Sjögren's Syndrome (jSS) is a rare phenomenon that may appear as primary jSS or associated with mixed connective tissue disease (MCTD) and other autoimmune diseases as secondary jSS. With currently no standard diagnostic procedures available, jSS in MCTD seems to be underdiagnosed. We intended to describe and identify similar distinct salivary gland ultrasound (SGUS) findings in a cohort of primary and secondary jSS patients, focusing on sicca like symptoms and glandular pain/swelling in the patients'history.

METHODS

We present a single-center study with chart data collection. B-mode examinations of salivary glands were obtained with a linear high-frequency transducer and evaluated using the scoring-system of Hocevar. Inclusion criteria were: (i) primary or secondary jSS and/or (ii) diagnosis of MCTD and additionally (iii) any presence of sicca like symptoms or glandular pain/swelling.

RESULTS

Twenty five patients with primary (pjSS) and secondary jSS (sjSS) were included in the study (n = 25, 21 female, 4 male), with a median age of 15.3 years at the time of first visit and a mean disease duration of 4.9 years. Pathologic SGUS findings were observed in 24 of 25 patients, with inhomogeneous parenchymal appearances with hypoechoic lesions present in 96% of patients. At least one submandibular gland was affected in 88.5% of the whole group, and all patients in the MCTD-group. Twenty of twenty five patients were scanned and scored on a second visit. Pre-malignancies or mucosa-associated lymphoid tissue (MALT) were detected in biopsies of three patients (Hocevar scoring of 40, 33, and 28).

CONCLUSION

SGUS in patients with pjSS and sjSS is a helpful first-line tool to detect and score salivary gland involvement, in particular when keratoconjunctivitis sicca, xerostomia, or glandular swelling occurs. Juvenile MCTD patients have a significant risk of developing secondary jSS. We propose SGUS as a method in the diagnostic workup and screening for inflammatory changes. Further studies have to determine the predictive value of SGUS for follow up.

Disease activity and damage in patients with primary Sjogren's syndrome: Prognostic value of salivary gland ultrasonography

OBJECTIVES

To assess the association between salivary ultrasonography (sUS) findings and disease activity and damage in patients with primary Sjogren's syndrome (pSS). We investigated the potential prognostic role of sUS as a tool in the assessment of disease activity.

METHODS

In 303 pSS patients, disease activity was assessed by the European League Against Rheumatism (EULAR) Sjogren's Syndrome Disease Activity Index (ESSDAI), the EULAR Sjogren's Syndrome Patient Reported Index (ESSPRI), the Sjogren's Syndrome Disease Activity Index (SSDAI) and the Sjogren's Syndrome Disease Damage Index (SSDDI). The sUS parenchymal inhomogeneity (de Vita scoring system) was assessed in 303 pSS patients and 111 heathy controls. A receiver operating characteristic (ROC) curve was used to determine the cut-off value of the pathological sUS score. Logistic regression analysis was performed to assess risk factors for moderate and high disease activity.

RESULTS

A pathological sUS score ≥ 2 was recorded in 271 (89.7%) patients and 8 (8.6%) healthy controls. Patients with moderate and high ESSDAI and SSDAI scores had significantly higher US activity in comparison to that of pSS patients with low disease activity (p = 0.006; p = 0.01, respectively). Additionally, pSS patients with moderate and high SSDDI scores had higher US activity (p = 0.031). Pathological sUS correlated with the glandular domain within the ESSDAI and SSDDI (p<0.001). The patients with a severe US score (5-6) had a 3.5 times greater chance of having moderate or high disease activity. The specificity of the severe de Vita sUS score for ESSDAI and SSDAI was 85.1% and 85.2%, respectively. In contrast, the sensitivity of a severe de Vita sUS score for ESSDAI was low, at 29.2%, while the sensitivity for the SSDAI was higher, 42.3%. In the analysis of disease activity, a de Vita score ≥ 5 could be used as a risk factor for moderate and high ESSDAI (p = 0.042) and SSDAI (p = 0.006).

CONCLUSIONS

Pathological salivary gland ultrasonography is associated with high disease activity and damage in pSS. Consequently, sUS abnormalities might be surrogate items for glandular domains in the assessment of disease activity and damage. Thus, ultrasonography of the salivary gland combined with clinical and serological markers might be part of the next prognostic and therapeutic algorithm in the near future.

Recommendations from the Brazilian society of rheumatology for the diagnosis of Sjögren's syndrome (Part I): glandular manifestations (systematic review)

BACKGROUND

Primary Sjögren's syndrome (pSS) is a systemic immune-mediated disease whose main characteristic is exocrine gland inflammation and, subsequent reduction in tear and saliva production. A delayed diagnosis is common due to the nonspecific clinical manifestations of disease. The aim of the present study was to develop recommendations for the diagnosis of glandular manifestations of pSS based on evidence and expert opinion. We conducted a systematic literature review to retrieve the best evidence available on the accuracy of diagnostic tests for pSS. We also held two in-person meetings with experts (rheumatologists, pathologists, ophthalmologists and dentists) to establish their level of agreement using the Delphi method. Ultimately, we generated 18 recommendations that aim to facilitate the diagnosis of the glandular manifestations of pSS.

CONCLUSION

The diagnosis of glandular manifestations of pSS is complex and multidisciplinary. It requires specific knowledge in the field of ophthalmology, immunology, pathology and imaging, making it compulsory for the rheumatologist to work with professionals from these different areas in order to improve accuracy and early diagnosis. Glandular dysfunction tests, ANA, RF, Anti-Ro, protein electrophoresis, urinalysis, blood count, C-Reactive protein, complement, testing for syphilis and viruses (HCV, HIV) and SGUS should be investigated when dryness or systemic manifestation are present. Minor salivary gland biopsy is recommended for all anti-Ro negative or incomplete criteria cases.

Latest Advances in Ultrasound Assessment of Salivary Glands in Sjögren Syndrome

OBJECTIVE

There are different imaging techniques to assess the parotid glands (i.e., sialography, salivary gland scintigraphy) in patients with Sjögren syndrome (SS). However, their use is limited by the invasive character or high cost. Ultrasound (US) is gaining interest by rheumatologists as a complementary diagnostic tool for SS. To date, there is an increasing body of evidence supporting its sensitivity in the assessment of salivary glands in SS. The aim of our study was to analyze the potential role of US as a diagnostic and prognostic tool in SS and to discuss existing evidence to support its application use.

METHODS

A systematic search was performed in the electronic database PubMed, using the following search terms: (salivary glands OR parotid glands OR submandibular glands) AND Sjögren's syndrome AND (ultrasonography OR ultrasound OR sonography). Titles, abstracts, and full reports were systematically screened.

RESULTS

The results of the studies analyzed in this review show encouraging results in terms of accuracy, validity, and diagnostic value, which leads us to believe that in the future US could become the reference imaging tool to assess SS. The studies include a small cohort of patients, and there is no standardized approach in terms of US techniques for the assessment of salivary glands.

CONCLUSIONS

Ultrasound of major salivary glands is a useful tool for diagnosis, prognostic evaluation, and response to treatment in SS. The use of this imaging technology is still under development, and more multicentric studies are needed to validate this tool.

Diagnostic value of major salivary gland ultrasonography in primary Sjögren's syndrome: the role of grey-scale and colour/power Doppler sonography

Primary Sjögren's syndrome (pSS) is an autoimmune connective tissue disease characterized primarily by chronic inflammatory involvement of the exocrine glands, particularly the salivary glands. The use of ultrasound in the study of salivary glands (SGUS) has expanded considerably in recent years. The ultrasound can document structural alterations that can be visualized as hyperechogenic and hypoechogenic areas, or as areas with non-homogeneous echogenicity. To date, several systems of SGUS scoring systems of abnormalities during pSS are available. From the studies published in recent decades, it has been possible to document the high sensitivity and specificity of the pathological findings that can be documented by SGUS. SGUS can also provide added value in identifying patients at risk for developing disease complications such as lymphoma. The Doppler technique can also supply information about glandular tissue vascularization, which is very useful for diagnostic and differential purposes. In this review we will present the state of the art of SGUS, with a prevailing focus on diagnostic use and possible future developments.

Ultrasound detection of incidental diffuse parotid disease: A single-center study

In this study, we compared ultrasound (US) features between normal parotid parenchyma (NPP) and incidental diffuse parotid disease (DPD). From January 2008 to December 2017, 180 patients underwent neck US before parotid surgery at our hospital. From these, 82 were excluded because of the lack of histopathological data concerning the parotid parenchyma or inadequate US images. A single radiologist blinded to the clinicoserological data and histopathological results, retrospectively investigated all US features and categorizations for the parotid glands using a picture archiving and communication system. Retrospective histopathological analysis of the parotid parenchyma was performed by a single pathologist. On the basis of the histopathological analyses, the 98 patients were divided into NPP (n = 70) and DPD (n = 28) groups. Among US features, parenchymal echogenicity and echotexture showed statistically significant differences between the two groups (p < 0.0001), whereas the gland size, margin, and vascularity showed no significant differences (p > 0.05). The US-based categorization significantly differentiated between NPP and DPD (p < 0.0001), and receiver operating characteristic curve analysis revealed that US categorization based on ≥2 abnormal US features showed the best diagnostic performance for detecting DPD. Thus, US can aid in differentiating DPD from NPP.

Ultrasonography Features of Normal Submandibular Parenchyma and Incidental Diffuse Submandibular Disease: A Single-Center Study

This study aimed to assess ultrasonography (US) features of normal submandibular parenchyma (NSP) and incidental diffuse submandibular disease (DSD). From January 2013 to December 2017, 39 patients underwent preoperative US of the submandibular gland before submandibular surgery in our hospital. Among them, 9 were excluded because of inadequate histopathologic data (n = 7) or poor US image quality (n = 2). The US features of the resected submandibular glands were retrospectively investigated by a single radiologist, blinded to clinicoserological information and the histopathologic result, using a picture archiving and communication system. Histopathologic analysis of the submandibular gland was retrospectively performed by a single pathologist. After histopathologic analysis, 11 of the 30 patients were classified as DSD and 19 as NSP. Of the individual US features, only parenchymal echotexture exhibited a statistically significant difference between NSP and DSD (P < 0.0001), whereas the other US features showed no significant differences (P > 0.05). There was no significant relationship between diffuse fibrosis and glandular size (P = 0.310) or the other US features (P = 1.000). In conclusion, US may be helpful for differentiating incidental DSD from NSP.

Oral Disorders in Sjögren’s Syndrome

Sjogren’s syndrome (SS) is a complex, chronic, systemic, autoimmune disease that mainly affects the exocrine glands, especially the salivary and lacrimal glands, leading to the dryness of the mouth and eyes, along with fatigue, joint and muscle pain. The prevalence of SS is estimated to be between 0.05% and 1% in European population. Diagnosis of SS is based on the revised criteria of the American-European consensus group (AECG). Sjogren’s syndrome can be subclassified into primary disease (primary Sjogren syndrome, pSS) and a secondary disease (secondary Sjogren syndrome, sSS) when present with rheumatoid arthritis (RA), systemic lupus erythematosus (SLE) and systemic sclerosis. The decrease in salivary flow and qualitative alterations in saliva could explain many of the oral manifestations frequently present in patients with SS. Low salivary flow may affect chewing, swallowing, speech and sleeping in pSS patients. Oral manifestations include dental erosion, dental caries, mucosal infection, ulcers and oral candidiasis. Recent studies reveal that pSS patients experience impaired olfactory and gustatory functions and have higher occurrence of oral complications such as dysgeusia, burning sensation in the tongue (BST) and halitosis. The exocrine manifestations and systemic involvement in SS significantly impact the patient’s perception of oral healthrelated quality of life (OHRQoL).

Diagnostic accuracy of salivary gland ultrasonography with different scoring systems in Sjögren's syndrome: a systematic review and meta-analysis

Noninvasive objective salivary gland ultrasonography (SGU) had been widely used to evaluate major salivary gland involvement in primary Sjögren’s syndrome (pSS) and treatment responses. However, the evaluation score, diagnostic sensitivity, and diagnostic specificity significantly varied among clinical studies. We conducted this meta-analysis to assess the diagnostic accuracy of different SGU scoring systems using the American-European Consensus Group criteria. Of the 1301 articles retrieved from six databases, 24 met the criteria for quality assessment and 14 for meta-analyses. The pooled sensitivities were 75% (0–4) with I² = 92.0%, 84% (0–16) with I² = 63.6%, and 75% (0–48) with I² = 90.9%; the pooled specificities were 93% (0–4) with I² = 71.5%, 88% (0–16) with I² = 65.4%, and 95% (0–48) with I² = 83.9%; the pooled diagnostic odds ratios were 71.26 (0–4) with I² = 0%, 46.3 (0–16) with I² = 73.8%, and 66.07 (0–48) I² = 0%; the areas under the SROC curves were 0.95 (0–4), 0.93 (0–16), and 0.94 (0–48). These results indicated that the 0–4 scoring system has a higher specificity and a less heterogeneity than other systems, and could be used as a universal SGU diagnostic standard.

What is the best salivary gland ultrasonography scoring methods for the diagnosis of primary or secondary Sjögren's syndromes?

OBJECTIVE

To evaluate the performance of salivary gland ultrasonography for the diagnosis of primary and secondary Sjögren's syndromes (pSS and sSS).

METHOD

Multicenter cross-sectional study on 97 patients with clinical sicca symptoms. The pSS (n = 22) met the American-European Consensus Group (AECG) classification criteria. The control patients (n = 36) with sicca symptoms did not fulfill the AECG criteria. Four scores were used to evaluate the 4 major salivary gland echostructure: the Salaffi score (0-16), Jousse-Joulin score (0-4), Hocevar score (0-48) and Milic score (0-12).

RESULTS

The medians of ultrasonographic (US) scores were higher in the pSS and sSS groups than in the control group (P < 0.001). The receiver-operating characteristic (ROC) curves and the positive likelihood ratio (LR+) of the four scores showed a good diagnostic performance for the US diagnosis of pSS and sSS. Respectively, for pSS and sSS, the AUC were 0.891 (95%CI 0.812-0.970) and 0.824 (95%CI 0.695-0.954) for Hocevar score, 0.885 (95%CI 0.804-0.965) and 0.808 (95%CI 0.673-0.943) for Milic score, 0.915 (95%CI 0.848-0.982) and 0.844 (95%CI 0.724-0.965) for Salaffi score, 0.897 (95%CI 0.821-0.973) and 0.851 (95%CI 0.735-0.968) for Jousse-Joulin score. This study showed an interesting inter-observer reproducibility (kappa = 0.714 ± 0.131) of the US evaluation with 85.7% agreement between reader to determine the pathological character of the salivary glands.

CONCLUSION

Salivary gland US is a simple, non-invasive and performant imaging procedure for the diagnosis of pSS and sSS, with Salaffi, Milic and Jousse-Joulin scores.

Ultrasound elastography in assessment of salivary glands involvement in primary Sjögren's syndrome

OBJECTIVE

Our study aimed to assess the pathological sonoelastographic changes in the major salivary glands and to demonstrate the diagnostic effectiveness of Sonoelastography as an additional method to US in Sjögren's syndrome.

METHODS

Fifty eight patients with primary Sjögren's syndrome (pSS) were selected according to the American-European Consensus Group Classification criteria. Twenty five healthy volunteers involved in this study. All patients were evaluated with B-mode and elastography by using Hitachi EUB 7500 digital ultrasound equipment. All subjects were female. The sonoelastography examination, which allowed us to assess the elasticity of the parenchyma, was performed and strain ratios were measured by comparing with the adjacent tissues.

RESULTS

Statistically significant differences were found between the pSS and control groups for the elastographic scores and strain ratios (p < 0.001). The highest sensitivity and specificity levels were obtained when the strain ratio cut-off value was taken as 1.55 for the submandibular gland and 2.45 for the parotid gland (sensitivity and specificity were 83% and 88% respectively for the submandibular gland and 83% and 92% respectively for the parotid gland). However, no statistically significant differences were found between the disease duration and the elasticity scores or strain ratios in pSS group (p > 0.05).

CONCLUSION

US examination is an efficient method to assess major salivary gland involvement in the diagnosis of pSS. Sonoelastography is a modality which can contribute to the diagnosis by improving specificity in the differential diagnosis of pSS. Strain ratio measurement, which is a semi-quantitative method, increases the diagnostic effectiveness by providing high sensitivity, specificity, and negative predictive values.

Salivary gland ultrasound is linked to the autoimmunity profile in patients with primary Sjögren's syndrome

Objective

Methods

Results

Conclusions

Salivary gland ultrasonography findings are associated with clinical, histological, and serologic features of Sjögren's syndrome

OBJECTIVE

Salivary gland ultrasonography (SGUS) has been applied in the diagnosis of Sjögren's syndrome (SS). The aim of this study is to investigate the association of SGUS findings with clinical, histological, and serologic features of SS.

METHODS

A total of 104 patients with suspected SS underwent SGUS for evaluation of salivary gland involvement. Patients with primary SS were determined according to the classification criteria for SS. The parenchymal inhomogeneity of bilateral parotid and submandibular glands was graded from 0 (homogeneity) to 4 (gross inhomogeneity). Receiver operating characteristic curve analysis was performed to compare the diagnostic performance of different SGUS scoring methods. Clinical and serologic features were compared between groups classified by SGUS score. The association between SGUS and these features of SS was explored by multivariable linear regression analysis.

RESULTS

Study participants were predominantly women (96.2%) and had a mean age of 54.1 years. Eighty-seven patients and 88 patients with primary SS were identified based on AECG criteria and ACR/EULAR classification criteria for SS, respectively. Among the different scoring methods, the sum of the grades of four salivary glands (range 0-16) had the best diagnostic performance, with sensitivity of 77.3% and specificity of 87.5% (cutoff value, 7) for distinguishing primary SS from sicca non-SS. SGUS score was associated with focus score in labial salivary gland biopsy (β = 0.240, p = 0.033) and anti-Ro/SSA serology (β = 0.283, p = 0.016) and inversely associated with unstimulated whole salivary flow (β = -0.298, p = 0.011).

CONCLUSION

Ultrasonography of major salivary glands is associated with histopathology of minor salivary glands, serology of SS, and salivary gland function.

Salivary gland ultrasonography as a predictor of clinical activity in Sjögren's syndrome

Purpose

Primary Sjögren’s syndrome is a multisystem autoimmune disease characterized by hypofunction of salivary and lacrimal glands and possible multi-organ system manifestations. Over the past 15 years, three sets of diagnostic criteria have been proposed, but none has included salivary gland ultrasonography. However, recent studies support its role in the diagnosis and prognostic evaluation of patients with Sjögren’s syndrome. This study aimed to determine the value of salivary gland ultrasonography in the diagnosis and prognosis of Sjögren’s syndrome by relating ultrasonography severity scores to clinical and laboratory data.

Methods

Seventy patients who fulfilled the 2002 American-European Consensus Group diagnostic criteria for primary Sjögren’s syndrome were selected from 84 patients receiving care in specialized outpatient clinics at our institution from November 2013 to May 2016. Their serology, European League Against Rheumatism Sjögren’s syndrome disease activity index (ESSDAI), salivary flow rate, immunoglobulin G, and salivary and serum beta-2 microglobulin levels were measured. Salivary gland ultrasonography was performed by an experienced radiologist, using scores of 1–4 to classify salivary gland impairment.

Results

Salivary gland ultrasonography scores of 1 or 2 were associated with an ESSDAI < 5. Ultrasonography scores of 3 or 4 were associated with an ESSDAI ≥5 (p = 0.064), a positive antinuclear antibody test (p = 0.006), positive anti-Ro/SSA antibodies (p = 0.003), positive anti-La/SSB antibodies (p = 0.077), positive rheumatoid factor (p = 0.034), and immunoglobulin G levels > 1600 mg/dL (p = 0.077). Salivary flow rate was lower in patients with scores 3 or 4 (p = 0.001).

Conclusion

This study provides further evidence that salivary gland ultrasonography can be used not only for diagnosis but also for prognostic evaluation of primary Sjögren’s syndrome. These findings confirm what has been reported in the literature. However, further analyses involving larger matched samples are required to support this finding and include salivary gland ultrasonography as part of the diagnostic criteria for Sjögren’s syndrome.

Salivary gland ultrasound abnormalities in primary Sjögren's syndrome: consensual US-SG core items definition and reliability

Objectives

Ultrasonography (US) is sensitive for detecting echostructural abnormalities of the major salivary glands (SGs) in primary Sjögren’s syndrome (pSS). Our objectives were to define selected US-SG echostructural abnormalities in pSS, set up a preliminary atlas of these definitions and evaluate the consensual definitions reliability in both static and acquisition US-SG images.

Methods

International experts in SG US in pSS participated in consensus meetings to select and define echostructural abnormalities in pSS. The US reliability of detecting these abnormalities was assessed using a two-step method. First 12 experts used a web-based standardised form to evaluate 60 static US-SG images. Intra observer and interobserver reliabilities were expressed in κ values. Second, five experts, who participated all throughout the study, evaluated US-SG acquisition interobserver reliability in pSS patients.

Results

Parotid glands (PGs) and submandibular glands (SMGs) intra observer US reliability on static images was substantial (κ > 0.60) for the two main reliable items (echogenicity and homogeneity) and for the advised pSS diagnosis. PG inter observer reliability was substantial for homogeneity. SMGs interobserver reliability was moderate for homogeneity (κ = 0.46) and fair for echogenicity (κ = 0.38). On acquisition images, PGs interobserver reliability was substantial (κ = 0.62) for echogenicity and moderate (κ = 0.52) for homogeneity. The advised pSS diagnosis reliability was substantial (κ = 0.66). SMGs interobserver reliability was fair (0.20< κ ≤ 0.40) for echogenicity and homogeneity and either slight or poor for all other US core items.

Conclusion

This work identified two most reliable US-SG items (echogenicity and homogeneity) to be used by US-SG trained experts. US-PG interobserver reliability result for echogenicity is in line with diagnosis of pSS.

[Ultrasound diagnostics in Sjögren's syndrome]

Ultrasound of the salivary glands is a specific examination for detecting pathology of salivary glands in the diagnosis of Sjögren's syndrome. It is easy to learn, rapidly performed, non-invasive and inexpensive. Other imaging techniques, such as sialography and scintigraphy, are currently only rarely performed. For the examination, linear ultrasound probes with frequencies between 7 and 12 MHz are recommended. Such probes are already widely available to the rheumatologist performing musculoskeletal ultrasound. The parotid and submandibular glands are bilaterally scanned both in longitudinal and transverse planes as a standard.Normal salivary glands have uniformly hyperechoic and homogeneous tissue. They can be clearly delineated from the surrounding muscles and soft tissue and appear similar to the thyroid gland. The salivary glands are typically hypoechoic and inhomogeneous in Sjögren's syndrome. Focal or diffuse hypoechoic or anechoic foci are found in the glands. The submandibular glands may become atrophic (sagittal diameter <8 mm). Particularly in disease flares, the parotid glands may become enlarged (sagittal diameter >20 mm). The sensitivity for the diagnosis is 60 to 90% and the specificity is over 90%.Doppler sonography does not further improve the diagnostic accuracy. Sonography has thus become an important tool in the diagnosis of Sjögren's syndrome.

Sonoelastographic Modalities in the Evaluation of Salivary Gland Characteristics in Sjögren's Syndrome

The purpose of this study was to investigate salivary tissue assessment with various sonoelastographic modalities (real-time tissue elastography, Virtual Touch imaging and quantification) in patients with Sjögren's syndrome as compared with an appropriate control group. The sonoelastographic modalities were evaluated in 50 patients with primary Sjögren's syndrome (pSS). Patients underwent high-resolution ultrasonography of the submandibular and parotid glands. Results of B-mode, real-time tissue elastography, Virtual Touch imaging-each graded with the appropriate scoring system-and Virtual Touch quantification were compared with those for 50 patients with sicca symptoms who did not fulfill the American-European consensus group criteria. In B-mode, 34 of 50 parotid glands in patients with pSS and 8 of 50 in the control group had abnormal findings (p < 0.001). Compared with 9 of 50 control patients, 38 of 50 patients with pSS had abnormal findings in submandibular gland B-mode (p < 0.001). With real-time tissue elastography, there was a trend toward higher scores for parotid glands in the pSS group (p = 0.238), whereas scores for submandibular glands in the control group were higher (p = 0.107). Virtual Touch imaging did not indicate any difference (p = 0.647 and p = 0.658). In Virtual Touch quantification, values for parotid (mean: 2.99 m/s) and submandibular glands (mean: 2.54 m/s) in the pSS group were higher than those for parotid (mean: 2.16 m/s) and submandibular (mean: 2.04 m/s) glands in the control group (p < 0.001 and p = 0.008). Glandular stiffness, measured by Virtual Touch quantification, was significantly higher in patients with Sjögreńs syndrome than in patients with sicca symptoms.

Multiobserver Reliability of Ultrasound Assessment of Salivary Glands in Patients with Established Primary Sjögren Syndrome

Objective.

To evaluate the multiobserver reliability of salivary gland ultrasonography (SGUS) for scoring greyscale (GS) parenchymal inhomogeneity and parenchymal color Doppler (CD) signal in patients with established primary Sjögren syndrome (pSS).

Methods.

The study comprised 2 multiobserver reliability assessments in patients with pSS in 2 European centers. The first reliability exercise was performed on 24 patients with pSS and 8 controls who were independently evaluated with GS and CD US by 5 observers at the Institute of Rheumatology, Belgrade, Serbia. The second reliability exercise was carried out on 10 patients with pSS who were independently assessed with GS and CD US by 8 observers at the Hospital G.U. Gregorio Marañón, Madrid, Spain. SGUS parenchymal inhomogeneity and parenchymal CD signal were semiquantitatively scored using a 4-grade scoring system. The multiobserver agreement was calculated by the overall agreement and Light’s κ statistics.

Results.

A total of 640 SGUS examinations were performed in the first reliability exercise and a total of 320 examinations in the second reliability exercise. Multiobserver reliability was good (κ = 0.71–0.79) to excellent (κ = 0.81–0.82) for GS parenchymal inhomogeneity in both exercises. There was a moderate (κ = 0.53–0.58) to good (κ = 0.70) multiobserver reliability for parenchymal CD signal in the first exercise. However, there was no agreement or only a fair agreement (κ = 0.03–0.29) for parenchymal CD signal in the second exercise.

Conclusion.

US may be a reliable technique in the multiobserver scoring of GS parenchymal inhomogeneity of major SG in patients with established pSS. CD scoring of SG needs further standardization to be used in multicenter studies.

Standards for the assessment of salivary glands - an update

The paper is an update of 2011 Standards for Ultrasound Assessment of Salivary Glands, which were developed by the Polish Ultrasound Society. We have described current ultrasound technical requirements, assessment and measurement techniques as well as guidelines for ultrasound description. We have also discussed an ultrasound image of normal salivary glands as well as the most important pathologies, such as inflammation, sialosis, collagenosis, injuries and proliferative processes, with particular emphasis on lesions indicating high risk of malignancy. In acute bacterial inflammation, the salivary glands appear as hypoechoic, enlarged or normal-sized, with increased parenchymal flow. The echogenicity is significantly increased in viral infections. Degenerative lesions may be seen in chronic inflammations. Hyperechoic deposits with acoustic shadowing can be visualized in lithiasis. Parenchymal fibrosis is a dominant feature of sialosis. Sjögren syndrome produces different pictures of salivary gland parenchymal lesions at different stages of the disease. Pleomorphic adenomas are usually hypoechoic, well-defined and polycyclic in most cases. Warthin tumor usually presents as a hypoechoic, oval-shaped lesion with anechoic cystic spaces. Malignancies are characterized by blurred outlines, irregular shape, usually heterogeneous echogenicity and pathological neovascularization. The accompanying metastatic lesions are another indicator of malignancy, however, final diagnosis should be based on biopsy findings.

A Point-Scoring System for the Clinical Diagnosis of Sjögren's Syndrome Based on Quantified SPECT Imaging of Salivary Gland

Objective

To establish a point-scoring diagnostic system for Sjögren's syndrome (SS) based on quantified SPECT imaging of salivary gland, and evaluate its feasibility and performance compared with 2002 AECG criteria and 2012 ACR criteria.

Methods

213 patients with suspected SS enrolled in this study. The related clinical data of all patients were collected. All patients were evaluated and grouped on a clinical basis and posttreatment follow-up by rheumatology specialists as the unified standard (SS group with 149 cases and nSS group with 64 cases). From SPECT imaging of salivary gland, T_max, UI_max, T_s and EF_s were derived for bilateral parotid and submandibular glands, and compared between the groups. A point-scoring diagnostic system for SS was established based on the quantified SPECT imaging of salivary gland. We estimated the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy for the new diagnostic system, compared with 2002 AECG criteria and 2012 ACR criteria.

Results

When 7.0 was used as the cut-off point, the sensitivity, specificity, PPV, NPV and accuracy for the new point-scoring system in diagnosing SS were 89.93% (134/149), 93.75% (60/64), 97.10% (134/138), 80.00% (60/75) and 91.08% (194/213), respectively. The new point-scoring diagnostic system based on quantified SPECT imaging of salivary gland keeps the specificity comparatively to 2002 AECG criteria and 2012 ACR criteria, but improves the sensitivity significantly (P<0.01).

Conclusion

The new point-scoring diagnostic system for SS based on quantified SPECT imaging of salivary gland may be superior to 2002 AECG criteria and 2012 ACR criteria, with higher sensitivity and similar specificity in the diagnosis of SS. Additionally, it also has good feasibility in the clinical settings.

Combination of Salivary Gland Ultrasonography and Virtual Touch Quantification for Diagnosis of Sjögren's Syndrome: A Preliminary Study

A total of 136 subjects (51 SS patients, 35 sicca syndrome patients without SS, and 50 healthy volunteers) were enrolled in this study. The mean SWV value for salivary glands of SS patients was statistically higher than that of controls (2.81 ± 0.66 m/s versus 1.85 ± 0.28 m/s for parotid glands and 2.29 ± 0.34 m/s versus 1.82 ± 0.25 m/s for submandibular glands, resp.). Combining SWV values of parotid and submandibular glands gives a sensitivity of 88.2% (95% CI: 76.1-95.6%) and specificity of 96.0% (95% CI: 86.3-99.5%) at the cutoff point of 2.19 m/s, with an AUROC of 0.954 (95% CI: 0.893-0.986). In addition, combining SGUS score and SWV value yields a sensitivity of 98.0% (95% CI: 89.6-100%), specificity of 90.0% (95% CI: 78.2-96.7%), and AUROC of 0.962 (95% CI: 0.904-0.990). Classification tree considering the sequential use of SGUS score and SWV value achieved 92.1% accuracy for diagnosis of SS. Similarly, the ROC curve of combined SGUS scores and SWV values yields an AUROC of 0.954 (95% CI: 0.885-0.987), sensitivity of 97.1% (95% CI: 85.1-99.9%), and specificity of 92.2% (95% CI: 81.1-97.8%) for separating sicca syndrome patients (without SS) from SS patients. Combining SGUS and VTQ provides a promising tool for diagnosis of SS.