What is the agreement between pathological features of parotid gland and labial salivary gland biopsies?

Value of magnetic resonance imaging and sialography of the parotid gland for diagnosis of primary Sjögren syndrome

AIM

To evaluate the utility of magnetic resonance imaging (MRI) and magnetic resonance sialography (MRS) for diagnosis of primary Sjögren syndrome (pSS) singly or integrated with 2016 American College of Rheumatology (ACR)/European League Against Rheumatic Diseases (EULAR) classification criteria.

METHODS

The diagnostic efficiencies of MRI, MRS, and labial salivary gland biopsy (LSGB) were evaluated. The prediction model was established by multivariate analysis. Finally, performance of the ACR/EULAR criteria was evaluated after addition of MRI + MRS or replacement of original items by MRI + MRS.

RESULTS

The combined use of LSGB + MRI + MRS provided the greatest diagnostic value. MRI and MRS grade had positive correlations with disease duration and pathological grade of the labial gland (both P < 0.001). MRI and MRS grade had positive correlations with xerostomia severity and negative correlations with unstimulated salivary flow rate (both P < 0.001). The consistency of MRI grade and MRS grade in the diagnosis of parotid gland lesions was poor (κ = 0.253, P < 0.001). The diagnostic efficiency of our prediction model (AUC 0.906) was similar to that of criteria from the ACR/EULAR (AUC 0.930). Adding MRI + MRS to the ACR/EULAR criteria improved the sensitivity (92.3% vs 90.8%), whereas the specificity remained the same (88.9% vs 89.1%). Replacing LSGB by MRI + MRS in the ACR/EULAR criteria decreased both sensitivity and specificity (88.1% vs 90.8% and 86.4% vs 89.1%, respectively).

CONCLUSION

The combined application of MRI and MRS has ideal clinical application value in the diagnosis of early-stage pSS. Validity of the ACR/EULAR criteria remains high after incorporation of MRI + MRS.

Diagnostic utility of a second minor salivary gland biopsy in patients with suspected Sjögren's syndrome: A retrospective cohort study

OBJECTIVE

To determine whether repeated minor salivary gland biopsy (MSGB) has a clinical diagnostic utility in patients with suspicion of Sjögren's syndrome (SS).

METHODS

Clinical, biological, pathological data and physician's diagnosis after each MSGB from patients with suspected primary or secondary SS who had benefited from 2 MSGB at Brest University Hospital between January 1st, 1990 and January 14th, 2015, were retrospectively collected. We compared the characteristics of patients with and without first positive MSGB, concordance between the MSGB, and analyzed the modifications of diagnosis after the second MSGB.

RESULTS

Ninety-three patients were included, first MSGB was positive for 23 and negative for 70. Patients with first positive MSGB had more often renal involvement (P<0.05) and hypergammaglobulinemia (P=0.01), anti-SSA antibodies (P<0.05) and positive second biopsy with focus score ≥ 1 or Chisholm>2 (P<0.01). The mean time between the 2 MSGB was 5.7±4.3 years. The concordance between the results of the 2 biopsies was low (κ = 0.34). MSGB influenced diagnostic's change in 10 cases where the second MSGB was always guided by new specific clinical manifestations.

CONCLUSION

We observed a low concordance between 2 MSGB in patients with suspected pSS in our study. Despite this variability, performing a second MSGB changed the initial diagnosis in only a minority of the patients and was particularly useful when clinical manifestations had deeply evolved.

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.

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.

Salivary gland ultrasonography in primary Sjögren's syndrome: opportunities and challenges

Salivary gland ultrasonography (SGUS) has an established role in detecting typical structural gland abnormalities in primary Sjögren's Syndrome (pSS). SGUS might be included in pSS classification and could be used as a prognostic and follow-up biomarker, but for this purpose additional efforts, new techniques and larger cohort studies are needed. HarmonicSS, an ongoing Horizon, EU-supported project in pSS, will apply artificial intelligence to SGUS in pSS. Many questions are still unresolved and challenging, but data collected up to now underscore the concept that SGUS will be an important tool for the study of pSS in the near future.

Current concepts on Sjögren's syndrome - classification criteria and biomarkers

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.

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

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.