POS0742 DISCRIMINATIVE POWER OF SALIVARY GLAND ULTRASOUND IN RELATION TO ENDOTYPES IN SUSPECTED AND DEFINITE PRIMARY SJÖGREN’S SYNDROME

Background

Primary Sjögren’s Syndrome (pSS) is an auto-immune disease with characteristic complaints of oral and ocular dryness, typically affecting adult women. In addition, up to 30-40% of patients suffers from systemic manifestations and lymphoma risk is increased 15-20 fold. pSS is thus highly heterogenous both in presentation and pathophysiology. In an attempt to address this issue Tarn et al. applied cluster analysis based on patient reported outcomes assessing dryness, fatigue, pain and features of anxiety and depression, on a population of pSS patients. This resulted in four groups: low symptom burden (LSB), pain dominant with fatigue (PDF), dryness dominant with fatigue (DDF) and high symptom burden (HSB). These groups, referred to as endotypes, also seemed to have different biological profiles.(1)

Objectives

The aim of this study was to explore salivary gland ultrasound (SGUS) in relation to symptom-based endotypes in a cohort of patients with definite and suspected pSS.

Methods

Data from the Belgian Sjögren’s Syndrome Transition Trial (BeSSTT) were used in which patients positive for at least one of the 2016 American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) classification criteria, were enrolled. Patients were considered ‘definite pSS’ when fulfilling these criteria and ‘suspected pSS’ otherwise.

The Newcastle Sjögren’s Stratification Tool, developed and provided by J. Tarn and colleagues, was applied to stratify the cohort into endotypes. Hocevar score (0-48) was used to assess SGUS abnormalities. Scores of at least 17 were considered positive.

Results

Stratification of the BeSSTT (n=241) cohort resulted in 4 endotypes, both in definite (n=141) and suspected pSS (n=100). The proportion of anti-SSA positive patients was high in definite pSS in all endotypes (91.9%; p=0.239). This proportion was significantly lower in suspected pSS patients in all endotypes (27.6%; p=0.064) albeit that the difference was less pronounced in LSB (50.0%) and, to a lesser degree, in PDF (32.7%) endotypes.

SGUS scores were higher in definite than suspected pSS (22 (12-37) vs 10 (2-16); p<0.001) in all endotypes (Figure 1). In definite pSS, Hocevar scores were highest in DDF compared to other endotypes (35 (24-43); p<0.001) and SGUS had a very strong discriminating power in this endotype (PPV=94.1%, NPV=76.2%). Salivary gland function was poorest in the definite pSS DDF endotype.

Figure 1.

Scatter plot of Hocevar score (0-48) by endotype. The upper plot represents patients with definite and the lower with suspected pSS. The colour of the dots indicates presence or absence of anti-SSA antibodies. The horizontal line is drawn at a Hocevar score of 17 and represents cut-off for positive SGUS.

In the suspected pSS subgroup, Hocevar scores tended to be higher in the LSB endotype (17 (6-26); p=0.053) and were significantly higher in anti-SSA positive than negative patients (12 (6-26) vs 8 (1-14); p=0.017) (Figure 1). Of the 24 suspected pSS patients (24.0%) with a positive SGUS, 12 (50.0%) were anti-SSA positive. Anti-SSA positive suspected pSS patients with an aberrant SGUS were markedly younger than the rest of the BeSSTT cohort (mean±SD age of 36 ±15 years vs 52 ±14 years) suggesting they may represent an early at-risk population.

Conclusion

These results show prominent SGUS differences between endotypes in pSS, supporting its potential as biomarker. Hocevar scores are highest in patients with DDF endotypes, further suggesting a different biological profile. SGUS is a powerful tool to identify definite pSS patients from a group of patients with DDF endotypes who fulfil at least one of the ACR/EULAR classification criteria. In addition, a subset of young anti-SSA positive patients without overt dryness (LSB and PDF endotype) reveals high SGUS scores. We would thus propose SGUS in all anti-SSA positive patients, regardless of symptoms, to reveal this glandular involvement.

References

[1]Tarn JR et al, Lancet Rheumatol. 2019

Disclosure of Interests

None declared

Human decellularized dermal matrix seeded with adipose-derived stem cells enhances wound healing in a murine model: Experimental study

Objective

Full-thickness cutaneous wounds treated with split-thickness skin grafts often result in unaesthetic and hypertrophic scars. Dermal substitutes are currently used together with skin grafts in a single treatment to reconstruct the dermal layer of the skin, resulting in improved quality of scars. Adipose-derived stem cells (ASCs) have been described to enhance wound healing through structural and humoral mechanisms. In this study, we investigate the compatibility of xenogen-free isolated human ASCs seeded on human acellular dermal matrix (Glyaderm®) in a murine immunodeficient wound model.

Methods

Adipose tissue was obtained from abdominal liposuction, and stromal cells were isolated mechanically and cultured xenogen-free in autologous plasma-supplemented medium. Glyaderm® discs were seeded with EGFP-transduced ASCs, and implanted on 8 mm full-thickness dorsal wounds in an immunodeficient murine model, in comparison to standard Glyaderm® discs. Re-epithelialization rate, granulation thickness and vascularity were assessed by histology on days 3, 7 and 12. Statistical analysis was conducted using the Wilcoxon signed-rank test. EGFP-staining allowed for tracking of the ASCs in vivo. Hypoxic culture of the ASCs was performed to evaluate cytokine production.

Results

ASCs were characterized with flowcytometric analysis and differentiation assay. EGFP-tranduction resulted in 95% positive cells after sorting. Re-epithelialization in the ASC-seeded Glyaderm® side was significantly increased, resulting in complete wound healing in 12 days. Granulation thickness and vascularization were significantly increased during early wound healing. EGFP-ASCs could be retrieved by immunohistochemistry in the granulation tissue in early wound healing, and lining vascular structures in later stages.

Conclusion

Glyaderm® is an effective carrier to deliver ASCs in full-thickness wounds. ASC-seeded Glyaderm® significantly enhances wound healing compared to standard Glyaderm®. The results of this study encourage clinical trials for treatment of full-thickness skin defects. Furthermore, xenogen-free isolation and autologous plasma-augmented culture expansion of ASCs, combined with the existing clinical experience with Glyaderm®, aid in simplifying the necessary procedures in a GMP-laboratory setting.

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ASCs obtained from human liposuction fat were isolated mechanically and cultured xenogen-free in autologous plasma-supplemented medium.

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Hypoxic culture of the ASCs was performed to evaluate increased cytokine production.

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Glyaderm® discs were seeded with EGFP-transduced ASCs, and implanted on full-thickness dorsal wounds in an immunodeficient murine model, in comparison to standard Glyaderm® discs.

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Reëpithelialisation, granulation and vascularization in the ASC-seeded Glyaderm® side were significantly increased, resulting in complete wound healing in 12 days.

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EGFP-ASCs could be retrieved by IHC in the granulation tissue in early wound healing, and lining vascular structures in later stages.

A Rare Presternal Soft Tissue Tumor: Ectopic Hamartomatous Thymoma (Branchial Anlage Mixed Tumor)

Ectopic hamartomatous thymoma is a rare benign tumor in adults, mostly located in the lower neck region. It was first reported in 1982 by Smith and McClure. Histopathologically these tumors are typically well marginated and composed of a mixture of spindle cells, mature adipose tissue, and epithelial cells, including both glandular and squamous elements. The histogenesis of this tumor is controversial. Recently, an origin from a remnant of the cervical sinus of His was proposed. Ectopic hamartomatous thymoma needs to be differentiated from malignant lesions such as synovial sarcomas or malignant peripheral nerve sheath tumors. These tumors can have similar clinical features and radiologic images. Recognition of this tumor is important because it follows a benign clinical course and conservative surgical excision is the treatment of choice. To our knowledge, 61 cases have previously been reported. We present the case of a 45-year-old women with an uncomplicated presternal located ectopic hamartomatous thymoma. The morphological and immunohistochemical findings are discussed and a review of literature is made.

Differentiation of a single melanocytic lesion of the esophagus: primary malignant melanoma of the esophagus or esophageal metastatic melanoma

A single melanocytic lesion of the esophagus should be differentiated from a primary malignant melanoma of the esophagus (PMME) or an esophageal metastatic melanoma (MME). This paper reviews the current knowledge about these entities and how to differentiate between them. Melanocytosis as a precursor of PMME is discussed as well.

Ectopic pancreatic tissue at the umbilicus in childhood: a case report and review of the literature

Ectopic pancreatic tissue at the umbilicus is very rare. To our best knowledge, only fourteen cases of ectopic pancreatic tissue at the umbilicus are reported. In this paper we present the case of a two-year-old boy with an abrasion at the umbilicus. He had a poorly healing scar that started bleeding after recurrent injuries. Abdominal ultrasound revealed an unclear cystic structure with no communication to intra-abdominal structures. Surgical resection was performed without complications. Histology diagnosed an ectopic pancreatic tissue with reactive epidermal changes. We present a review of the literature and the clinical manifestations and treatment of the previously reported fourteen cases.

Another case of "European hantavirus pulmonary syndrome" with severe lung, prior to kidney, involvement, and diagnosed by viral inclusions in lung macrophages

Puumala virus (PUUV) is considered a classic Old World etiologic agent of nephropathia epidemica (NE), or hemorrhagic fever with renal syndrome (HFRS). HFRS is considered to be distinct from hantavirus (cardio-)pulmonary syndrome (HPS or HCPS), described in the New World. Here, we report a severe case, which fulfilled most, if not all, Centers for Disease Control and Prevention (CDC) criteria for HPS, needing non-invasive ventilation and subsequent acute hemodialysis. However, the etiological agent was PUUV, as proved by serological testing, real-time polymerase chain reaction (PCR), and sequencing. Viral antigen was detected by specific anti-PUUV immunostaining, showing, for the first time, greenish intracytoplasmic inclusions in bronchoalveolar lavage (BAL) macrophages. This case definitely confirms that HPS can be encountered during PUUV infections. Interestingly, special findings could render the diagnosis easier, such as greenish homogeneous cytoplasmic inclusions, surrounded by a fine clear halo in BAL macrophages. Therefore, although the diagnosis remains difficult before the onset of renal involvement, the occurrence of severe respiratory failure mimicking community-acquired pneumonia must alert the clinician for possible HPS, especially in endemic areas.

Multiple abdominal cysts in a patient with Gorlin-Goltz syndrome: a case report

A rare case of symptomatic mesenteric cysts in a patient with Gorlin-Goltz syndrome, associated with various neoplasms, is presented. The patient, known with Gorlin-Goltz syndrome, consulted with increasingly severe abdominal pain and large abdominal cysts. At surgery, the cysts were excised and the postoperative course was uneventful. In conclusion, this case reminds clinicians to always maintain a wide differential diagnosis when dealing with patients known with Gorlin-Goltz syndrome.

An unusual tumour causing neonatal respiratory distress

PROBLEM

We present the case of a term neonate referred shortly after birth because of breathing and feeding difficulties.

METHODOLOGY

Fiber-endoscopic examination of the nasal cavity showed a pendulating mass in the nasopharynx.

RESULTS

A complete surgical resection was performed and the baby recovered completely. Microscopic examination of the mass showed an overlying non-keratinized squamous cell lining with an atypical cell population in some fragments. Histological features were compatible with a high-grade epithelial tumour like a midline carcinoma, but a final diagnosis of a salivary gland anlage tumour was established.

CONCLUSION

Flexible fiber endoscopy is the method of choice for examining the nasal passages and oropharynx in neonates with respiratory distress. Congenital salivary gland anlage tumour is a rare cause of neonatal nasal obstruction; it is benign and complete excision results in a cure. Histologically, it may mimic a malignant tumour owing to the high mitotic index.

Solitary fibrous tumour of the nasal cavity: a case report and literature review

A solitary fibrous tumour (SFT) is a rare tumour that originates from the mesenchyme and arises mainly in the pleura. In this report, we present a rare case of a 77-year-old man with a SFT in the left nasal cavity. On CT and MRI, a large mass is seen in the left nasal cavity, extending to the choana. The mass was radically resected via functional endoscopic sinus surgery (FESS). Histological examination showed a fibroblastic mesenchymal tumour with a prominent hemangiopericytic vascular branching pattern that stained diffusely positive for the immunohistochemical markers CD34, Bcl-2, and CD99, which was compatible with the histopathological diagnosis of a SFT. Imaging and histological features are discussed, along with the reports in literature, clinical management, and follow-up of this pathology.