Minor Salivary Gland Punch Biopsy for Evaluation of Sjögren’s Syndrome

The Role of Major Salivary Gland Ultrasound in the Diagnostic Workup of Sicca Syndrome: A Large Single-Centre Study

(1) Objective: To determine the diagnostic accuracy of major salivary gland ultrasonography (SGUS) in primary Sjogren's syndrome (SS), we used the Outcome Measures in Rheumatology Clinical Trials (OMERACT) scoring system on a large single-centre cohort of patients with sicca syndrome. (2) Method: We retrospectively collected the clinical, imaging and serological data of all the patients referred with a suspicion of SS who underwent SGUS and minor salivary glands biopsy. (3) Results: A total of 132 patients were included. The SGUS scores were correlated between the two sides (p < 0.001). The diagnostic cut-off for SS (AUROC: 0.7408) was 6 for the SGUS-global sum (sensitivity: 32.43%; specificity: 96.84%). The cut-off with the highest specificity for SS diagnosis was 7. In the patients with a final diagnosis of SS, the mean SGUS score was significantly higher (p < 0.001) than that of the non-SS patients (3.73 vs. 1.32 for the SGUS-global sum). A significant correlation was demonstrated between the SGUS scores and final SS diagnosis (p < 0.001), biopsy positivity (p < 0.001), ANA positivity (p = 0.016), Ro-SSA positivity (p = 0.01), and gland fibrosis (p = 0.02). (4) Conclusions: SGUS, using the OMERACT scoring system, has moderate sensitivity and high specificity for the diagnosis of SS. The scoring showed a strong and direct correlation with all the clinical hallmarks of SS diagnosis, such as the positivity of a labial salivary gland biopsy, ANA and Ro-SSA statuses, and salivary gland fibrosis. Because of its high specificity, a SGUS-global score > 6 could be therefore employed for the diagnosis of SS in the case of ANA negativity or the unavailability of a biopsy.

Diagnostic role of minor salivary glands biopsy in Sjögren's syndrome: correlations between histology and autoimmunity in a large, monocentric cohort

Introduction

Based on ACR/EULAR classification criteria, minor salivary glands biopsy (MSGB) is a useful diagnostic tool for the diagnosis of primary Sjögren's syndrome (SS). The main objective of our study was to evaluate the diagnostic role of MSGB, as well as to highlight correlations between histological findings and autoimmune profiles.

Material and methods

We retrospectively evaluated histological and autoimmunity data from patients who underwent MSGB in our department in cases of suspected SS, from March 2011 to December 2018. Salivary gland samples were evaluated using Chisholm and Mason (CM) grading and the focus score (FS).

Results

A total of 1,264 patients (108 males, 1,156 females) were included. The median age was 55.22 ±13.51 years (range: 15-87). In univariate binary logistic regression, CM ≥ 3 and FS ≥ 1 were significantly predicted by antinuclear antibodies (ANA), anti-extractable nuclear antigens (ENA) and anti-Ro/SSA titer as well as anti-La/SSB, anti-Ro/SSA, rheumatoid factor (RF) and anti-citrullinated protein antibodies (ACPA) positivity. In multivariate analysis, CM ≥ 3 and MSGB positivity were significantly associated with ANA titer; FS ≥ 1 was not associated with laboratory findings. A positive biopsy was associated with laboratory findings, as ANA and ENA titers, anti-Ro/SSA, anti-La/SSB, RF and ACPA positivity may discriminate patients with SS-related histological findings.

Conclusions

Minor salivary glands biopsy is a useful tool to diagnose SS in cases of highly suggestive clinical symptoms but in the absence of a specific autoimmunity.

Minor Salivary Gland Surgery and Histopathological Scoring System: A Systematic Review

Sjögren’s syndrome is a systemic autoimmune disease characterized by chronic inflammation of the exocrine glands with an associated functional deficit. The clinical picture is characterized by symptoms such as dry eyes (xerophthalmia) and dry mouth (xerostomia). The disease is defined as primary if no other autoimmune diseases are associated, otherwise, it is defined as secondary. A systematic review was made using the databases PubMed (MEDLINE), Scopus, and keywords “biopsy,” “classification,” “clinical pathology,” “salivary glands,” and “Sjogren’s syndrome.” The diagnosis of Sjögren’s syndrome is based on a combination of clinical, serologic, instrumental, and histological features. In addition to ocular tests, a biopsy of the minor salivary glands represents one of the most relevant examinations for the diagnosis. In fact, the evaluation of specific histopathological features represents one of the most important criteria proposed in the last international consensus of 2016, which developed the most recent classification criteria for Sjögren’s syndrome. Knowledge of classification criteria, minor salivary gland biopsy techniques, and histopathological features are essential for the clinician to evaluate the pathology report and make a diagnosis of Sjögren’s syndrome. The aim of this review is to describe the classification criteria of the disease proposed to date, the main biopsy techniques used to analyze the minor salivary glands, and finally, the histopathological diagnostic scoring systems currently applied.

Current Salivary Glands Biopsy Techniques: A Comprehensive Review

Biopsy is a surgical procedure performed to collect a portion of tissue or organ for diagnostic studies. The aim of the present manuscript is to describe state-of-the-art major and minor salivary gland biopsy techniques and assess the indications and complications of other salivary gland biopsy techniques. A search was performed using the following MeSH terms: biopsy, fine-needle biopsies, image-guided biopsies, frozen sections, and salivary glands disease. A current overview of major and minor salivary glands biopsy techniques was provided. In the oncological field, a comparison was made between the most widely used biopsy method, ultrasound-guided fine-needle aspiration biopsy (US-FNAB), and an alternative method, ultrasound-guided core needle biopsy (US-guided CNB), highlighting the advantages and disadvantages of each. Finally, intra-operative frozen sections (IOFSs) were presented as an additional intraoperative diagnostic method. Minor salivary gland biopsy (MSGB) is the simplest diagnostic method used by clinicians in the diagnosis of inflammatory and autoimmune diseases. In neoplastic lesions, US-FNAB represents the most performed method; however, due to its low diagnostic accuracy for non-neoplastic specimens, US-guided CNB has been introduced as an alternative method.

Minor Salivary Gland Biopsy in Diagnosis of Sjögren’s Syndrome

Objective

Previous studies have questioned the safety and efficacy of minor salivary gland biopsy in the diagnosis of Sjögren’s syndrome, citing complications and difficulty of pathologic evaluation. This study aims to determine the rate of biopsy specimen adequacy and the risk of complications after minor salivary gland biopsy.

Study Design

Case series.

Setting

Single tertiary care center.

Methods

We reviewed the records of all patients who underwent minor salivary gland biopsy at our institution from October 1, 2016, to September 1, 2021. Demographics, comorbidities, symptoms, and serologic results were recorded. The primary outcome was adequacy of the tissue sample. Complications of the procedure were recorded. Biopsies with at least one focus of ≥50 lymphocytes per 4-mm2 sample were considered positive.

Results

We identified 110 patients who underwent minor salivary gland biopsy. Ninety-three (85%) were female, and the median age was 49.1 years (range, 18.7-80.5). Seventy-seven procedures (70%) were performed in the office setting, and 33 (30%) were performed in the operating room. Nearly all biopsy samples (n = 108, 98%) were adequate, and 33 (31%) were interpreted as positive. Four patients (4%) experienced temporary lip numbness, which resolved with conservative management. No permanent complications were reported after lip biopsy. Nineteen (58%) patients with positive biopsy results had no Sjögren’s-specific antibodies. Most patients with positive biopsy results (n = 20, 61%) subsequently started immunomodulatory therapy.

Conclusion

Minor salivary gland biopsy can be performed safely and effectively in both the office and the operating room. This procedure provides clinically meaningful information and can be reasonably recommended in patients suspected to have Sjögren’s syndrome.

Low muscle mass and body composition analysis in a group of postmenopausal women affected by primary Sjögren's syndrome

Objectives

Sarcopenia is the pathological reduction of skeletal muscle mass and strength. This condition is often underestimated in clinical practice, particularly in connective tissue diseases. The purpose of this study is to evaluate the prevalence of low muscle mass in primary Sjögren’s syndrome (pSS) and to explore the relationships linking muscles and bone tissue.

Material and methods

Twenty-eight postmenopausal pSS patients were matched with 30 healthy controls and their body composition analysis was performed by dual-energy X-ray absorptiometry to investigate for sarcopenia considering appendicular lean mass (ALM) and the skeletal muscle mass index (SMI) as references. Bone mineral density analysis of lumbar spine (L1–L4), whole femur, femoral neck and whole body was also performed. Linear regression was used to assess the relationship between body composition and bone mineralization.

Results

Low muscle mass was significantly higher in the pSS group compared to controls whether expressed as ALM, SMI [odds ratio (OR) = 18.40, confidence interval (CI): 4.84–72.08, p < 0.0001] or considering total body lean masses. Lean masses appeared to be the best estimators of bone mineralization: total lean body mass (TLBM) lumbar spine R² = 0.72, p < 0.0001; TLBM femoral neck R² = 0.36, p < 0.004; lean mass of upper limbs lumbar spine R² = 0.70, p < 0.0001; femoral neck R² = 0.66; lean mass of lower limbs lumbar spine R² = 0.66, p < 0.0001; femoral neck R² = 0.44, p = 0.008). Primary Sjögren’s syndrome patients had a significantly higher android/gynoid fat ratio compared to controls.

Conclusions

Female pSS patients have lower muscle mass compared to healthy controls and are exposed to a higher risk of developing sarcopenia than healthy subjects. Our research demonstrates that the amount of lean tissue is the main predictor of bone mineralization in pSS.

Adverse post-operative events of salivary gland biopsies: A systematic review and meta-analysis

OBJECTIVES

The study aimed to perform a systematic review and meta-analysis of the complications following major and minor salivary gland biopsy.

MATERIALS AND METHODS

Observational studies assessing postoperative complications of minor salivary gland biopsy and indexed at Medline/PubMed, EMBASE, Cinahl, LILACS, or Scopus were selected. This review was registered under the protocol number: CRD42020211169. The level of significance considered was 0.05, and the R software (The R Foundation) was used for the meta-analysis.

RESULTS

Twenty-seven studies reporting 3208 patients were included in this review. The combined prevalence of postsurgical complications was 11% (95% CI, 8 to 13%, p = 0.01). The percentage of the combined prevalence of neurological complications was 3% (95% CI, 1-6%, p = 0.01). The surgical technique did not influence the frequency of overall and neurological complications.

CONCLUSION

Minor salivary gland biopsies are a safe and predictable procedure that should be performed on the lower lip. Postoperative complications are more common than previously reported, but permanent complaints are uncommon.

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.

Parotid Gland Biopsy, the Alternative Way to Diagnose Sjögren Syndrome

Salivary gland biopsy is a technique broadly applied for the diagnosis of Sjögren syndrome (SS), lymphoma in SS, and connective tissue disorders (sarcoidosis, amyloidosis). In SS characteristic histology findings are found, including lymphocytic infiltration surrounding the excretory ducts in combination with destruction of acinar tissue. In this article the main techniques are described for taking labial and parotid salivary gland biopsies with respect to their advantages, postoperative complications, and usefulness for diagnostic procedures, monitoring disease progression, and evaluation of treatment.

A convenient and less invasive technique of labial minor salivary gland biopsy using a minimal incision with a needle tip

Objectives

This study was to show the technique and to compare the usefulness and complications of biopsy using a minimal incision with a needle tip of the labial minor salivary glands with those of conventional incisional lip biopsy in the diagnosis of Sjögren's syndrome.

Methods

We retrospectively reviewed the medical records of the patients who had the labial minor salivary gland biopsy for the diagnosis of Sjögren's syndrome between January 2005 and December 2008. One hundred forty-three patients were enrolled in this study. The yields of diagnostic salivary tissues and complications of the biopsy using a minimal incision with a needle tip and the conventional incisional lip biopsy were compared.

Results

Out of 143 patients, 56 patients underwent the conventional incisional lip biopsy and 87 patients received the biopsy using a minimal incision with a needle tip. In the biopsy using a minimal incision with a needle tip group, adequate salivary gland tissues were obtained in 85 patients out of 87 patients (97.7%). In the conventional incisional lip biopsy group, adequate specimens were acquired in 44 patients out of 56 patients (78.6%). There was no complication after the biopsy using a minimal incision with a needle tip, whereas there was one patient complained transient numbness of the lip after the conventional incisional lip biopsy.

Conclusion

The less invasive labial minor salivary gland biopsy using a minimal incision with a needle tip was easy to perform and safe and showed the better result than the conventional incisional lip biopsy in terms of the adequate specimen in the diagnosis of Sjögren's syndrome. So it might be a good alternative to the conventional incisional lip biopsy.

Neurological adverse events related to lip biopsy in patients suspicious for Sjögren's syndrome: a systematic review and prevalence meta-analysis

OBJECTIVE

The aim of this study was to compare the prevalence of neurological complications related to lip biopsy for SS diagnosis using conventional vs minimally invasive techniques.

METHODS

We performed a systematic review and prevalence meta-analysis using the search strategy [(salivary gland biopsy OR labial biopsy OR lip biopsy) AND (Sjögren)] in the MEDLINE, EMBASE and Web of Science Conference Proceedings Citation Index databases. Studies were selected if they included original data for minor salivary gland biopsy, sample size, exposure of interest (technique description), number of complications and number of affected patients. The prevalence of total and permanent neurological adverse effects was calculated. Both fixed-effects and random-effects pooled estimates were assessed. Heterogeneity was calculated using an adaptation of the DerSimonian and Laird Q test.

RESULTS

Sixteen articles were selected for the study. In the minimally invasive group (n = 3), the pooled prevalence of total adverse events is almost four times higher than that in the linear incision group (n = 12) (4.73% vs. 1.20%). In contrast, the pooled prevalence of the permanent or potentially permanent neurological adverse events is 8.5 times lower in the minimally invasive technique group than in the studies using linear incisions (0.17% vs. 1.45%).

CONCLUSION

With the limitations intrinsic to the potential biases in the studies included in this meta-analysis, we conclude that the minimally invasive lip biopsy technique for SS diagnosis induces fewer permanent neurological complications than conventional approaches with large linear incisions in the lower lip.

Minor salivary gland biopsy in Sjögren's syndrome: a review and introduction of a new tool to ease the procedure

Objectives: To review the existing techniques for minor salivary gland biopsy (MSGB) in the lip and to suggest a new approach to ease the procedure and reduce post-operative complications. Study Design: A comprehensive literature review and a descriptive study of a new surgical technique. Results: Diverse incisions have been suggested for MSGB with different designs (ellipse, circular, linear), different directions (parallel, oblique, vertical) and a wide range of lengths (from 1 mm up to 3 cm), but no comparative studies supporting the advantages of a particular type of incision over the others could be retrieved. A variety of features of the existing techniques for MSGB are linked to undesired events and surgical complications which could be minimized by modifying certain aspects of these procedures. The technique described, together with the use of the S forceps, represents a significant improvement over the already described chalazion forceps because it allows for a better access and positioning of the lower lip, improves the ergonomic conditions of the assistant, and facilitates the identification of lip areas with more superficial gland lobules. Conclusions: The suggested approach for lip MSGB includes a specifically designed instrument whose performance during lip biopsy may contribute to minimize post-operative complications.

Key words:Sjögren’s syndrome, diagnosis, minor salivary gland biopsy, surgical technique, lower lip.

Comparison of two different labial salivary gland biopsy incision techniques: a randomized clinical trial

Objectives: To compare the reliability of two different labial salivary gland biopsy (LSGB) incision techniques (vertical versus horizontal incision techniques) and to report the related complications and discomfort. Study Design: 163 patients who underwent LSGB were included in this study. Patients were randomly divided as vertical incision group (n=81) and horizontal incision group (n=82). Demographic and clinical information of each patient were recorded. A questionnaire was prepared and applied together with Visual Analog Scale (VAS) on the subjects verbally at the 7th day, postoperatively. Intraoperative, short- term and delayed complications were evaluated. Results: The mean age of patients (117 female, 46 male) was 47.3 years (range 19-79 years). Vertical incision technique was associated with less pain (p<0.001), less swelling (p<0.05), less scar formation (p<0.05) and less difficulty in eating (p<0.05) when compared with horizontal incision technique. No statistically significant differences were observed between the 2 groups in terms of hematoma, parasthesia and speech difficulty (p>0.05). Additionally, two subjects in the horizontal incision group revealed permanent paresthesia during the follow-up period of two years. Conclusions: This prospective study demonstrated that the subjects in the vertical incision group had less complication rates and discomfort after labial salivary gland procedure than those in the horizontal incision group.

Key words:Salivary gland, biopsy, incision.

Salivary gland biopsy: a comprehensive review of techniques and related complications

OBJECTIVE

This study proposes a revision of the literature on the current techniques employed in salivary gland biopsy.

METHODS

A systematic review of the literature between January 1990 and January 2010 was conducted using MEDLINE, Embase and the Cochrane Central Register of Controlled Trials. The search terms were: 'biopsy AND parotid AND Sjögren'; 'biopsy AND sublingual salivary gland AND Sjögren'; 'biopsy AND minor salivary gland AND Sjögren'; 'biopsy AND labial salivary gland AND Sjögren' and 'biopsy AND salivary glands AND connective disorders'.

RESULTS

No study reporting submandibular salivary gland biopsy was found; 3 studies reported sublingual salivary gland biopsy; 1 study reported palate biopsy; 4 studies reported parotid gland biopsy and 21 studies reported minor salivary gland biopsy.

CONCLUSION

Biopsy of salivary glands must be performed as last investigation and only when the other items are not complete enough to satisfy the diagnosis. The knowledge of complications and sequelae may be useful in order to minimize the risk.