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Mo YQ, Hao SY, Li QH, Liang JJ, Luo Y, Lan YQ, Zhong JL, Wang JW, Zhang XP, Huang WK, Dai L. Ultrasonography predicts the results of labial salivary gland biopsy in patients with suspected Sjögren's syndrome: a matrix risk model. Ther Adv Musculoskelet Dis 2021; 13:1759720X211010592. [PMID: 33995602 PMCID: PMC8071977 DOI: 10.1177/1759720x211010592] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 03/25/2021] [Indexed: 11/17/2022] Open
Abstract
Objective: Although a positive result of labial salivary gland biopsy (LSGB) is critical for the diagnosis of Sjögren’s syndrome, rheumatologists prefer assessing the non-invasive objective items and hope to learn the predicted probability of positive LSGB before referring patients with suspected Sjögren’s syndrome to receive biopsy. This study aimed to explore the predictive value of combined B-mode ultrasonography (US) and shear-wave elastography (SWE) examination on LSGB results. Methods: A derivation cohort and later a validation cohort of patients with suspected Sjögren’s syndrome were recruited. All participants received clinical assessments, B-mode US and SWE examination on bilateral parotid and submandibular glands before LSGB. Positive LSGB was defined by a focus score ⩾1 per 4 mm2 of glandular tissue. Results: In the derivation cohort of 91 participants, either the total US scores or the total SWE values of four glands significantly distinguished patients with positive LSGB from those with negative results (area under the curve (AUC) = 0.956, 0.825, both p < 0.001). The positive predictive value (PPV) was 100% in patients with total US scores ⩾9 or with total SWE values ⩾33 kPa. The negative predictive value (NPV) was 100% in patients with total US scores <5, but 68% in patients with total SWE values <27 kPa. A matrix risk model was derived based on the combination of total US scores and total SWE values. Patients can be stratified into high, moderate, and low risk of positive LSGB. In the validation cohort of 52 participants, the PPV was 94% in the high-risk subpopulation and the NPV was 93% in the low-risk subpopulation. Conclusion: A novel matrix risk model based on the combined B-mode US and SWE examination can help rheumatologists to make a shared decision with suspected Sjögren’s syndrome patients on whether the invasive procedure of LSGB should be performed.
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Affiliation(s)
- Ying-Qian Mo
- Department of Rheumatology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, P.R. China
| | - Shao-Yun Hao
- Department of Ultrasonography, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, P.R. China
| | - Qian-Hua Li
- Department of Rheumatology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, P.R. China
| | - Jin-Jian Liang
- Department of Rheumatology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, P.R. China
| | - Yi Luo
- Department of Ultrasonography, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, P.R. China
| | - Yu-Qing Lan
- Department of Ophthalmology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, P.R. China
| | - Jiang-Long Zhong
- Department of Oral & Maxillofacial Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, P.R. China
| | - Jun-Wei Wang
- Department of Rheumatology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, P.R. China
| | - Xue-Pei Zhang
- Department of Rheumatology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, P.R. China
| | - Wen-Ke Huang
- Department of Rheumatology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, P.R. China
| | - Lie Dai
- Department of Rheumatology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yanjiang West Road, Guangzhou, 510120, P.R. China
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Zandonella Callegher S, Zabotti A, Giovannini I, Treppo E, Quartuccio L, De Vita S. Normal-Appearing Salivary Gland Ultrasonography Identifies a Milder Phenotype of Primary Sjögren's Syndrome. Front Med (Lausanne) 2020; 7:602354. [PMID: 33363187 PMCID: PMC7756091 DOI: 10.3389/fmed.2020.602354] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 11/09/2020] [Indexed: 12/17/2022] Open
Abstract
Objective: Salivary gland ultrasound (SGUS) is emerging as a valid tool in the management of primary Sjögren's syndrome (pSS). This study aimed to investigate whether pSS patients with normal-appearing or pathological SGUS findings showed different clinical, laboratory, and pathologic pSS-related features, and to compare the results by using two different SGUS scores. Methods: Consecutive pSS patients, according to the ACR-EULAR classification criteria, were evaluated. Salivary glands were scored using the early 1992 score by De Vita et al. and the latest 2019 OMERACT score, both being semiquantitative 0-3 scoring systems focused on ultrasonographic parenchymal inhomogeneity (grades 0 and 1, normal-appearing; grades 2 and 3, pathological). The patients were then divided into two groups: "SGUS normal-appearing" if all the salivary glands had normal-appearing parenchyma (grade 0 or 1), or "SGUS pathological" if the grade was 2 or 3 in at least one salivary gland. The associations between SGUS and pSS-related clinical, laboratory, and pathological features were then investigated in the two groups. Results: One hundred pSS patients were evaluated, the mean age (±SD) was 60.9 ± 12.0 years, and mean disease duration was 11.7 ± 7.2 years. Twenty-nine out of 100 (29%) patients were in the "SGUS normal-appearing" group and 71/100 (71%) were in the "SGUS pathological" group. A normal-appearing SGUS was significantly associated with the absence of anti-La/SSB antibodies (p < 0.001) and normal unstimulated salivary flow rate (p = 0.02) by both univariate and multivariate analyses. By univariate analysis, a normal-appearing SGUS was significantly associated also with the absence of rheumatoid factor (p = 0.002) and of serum monoclonal component (p = 0.003), ESSDAI < 5 (p = 0.03), and with a negative lip biopsy (p = 0.029). No associations were found with other items, including anti-Ro/SSA (p = 0.145), Schirmer's test (p = 0.793), ESSPRI (p = 0.47), and demographic data. No differences in these results were observed by using the two SGUS scoring systems. Conclusion: The SGUS allowed the identification of different phenotypes of pSS, and different SGUS scores focused on salivary gland inhomogeneity may be effective to this end.
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Affiliation(s)
- Sara Zandonella Callegher
- Rheumatology Clinic, Department of Medical Area, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Alen Zabotti
- Rheumatology Clinic, Department of Medical Area, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Ivan Giovannini
- Rheumatology Clinic, Department of Medical Area, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Elena Treppo
- Rheumatology Clinic, Department of Medical Area, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Luca Quartuccio
- Rheumatology Clinic, Department of Medical Area, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Salvatore De Vita
- Rheumatology Clinic, Department of Medical Area, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
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Martino M, Fodor D, Fresilli D, Guiban O, Rubini A, Cassoni A, Ralli M, De Vincentiis C, Arduini F, Celletti I, Pacini P, Polti G, Polito E, Greco A, Valentini V, Sorrenti S, D'Andrea V, Masciocchi C, Barile A, Cantisani V. Narrative review of multiparametric ultrasound in parotid gland evaluation. Gland Surg 2020; 9:2295-2311. [PMID: 33447581 DOI: 10.21037/gs-20-530] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
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.
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Affiliation(s)
- Milvia Martino
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Daniela Fodor
- 2nd Internal Medicine Department, "Iuliu Hațieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Daniele Fresilli
- Department of Radiological Sciences, Oncology and Pathology, Policlinico Umberto I "Sapienza" University of Rome, Rome, Italy
| | - Olga Guiban
- Department of Radiological Sciences, Oncology and Pathology, Policlinico Umberto I "Sapienza" University of Rome, Rome, Italy
| | | | - Andrea Cassoni
- Department of Maxillofacial Surgery, Policlinico Umberto I "Sapienza" University of Rome, Rome, Italy
| | - Massimo Ralli
- Department of Sense Organs, Sapienza University of Rome, Rome, Italy
| | | | - Federico Arduini
- Department of Radiology, Ospedale Santa Maria del Carmine, Rovereto, Italy
| | - Ilaria Celletti
- Department of Radiological Sciences, Oncology and Pathology, Policlinico Umberto I "Sapienza" University of Rome, Rome, Italy
| | - Patrizia Pacini
- Department of Radiological Sciences, Oncology and Pathology, Policlinico Umberto I "Sapienza" University of Rome, Rome, Italy
| | - Giorgia Polti
- Department of Radiological Sciences, Oncology and Pathology, Policlinico Umberto I "Sapienza" University of Rome, Rome, Italy
| | - Eleonora Polito
- Department of Radiological Sciences, Oncology and Pathology, Policlinico Umberto I "Sapienza" University of Rome, Rome, Italy
| | - Antonio Greco
- Department of Sense Organs, Sapienza University of Rome, Rome, Italy
| | - Valentino Valentini
- Department of Maxillofacial Surgery, Policlinico Umberto I "Sapienza" University of Rome, Rome, Italy
| | - Salvatore Sorrenti
- Department of Surgical Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Vito D'Andrea
- Department of Surgical Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Carlo Masciocchi
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Antonio Barile
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Vito Cantisani
- Department of Radiological Sciences, Oncology and Pathology, Policlinico Umberto I "Sapienza" University of Rome, Rome, Italy
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Zabotti A, Zandonella Callegher S, Tullio A, Vukicevic A, Hocevar A, Milic V, Cafaro G, Carotti M, Delli K, De Lucia O, Ernst D, Ferro F, Gattamelata A, Germanò G, Giovannini I, Hammenfors D, Jonsson MV, Jousse-Joulin S, Macchioni P, Parisi S, Perricone C, Stradner MH, Filipovic N, Tzioufas AG, Valent F, De Vita S. Salivary Gland Ultrasonography in Sjögren's Syndrome: A European Multicenter Reliability Exercise for the HarmonicSS Project. Front Med (Lausanne) 2020; 7:581248. [PMID: 33330537 PMCID: PMC7719819 DOI: 10.3389/fmed.2020.581248] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 10/21/2020] [Indexed: 12/26/2022] Open
Abstract
Objectives: Salivary gland ultrasonography (SGUS) is increasingly applied for the management of primary Sjögren's syndrome (pSS). This study aims to: (i) compare the reliability between two SGUS scores; (ii) test the reliability among sonographers with different levels of experience. Methods: In the reliability exercise, two four-grade semi-quantitative SGUS scoring systems, namely De Vita et al. and OMERACT, were tested. The sonographers involved in work-package 7 of the HarmonicSS project from nine countries in Europe were invited to participate. Different levels of sonographers were identified on the basis of their SGUS experience and of the knowledge of the tested scores. A dedicated atlas was used as support for SGUS scoring. Results: Twenty sonographers participated in the two rounds of the reliability exercise. The intra-rater reliability for both scores was almost perfect, with a Light's kappa of 0.86 for the De Vita et al. score and 0.87 for the OMERACT score. The inter-rater reliability for the De Vita et al. and the OMERACT score was substantial with Light's Kappa of 0.75 and 0.77, respectively. Furthermore, no significant difference was noticed among sonographers with different levels of experience. Conclusion: The two tested SGUS scores are reliable for the evaluation of major salivary glands in pSS, and even less-expert sonographers could be reliable if adequately instructed.
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Affiliation(s)
- Alen Zabotti
- Rheumatology Clinic, Department of Medical Area, Academic Hospital S. Maria della Misericordia, University of Udine, Udine, Italy
| | - Sara Zandonella Callegher
- Rheumatology Clinic, Department of Medical Area, Academic Hospital S. Maria della Misericordia, University of Udine, Udine, Italy
| | - Annarita Tullio
- Institute of Epidemiology, Academic Hospital 'Santa Maria della Misericordia', Udine, Italy
| | - Arso Vukicevic
- Faculty of Engineering Science, University of Kragujevac, Kragujevac, Serbia.,Bioengineering Research and Development Center (BioIRC), Kragujevac, Serbia
| | - Alojzija Hocevar
- Department of Rheumatology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Vera Milic
- Institute of Rheumatology, Belgrade, Serbia
| | - Giacomo Cafaro
- Rheumatology Unit, Department of Medicine, University of Perugia, Perugia, Italy
| | - Marina Carotti
- Department of Radiology, Ospedali Riuniti, Università Politecnica delle Marche, Ancona, Italy
| | - Konstantina Delli
- Department of Oral and Maxillofacial Surgery, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Orazio De Lucia
- Unit of Clinical Rheumatology, Department of Rheumatology and Medical Sciences, Aziende Socio Sanitarie Territoriali (ASST) Centro Traumatologico Ortopedico G. Pini-Centri Traumatologici Ortopedici (CTO), Milan, Italy
| | - Diana Ernst
- Clinic for Immunology and Rheumatology, Hannover Medical School, Hannover, Germany
| | - Francesco Ferro
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Angelica Gattamelata
- Department of Internal Medicine and Medical Specialties, Rheumatology, Sapienza University of Rome, Rome, Italy
| | - Giuseppe Germanò
- Rheumatology Unit, Department of Internal Medicine, Azienda Ospedaliera Arcispedale Santa Maria Nuova (ASMN), Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy
| | - Ivan Giovannini
- Rheumatology Clinic, Department of Medical Area, Academic Hospital S. Maria della Misericordia, University of Udine, Udine, Italy
| | - Daniel Hammenfors
- Broegelmann Research Laboratory, Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Rheumatology, Haukeland University Hospital, Bergen, Norway
| | - Malin V Jonsson
- Broegelmann Research Laboratory, Department of Clinical Science, University of Bergen, Bergen, Norway.,Section for Oral and Maxillofacial Radiology, Department of Clinical Dentistry, University of Bergen, Bergen, Norway
| | - Sandrine Jousse-Joulin
- Rheumatology Department, Centre Hospitalier Universitaire (CHU) de Brest, Univ Brest, Brest, France.,UMR 1227, Lymphocytes B et Autoimmunité (LBAI), Inserm, Univ Brest, Brest, France
| | - Pierluigi Macchioni
- Rheumatology Unit, Department of Internal Medicine, Azienda Ospedaliera Arcispedale Santa Maria Nuova (ASMN), Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy
| | - Simone Parisi
- Unit of Rheumatology, Department of General and Specialty Medicine, Città della Salute e della Scienza, Turin, Italy
| | - Carlo Perricone
- Rheumatology Unit, Department of Medicine, University of Perugia, Perugia, Italy
| | | | - Nenad Filipovic
- Faculty of Engineering Science, University of Kragujevac, Kragujevac, Serbia.,Bioengineering Research and Development Center (BioIRC), Kragujevac, Serbia
| | - Athanasios G Tzioufas
- Department of Pathophysiology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Francesca Valent
- Institute of Epidemiology, Academic Hospital 'Santa Maria della Misericordia', Udine, Italy
| | - Salvatore De Vita
- Rheumatology Clinic, Department of Medical Area, Academic Hospital S. Maria della Misericordia, University of Udine, Udine, Italy
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5
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Ramsubeik K, Motilal S, Sanchez-Ramos L, Ramrattan LA, Kaeley GS, Singh JA. Diagnostic accuracy of salivary gland ultrasound in Sjögren's syndrome: A systematic review and meta-analysis. Ther Adv Musculoskelet Dis 2020; 12:1759720X20973560. [PMID: 33281953 PMCID: PMC7682247 DOI: 10.1177/1759720x20973560] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 10/25/2020] [Indexed: 12/19/2022] Open
Abstract
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.
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Affiliation(s)
- Karishma Ramsubeik
- Division of Rheumatology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Shastri Motilal
- Department of Para Clinical Sciences, The University of the West Indies, St Augustine, Trinidad and Tobago
| | - Luis Sanchez-Ramos
- Division of Maternal and Fetal Medicine, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Laurie Ann Ramrattan
- Division of Rheumatology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Gurjit S. Kaeley
- Division of Rheumatology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Jasvinder A. Singh
- Department of Medicine, Birmingham VA Medical Center, Faculty Office Tower 805B, 510, 20th Street South, Birmingham, AL 35233, USA
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6
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Aburiziza AJ. Primary Juvenile Sjögren's Syndrome in a 3-Year-Old Pediatric Female Patient: Diagnostic Role of Salivary Gland Ultrasonography: Case Report. Open Access Rheumatol 2020; 12:73-78. [PMID: 32581605 PMCID: PMC7269660 DOI: 10.2147/oarrr.s248977] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Sjögren’s syndrome (SS) is a chronic inflammatory autoimmune disease affecting mainly the salivary and lacrimal glands characterized by lymphocytic infiltration which results in gland destruction and impairment of functions. SS rarely affects pediatric patients, and there are no clear diagnostic criteria as there are with adult SS. The present case reports an atypical case of SS in a 3-year-old female who was closely followed up with for 5 years. The important role of salivary gland ultrasonography (SGUS) in early diagnosis, the change in clinical picture, as well as fluctuation of serology, are noticed.
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7
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James-Goulbourne T, Murugesan V, Kissin EY. Sonographic Features of Salivary Glands in Sjögren's Syndrome and its Mimics. Curr Rheumatol Rep 2020; 22:36. [PMID: 32562049 DOI: 10.1007/s11926-020-00914-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
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.
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Affiliation(s)
| | | | - Eugene Y Kissin
- Section of Rheumatology, 72 East Concord Str, Evans 501, Boston, MA, 02118, USA.
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8
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The Utility of Major Salivary Gland Ultrasonographic Parameters in the Diagnosis of Sjögren Syndrome. DISEASE MARKERS 2020; 2019:1716848. [PMID: 31929838 PMCID: PMC6942831 DOI: 10.1155/2019/1716848] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 11/25/2019] [Indexed: 02/08/2023]
Abstract
Objective To investigate ultrasonographically the salivary glands and to correlate ultrasonographic parameters with focus score, serum beta-2-microglobulin, and stimulated salivary flow rate. Material and Methods 32 patients with primary Sjögren's syndrome (pSS) and 32 healthy controls were enrolled in this case-control study, performed in the Department of Internal Medicine, Division of Rheumatology, "Victor Babeș" University of Medicine and Pharmacy, Timișoara, Romania. All the patients and controls were examined by salivary gland ultrasonography (B-mode, color and spectral Doppler, and sonoelastography), determining the following parameters: salivary gland ultrasonography (SGUS) score, resistive index (RI) of transverse facial artery, and shear wave velocity (SWV). Serum beta-2-microglobulin and stimulated saliva amount were determined in all the patients and controls. Minor salivary gland biopsy with focus score assessment was done in pSS patients. Results Patients with pSS presented higher SGUS score and parotid and submandibular SWV and reduced RI of transverse facial artery than controls (p < 0.0001). In pSS patients, statistically significant correlations were identified between assessed ultrasonographic parameters and focus score, serum beta-2-microglobulin, and respective stimulated saliva flow (p < 0.0001). Conclusions This study highlighted statistically significant correlations between salivary gland ultrasonographic parameters and focus score, serum beta-2-microglobulin, and stimulated saliva flow.
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9
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Vukicevic AM, Milic V, Zabotti A, Hocevar A, De Lucia O, Filippou G, Frangi AF, Tzioufas A, De Vita S, Filipovic N. Radiomics-Based Assessment of Primary Sjögren's Syndrome From Salivary Gland Ultrasonography Images. IEEE J Biomed Health Inform 2019; 24:835-843. [PMID: 31329136 DOI: 10.1109/jbhi.2019.2923773] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Salivary gland ultrasonography (SGUS) has shown good potential in the diagnosis of primary Sjögren's syndrome (pSS). However, a series of international studies have reported needs for improvements of the existing pSS scoring procedures in terms of inter/intra observer reliability before being established as standardized diagnostic tools. The present study aims to solve this problem by employing radiomics features and artificial intelligence (AI) algorithms to make the pSS scoring more objective and faster compared to human expert scoring. The assessment of AI algorithms was performed on a two-centric cohort, which included 600 SGUS images (150 patients) annotated using the original SGUS scoring system proposed in 1992 for pSS. For each image, we extracted 907 histogram-based and descriptive statistics features from segmented salivary glands. Optimal feature subsets were found using the genetic algorithm based wrapper approach. Among the considered algorithms (seven classifiers and five regressors), the best preforming was the multilayer perceptron (MLP) classifier (κ = 0.7). The MLP over-performed average score achieved by the clinicians (κ = 0.67) by the considerable margin, whereas its reliability was on the level of human intra-observer variability (κ = 0.71). The presented findings indicate that the continuously increasing HarmonicSS cohort will enable further advancements in AI-based pSS scoring methods by SGUS. In turn, this may establish SGUS as an effective noninvasive pSS diagnostic tool, with the final goal to supplement current diagnostic tests.
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10
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Baer AN, Walitt B. Update on Sjögren Syndrome and Other Causes of Sicca in Older Adults. Rheum Dis Clin North Am 2018; 44:419-436. [PMID: 30001784 DOI: 10.1016/j.rdc.2018.03.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Dry eye and dry mouth symptoms are each reported by up to 30% of persons more than 65 years of age, particularly in women. Medication side effects are the most common contributing factors. The evaluation of these symptoms requires measures of ocular and oral dryness. Sjögren syndrome is the prototypical disease associated with dryness of the eyes and mouth and predominantly affects women in their perimenopausal and postmenopausal years. In addition to topical treatment of the mucosal dryness, patients with Sjögren syndrome may require treatment with systemic immunomodulatory and immunosuppressive agents to manage a variety of extraglandular manifestations.
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Affiliation(s)
- Alan N Baer
- Division of Rheumatology, Department of Medicine, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Suite 4000, Mason Lord Center Tower, Baltimore, MD 21224, USA; National Institute of Dental and Craniofacial Research, National Institutes of Health, 10 Center Drive, Bethesda, MD 20892, USA.
| | - Brian Walitt
- National Institute of Dental and Craniofacial Research, National Institutes of Health, 10 Center Drive, Bethesda, MD 20892, USA
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Jonsson R, Brokstad KA, Jonsson MV, Delaleu N, Skarstein K. Current concepts on Sjögren's syndrome - classification criteria and biomarkers. Eur J Oral Sci 2018; 126 Suppl 1:37-48. [PMID: 30178554 PMCID: PMC6586012 DOI: 10.1111/eos.12536] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2018] [Indexed: 12/13/2022]
Abstract
Sjögren's syndrome is a lymphoproliferative disease with autoimmune features characterized by mononuclear cell infiltration of exocrine glands, notably the lacrimal and salivary glands. These lymphoid infiltrations lead to dryness of the eyes (keratoconjunctivitis sicca), dryness of the mouth (xerostomia), and, frequently, dryness of other surfaces connected to exocrine glands. Sjögren's syndrome is associated with the production of autoantibodies because B-cell activation is a consistent immunoregulatory abnormality. The spectrum of the disease extends from an organ-specific autoimmune disorder to a systemic process and is also associated with an increased risk of B-cell lymphoma. Current treatments are mainly symptomatic. As a result of the diverse presentation of the syndrome, a major challenge remains to improve diagnosis and therapy. For this purpose an international set of classification criteria for primary Sjögren's syndrome has recently been developed and validated and seems well suited for enrolment in clinical trials. Salivary gland biopsies have been examined and histopathology standards have been developed, to be used in clinical trials and patient stratification. Finally, ultrasonography and saliva meet the need of non-invasive imaging and sampling methods for discovery and validation of disease biomarkers in Sjögren's syndrome.
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Affiliation(s)
- Roland Jonsson
- Broegelmann Research LaboratoryDepartment of Clinical ScienceUniversity of BergenBergenNorway
- Department of RheumatologyHaukeland University HospitalBergenNorway
| | - Karl A. Brokstad
- Broegelmann Research LaboratoryDepartment of Clinical ScienceUniversity of BergenBergenNorway
| | - Malin V. Jonsson
- Department of Clinical Dentistry – Section for Oral and Maxillofacial RadiologyUniversity of BergenBergenNorway
| | - Nicolas Delaleu
- Broegelmann Research LaboratoryDepartment of Clinical ScienceUniversity of BergenBergenNorway
- 2C SysBioMedContraSwitzerland
| | - Kathrine Skarstein
- Gade Laboratory for PathologyDepartment of Clinical MedicineUniversity of BergenBergenNorway
- Department of PathologyHaukeland University HospitalBergenNorway
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12
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Abstract
Dry eye and dry mouth symptoms are each reported by up to 30% of persons more than 65 years of age, particularly in women. Medication side effects are the most common contributing factors. The evaluation of these symptoms requires measures of ocular and oral dryness. Sjögren syndrome is the prototypic disease associated with dryness of the eyes and mouth and predominantly affects women in their perimenopausal and postmenopausal years. In addition to topical treatment of the mucosal dryness, patients with Sjögren syndrome may require treatment with systemic immunomodulatory and immunosuppressive agents to manage a variety of extraglandular manifestations.
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Affiliation(s)
- Alan N Baer
- Division of Rheumatology, Department of Medicine, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Suite 4000, Mason Lord Center Tower, Baltimore, MD 21224, USA; National Institute of Dental and Craniofacial Research, National Institutes of Health, 10 Center Drive, Bethesda, MD 20892, USA.
| | - Brian Walitt
- National Institute of Dental and Craniofacial Research, National Institutes of Health, 10 Center Drive, Bethesda, MD 20892, USA
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13
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Le Goff M, Cornec D, Jousse-Joulin S, Guellec D, Costa S, Marhadour T, Le Berre R, Genestet S, Cochener B, Boisrame-Gastrin S, Renaudineau Y, Pers JO, Saraux A, Devauchelle-Pensec V. Comparison of 2002 AECG and 2016 ACR/EULAR classification criteria and added value of salivary gland ultrasonography in a patient cohort with suspected primary Sjögren's syndrome. Arthritis Res Ther 2017; 19:269. [PMID: 29208023 PMCID: PMC5717850 DOI: 10.1186/s13075-017-1475-x] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 11/16/2017] [Indexed: 11/25/2022] Open
Abstract
Background The objective was to evaluate concordance between 2002 American-European Consensus Group (AECG) and 2016 American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) classification criteria for primary Sjögren’s syndrome (pSS) and to assess how salivary gland ultrasonography (SGUS) might improve the classification of patients. Methods Patients with suspected pSS underwent a standardised evaluation, including SGUS, at inclusion into the single-centre Brittany DIApSS cohort. Agreement between the two criteria sets was assessed using Cohen’s κ coefficient. Characteristics of discordantly categorised patients were detailed. Results We prospectively included 290 patients between 2006 and 2016, among whom 125 (43%) met ACR/EULAR criteria and 114 (39%) also met AECG criteria; thus, 11 (4%) patients fulfilled only ACR/EULAR, no patients AECG only, and 165 (57%) patients neither criteria set. Concordance was excellent (κ = 0.92). Compared to patients fulfilling both criteria sets, the 11 patients fulfilling only ACR/EULAR criteria had similar age and symptom duration but lower frequencies of xerophthalmia and xerostomia (p < 0.01 for each) and salivary gland dysfunction (p < 0.01); most had systemic involvement (91%), including three (27%) with no sicca symptoms; 91% had abnormal salivary gland biopsy and 46% anti-Sjögren's-syndrome-related antigen A (anti-SSA); 64% were diagnosed with pSS by the physician. SGUS was abnormal in 12% of the 165 patients fulfilling no criteria set. Including SGUS among the ACR/EULAR criteria increased sensitivity from 87.4% to 91.1% when physician diagnosis was the reference standard. Conclusions Agreement between AECG and ACR/EULAR criteria sets is excellent. ACR/EULAR criteria are slightly more sensitive and classified some patients without sicca symptoms as having pSS. Including SGUS in the ACR/EULAR criteria may further improve their sensitivity.
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Affiliation(s)
- Maëlle Le Goff
- Centre National de Référence CERAINO, Service de Rhumatologie, Hôpital de la Cavale Blanche, BP 824, F 29609, Brest cedex, France
| | - Divi Cornec
- Centre National de Référence CERAINO, Service de Rhumatologie, Hôpital de la Cavale Blanche, BP 824, F 29609, Brest cedex, France. .,INSERM UMR1227, Lymphocytes B et Autoimmunité, Université de Bretagne Occidentale, Brest, France.
| | - Sandrine Jousse-Joulin
- Centre National de Référence CERAINO, Service de Rhumatologie, Hôpital de la Cavale Blanche, BP 824, F 29609, Brest cedex, France.,INSERM UMR1227, Lymphocytes B et Autoimmunité, Université de Bretagne Occidentale, Brest, France
| | - Dewi Guellec
- Centre National de Référence CERAINO, Service de Rhumatologie, Hôpital de la Cavale Blanche, BP 824, F 29609, Brest cedex, France
| | - Sebastian Costa
- INSERM UMR1227, Lymphocytes B et Autoimmunité, Université de Bretagne Occidentale, Brest, France.,Anatomie et Pathologie, CHRU Brest, Brest, France
| | - Thierry Marhadour
- Centre National de Référence CERAINO, Service de Rhumatologie, Hôpital de la Cavale Blanche, BP 824, F 29609, Brest cedex, France
| | | | - Steeve Genestet
- Explorations Fonctionnelles Neurologiques, CHRU Brest, Brest, France
| | | | | | - Yves Renaudineau
- INSERM UMR1227, Lymphocytes B et Autoimmunité, Université de Bretagne Occidentale, Brest, France.,Laboratoire d'Immunologie et Immunothérapie, CHRU Brest, Brest, France
| | - Jacques-Olivier Pers
- INSERM UMR1227, Lymphocytes B et Autoimmunité, Université de Bretagne Occidentale, Brest, France.,Odontologie, CHRU Brest, Brest, France
| | - Alain Saraux
- Centre National de Référence CERAINO, Service de Rhumatologie, Hôpital de la Cavale Blanche, BP 824, F 29609, Brest cedex, France.,INSERM UMR1227, Lymphocytes B et Autoimmunité, Université de Bretagne Occidentale, Brest, France
| | - Valérie Devauchelle-Pensec
- Centre National de Référence CERAINO, Service de Rhumatologie, Hôpital de la Cavale Blanche, BP 824, F 29609, Brest cedex, France.,INSERM UMR1227, Lymphocytes B et Autoimmunité, Université de Bretagne Occidentale, Brest, France
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14
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Carvajal Alegria G, Costa S, Jousse-Joulin S, Marcorelles P, Pers JO, Saraux A, Devauchelle-Pensec V, Cornec D. What is the agreement between pathological features of parotid gland and labial salivary gland biopsies? Ann Rheum Dis 2017; 77:e37. [PMID: 28970211 DOI: 10.1136/annrheumdis-2017-212289] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 09/02/2017] [Indexed: 12/15/2022]
Affiliation(s)
- Guillermo Carvajal Alegria
- Service de Rhumatologie, Hôpital de la Cavale Blanche, CHRU Brest, Brest, France.,INSERM UMR1227, Lymphocytes B et Autoimmunité, Université de Bretagne Occidentale, Brest, France
| | - Sebastian Costa
- INSERM UMR1227, Lymphocytes B et Autoimmunité, Université de Bretagne Occidentale, Brest, France.,Laboratoire d'Anatomie Pathologique et Cytologie, Hôpital Morvan, CHRU Brest, Brest, France
| | - Sandrine Jousse-Joulin
- Service de Rhumatologie, Hôpital de la Cavale Blanche, CHRU Brest, Brest, France.,INSERM UMR1227, Lymphocytes B et Autoimmunité, Université de Bretagne Occidentale, Brest, France
| | - Pascale Marcorelles
- Laboratoire d'Anatomie Pathologique et Cytologie, Hôpital Morvan, CHRU Brest, Brest, France
| | - Jacques-Olivier Pers
- INSERM UMR1227, Lymphocytes B et Autoimmunité, Université de Bretagne Occidentale, Brest, France
| | - Alain Saraux
- Service de Rhumatologie, Hôpital de la Cavale Blanche, CHRU Brest, Brest, France.,INSERM UMR1227, Lymphocytes B et Autoimmunité, Université de Bretagne Occidentale, Brest, France
| | - Valérie Devauchelle-Pensec
- Service de Rhumatologie, Hôpital de la Cavale Blanche, CHRU Brest, Brest, France.,INSERM UMR1227, Lymphocytes B et Autoimmunité, Université de Bretagne Occidentale, Brest, France
| | - Divi Cornec
- Service de Rhumatologie, Hôpital de la Cavale Blanche, CHRU Brest, Brest, France.,INSERM UMR1227, Lymphocytes B et Autoimmunité, Université de Bretagne Occidentale, Brest, France
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15
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Mossel E, Delli K, van Nimwegen JF, Stel AJ, Kroese FGM, Spijkervet FKL, Vissink A, Arends S, Bootsma H. Ultrasonography of major salivary glands compared with parotid and labial gland biopsy and classification criteria in patients with clinically suspected primary Sjögren's syndrome. Ann Rheum Dis 2017; 76:1883-1889. [PMID: 28754802 DOI: 10.1136/annrheumdis-2017-211250] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 05/30/2017] [Accepted: 07/01/2017] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To assess the validity of ultrasound of major salivary glands (sUS) compared with parotid and labial gland biopsies, sialometry, anti-SSA/Ro antibody status and classification criteria in patients clinically suspected with primary Sjögren's syndrome (pSS). METHODS 103 consecutive outpatients with clinically suspected pSS underwent sUS. Parenchymal echogenicity, homogeneity, hypoechogenic areas, hyperechogenic reflections and clearness of salivary gland border were scored according to the Hocevar scoring system. Total ultrasound score was calculated as the sum of these domains (range 0-48). RESULTS Absolute agreement between sUS and parotid (83%) and labial (79%) gland biopsy outcome was good. Negative sUS predicts negative parotid gland biopsy, and positive sUS predicts positive labial gland biopsy. Compared with the American European Consensus Group (AECG) classification, sUS showed an absolute agreement of 82%, sensitivity of 71% and specificity of 92%. Compared with the American College of Rheumatology (ACR) classification, absolute agreement was 86%, sensitivity was 77% and specificity was 92%. Compared with the ACR-European League Against Rheumatism (EULAR) classification, absolute agreement was 80%, sensitivity was 67% and specificity was 94%. Positive sUS predicts classification, but negative sUS does not exclude classification. The combination of positive sUS with presence of anti-SSA/Ro antibodies or negative sUS with absence of anti-SSA/Ro antibodies showed a high predictive value for classification as pSS or non-pSS. CONCLUSION In our prospective inception cohort study derived from daily clinical practice, absolute agreement between sUS and salivary gland biopsies was slightly higher for parotid compared with labial gland biopsies. The combination of positive sUS and presence of anti-SSA/Ro antibodies highly predicts classification according to the AECG, ACR and ACR-EULAR classification criteria.
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Affiliation(s)
- Esther Mossel
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Konstantina Delli
- Department of Oral and Maxillofacial Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jolien F van Nimwegen
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Alja J Stel
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Frans G M Kroese
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Fred K L Spijkervet
- Department of Oral and Maxillofacial Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Arjan Vissink
- Department of Oral and Maxillofacial Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Suzanne Arends
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Hendrika Bootsma
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Chen S, Wang Y, Zhang G, Chen S. Combination of Salivary Gland Ultrasonography and Virtual Touch Quantification for Diagnosis of Sjögren's Syndrome: A Preliminary Study. BIOMED RESEARCH INTERNATIONAL 2016; 2016:2793898. [PMID: 28078285 PMCID: PMC5203879 DOI: 10.1155/2016/2793898] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 11/23/2016] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- Shaoqi Chen
- Department of Ultrasound, The First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Yukai Wang
- Department of Rheumatology, Shantou Central Hospital, Shantou, Guangdong, China
- *Yukai Wang: and
| | - Guohong Zhang
- Department of Pathology, Shantou University Medical College, Shantou, Guangdong, China
- *Guohong Zhang:
| | - Shigao Chen
- Department of Radiology, Mayo Clinic College of Medicine, Rochester, MN, USA
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[Clinical usefulness of salivary gland ultrasonography in Sjögren's syndrome: Where are we now?]. Rev Med Interne 2015; 37:186-94. [PMID: 26608250 DOI: 10.1016/j.revmed.2015.10.341] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 10/19/2015] [Indexed: 12/18/2022]
Abstract
Salivary gland ultrasonography is a simple, noninvasive and inexpensive procedure, which provides valuable information for the diagnosis of primary Sjögren's syndrome (pSS). The main sonographic characteristic of the major salivary glands (parotid and submandibular) in pSS patients is the heterogeneity of the parenchyma, with the appearance of hypoechoic areas. Numerous studies published over the past 20 years report a sensitivity of 70% and a specificity of more than 90% for the diagnosis of pSS. Before the widespread use of this procedure in daily practice and its integration into classification criteria of the disease, it has yet to be validated in terms of reproducibility and a consensus score should be established. This work is being conducted by an international group of experts. Other ultrasound techniques such as elastography could also be of interest to objectively quantify changes in the glandular tissue that occur during the disease.
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