POS0778 THE USEFULNESS OF ULTRASOUND-GUIDED CORE NEEDLE BIOPSY OF THE PAROTID GLAND FOR THE DIAGNOSIS OF PRIMARY SJÖGREN’S SYNDROME

Background

Ultrasound-guided Core Needle Biopsy (US-guided CNB) of the parotid gland has proved to be a novel and safe technique for the diagnosis of lymphoma in Sjögren’s Syndrome (pSS) patients with salivary gland enlargement.1 The potential role of US-guided CNB for the diagnosis of pSS has been never reported, while only one group uses open surgical parotid biopsy to this end in pSS2.

Objectives

To explore the value of US-guided CNB of the parotid gland as a diagnostic tool for pSS.

Methods

From September 2019 to June 2021, 22 patients with a clinical diagnosis of pSS underwent US-guided CNB of the parotid gland due to persistent (≥2 months) parotid swelling and suspected glandular lymphoma. In 21/22 (95.4%) patients, the tissue sampling was adequate for the histopathological diagnosis. No persistent complications were reported. For the aim of this study, 2/21 (9.5%) patients were excluded for a different final diagnosis (i.e., IgG4-RD and sarcoidosis), and 13/21 (61.9%) patients for a diagnosis of parotid gland lymphoma. Six out of 21 (28.5%) were finally included for the evaluation of US-guided CNB in the histopathological diagnosis of pSS. The following histopathological features related to pSS were studied: focus score (FS); presence of germinal centres (GCs); presence of lymphoepithelial lesions (LELs); and presence of Myo-/Lympho-epithelial sialadenitis (MESA/LESA).

Results

All 6 patients already satisfied the ACR/EULAR classification criteria for pSS and were females, with a mean age of 47.6 years (SD ±17.0) and a mean disease duration of 8.3 years (SD ±8.0). In all of them, specific findings of pSS were observed (Table 1). The FS could be calculated in 3/6 cases and was ≥1 in 2/3 cases, while in 3/6 cases it could be not calculated due to the evidence of MESA/LESA. GCs were found in 4/7 cases, while LELs were present in 3/7 cases (Table 1).

Table 1.

Histopathological features in the parotid gland biopsy.

#PatientFocus scoreLELsGCsMESA/LESA#1 NINot applicable✗✗✓#2 BM≥1✓✓✗#3 CMNot applicable✓✓✓#4 RC<10✓✗#5 FRNot applicable✓✓✓#6 RV≥1✗✗✗

Conclusion

US-guided CNB of the parotid gland could represent a potential novel tool for the diagnosis of pSS patients. When parotid swelling is present, it may be more convenient than lip biopsy. In addition, CNB can be ultrasound-guided in specific glandular areas showing different sonographic appearances, consistent with different histopathology, leading the way for the role as diagnostic tool for pSS, and not only as improved lymphoma detection tool.

The next step is to evaluate US-guided CNB in pSS patients without glandular swelling, and to compare the results with labial biopsy.

References

[1]Zabotti A, Zandonella Callegher S, Lorenzon M, et al. Ultrasound-guided core needle biopsy compared with open biopsy: a new diagnostic approach to salivary gland enlargement in Sjögren’s syndrome? Rheumatology. Published online September 17, 2020:keaa441. doi:10.1093/rheumatology/keaa441

[2]Spijkervet FKL, Haacke E, Kroese FGM, Bootsma H, Vissink A. Parotid Gland Biopsy, the Alternative Way to Diagnose Sjögren Syndrome. Rheumatic Disease Clinics of North America. 2016;42(3):485-499. doi:10.1016/j.rdc.2016.03.007

Disclosure of Interests

Alen Zabotti Speakers bureau: Not relevant for this study, Consultant of: Not relevant for this study, Ivan Giovannini Speakers bureau: Not relevant for this study, Valeria Manfrè: None declared, Michele Lorenzon Speakers bureau: Not relevant for this study, Enrico Pegolo Speakers bureau: Not relevant for this study, Christian Dejaco Speakers bureau: Not relevant for this study, Consultant of: Not relevant for this study, ALOJZIJA HOCEVAR Speakers bureau: Not relevant for this study, Consultant of: Not relevant for this study, Luca Quartuccio Speakers bureau: Not relevant for this study, Consultant of: Not relevant for this study, Salvatore De Vita Speakers bureau: Not relevant for this study, Consultant of: Not relevant for this study

POS1414 RISK OF CANCER IN CONNECTIVE TISSUE DISORDERS IN THE NORTH EAST OF ITALY OVER 15 YEARS OF FOLLOW-UP

Background

Connective tissue diseases (CTD) include systemic lupus erythematosus (SLE), Sjögren’s syndrome (SS), systemic sclerosis (SSc), polymyositis (PM), and dermatomyositis (DM). CTD are characterized by dysfunction of the immune system that leads to the loss of tolerance to self-antigens [1]. Shared genetics, environmental factors, medical treatment of autoimmune diseases and dysregulated immune function have led to speculation of an elevated cancer incidence in patients with autoimmune diseases [2].

Objectives

The present study aimed to evaluate the cancer risk associated with the most relevant CTD in the northern Italian region of Friuli Venezia Giulia over the years 2002-2017. The primary objective was to determine whether the risk of malignancy was higher among these rheumatic conditions than the age- and sex-corresponding general population.

Methods

A retrospective population-based cohort study was conducted using data from healthcare databases of the Friuli Venezia Giulia region, north-east of Italy (1,206,000 inhabitants). Information on demographic characteristics, hospital discharges, exemption from medical charges, drug prescriptions, were individually matched with data from the population-based cancer registry. The cancer risk was assessed in people diagnosed with the following diseases: SLE, SS, SSc, PM, and DM. To compare the cancer incidence in the cohort with the general population, Standardized Incidence Ratios (SIRs) were calculated as the ratio between the observed and the expected number of cancer cases. The cohort included subjects resident in the Friuli Venezia Giulia region, diagnosed with at least one of the following diseases: SLE, SSc, SS, DM, and PM. To guarantee the highest homogeneity and comparability of the exemptions codes, the analysis was restricted to the years 2002-2017.

Excluding criteria were: (1) follow-up shorter than 90 days; (2) concurrent diagnoses of rheumatoid arthritis (RA), psoriatic arthritis or ankylosing spondylitis; (3) ever use of biologic drug specific to treat RA (with the exception of rituximab), psoriatic arthritis or ankylosing spondylitis.

The patients were observed starting from 90 days after the first date when the diagnosis was mentioned in hospital discharges or exemptions, and they were followed until cancer diagnosis, death, change of regional residence, or December 31, 2017, whichever came first.

For the aim of this study, we excluded from the analysis NMSC (ICD-10: C44) and diagnoses based on autopsy only or Death Certificate Only.

Results

2504 patients were followed-up for a total of 18,006 person-years (median follow-up: 6.8 years). After 5 and 10 years of follow-up, the cumulative cancer incidence was 2.6% and 8.5%, respectively. The most common cancers were breast (n=34), lung (n=24), colon-rectum-anus (n=20), and non-Hodgkin lymphomas (NHL) (n=20). Overall, no excess cancer risk was noted (SIR=0.87, 95% CI: 0.75-1.00), whereas the number of observed NHL cases was more than two-fold significantly higher than expected (SIR=2.52, 95% CI: 1.54-3.89). The subgroup analysis showed a higher risk of NHL among SS patients (SIR=3.84, 95% CI: 1.92-6.87) and SLE patients (SIR=2.69, 95% CI: 0.99-5.84). Conversely, the study population showed a decreased risk for cancers of breast (SIR=0.61, 95% CI: 0.42-0.85) and corpus uteri (SIR=0.21, 95% CI: 0.03-0.77).

Conclusion

The incidence of NHL was higher among patients with SS and SLE. A careful surveillance for haematological malignancies in these patients is recommended. The lower risk of cancer for breast and corpus uteri in CTD indirectly supports cancer screening programs and highlights the role of the continuous clinical follow-up for these chronic conditions.

References

[1]Wang, L.; Wang, F.-S.; Gershwin, M.E. Human Autoimmune Diseases: A Comprehensive Update. J. Intern. Med.2015, 278, 369–395.

[2]Hemminki, K.; Huang, W.; Sundquist, J.; Sundquist, K.; Ji, J. Autoimmune Diseases and Hematological Malignancies: Exploring the Underlying Mechanisms from Epidemiological Evidence. Semin. Cancer Biol.2020, 64, 114–121.

Disclosure of Interests

None declared

Effects of competitive physical activity on serum irisin levels and bone turnover markers

BACKGROUND

Irisin, a myokine, is a polypeptide derived from the cleavage of the extracellular domain of fibronectin domain-containing protein 5, a receptor that is present on different tissues (skeletal muscle, pericardium, myocardium, and brain), whose functions are not yet fully defined.

PURPOSE

The main aim of our study was to evaluate the effect of competitive physical activity on serum irisin levels and bone turnover markers.

METHODS

Fifteen male footballers and an equal number of subjects of the same age and gender, but with a predominantly sedentary lifestyle, had their serum levels of irisin and bone turnover markers measured. Bone mineral status was evaluated in both groups by quantitative bone ultrasound of the calcaneus. In addition, only in footballers, biochemical analyses were repeated after 3 months.

RESULTS

We did not observe significant differences in the serum levels of calcium, phosphorus, and parathyroid hormone between the two groups. The footballers had significantly higher quantitative bone ultrasound, 25-OH vitamin D, and creatinine values than the controls. There were also no significant differences in the bone alkaline phosphatase, carboxy-terminal telopeptide of type I collagen, osteoprotegerin, sclerostin or Dkk-1 values, while the irisin levels (+ 89%, p < 0.001) and RANKL were significantly higher in the footballers compared to those in the controls.

CONCLUSION

Our study shows that footballers have significantly higher serum irisin values than the general population. Irisin could be the "trait d'union" between bone health and physical activity.

POS0735 ULTRASOUND-GUIDED CORE NEEDLE BIOPSY FOR SALIVARY GLAND ENLARGEMENT IN SJÖGREN’S SYNDROME: PROCEDURE SAFETY AND PATIENT TOLERANCE

Background:

Persistent enlargement of major salivary glands (SGs) is one of the main risk factors for B-cell lymphoma in primary Sjögren’s syndrome (pSS). The Ultrasound-guided Core Needle Biopsy (US-guided CNB) could be a novel technique for the management of SGs enlargement in pSS (1).

Objectives:

To evaluate the procedure safety and the patient tolerance of US-guided CNB in pSS patients with major SGs enlargement.

Methods:

Consecutive patients, with either definite or clinically suspected pSS, and with clinical indication for SGs biopsy due to persistent glandular enlargement were screened for US-guided CNB from September 2019 to December 2020. All patients were evaluated clinically between 1 and 2 weeks and 12 weeks following US-guided CNB. All patients were asked to complete a questionnaire to report post-procedural complications (Figure 1, English version) and intra- and post-procedural pain Visual Analogue Scale (VAS). The complications were classified as transient (<12 weeks) or persistent (≥12 weeks).

Results:

US-guided CNB was performed in 21 glands (12 parotid and 9 submandibular glands) in 20 pSS patients. 16/20 (80%) patients fulfilled the ACR-EULAR classification criteria for pSS (2). The mean age at the time of biopsy was 62.1 (±11.7) years. US-guided CNB was well tolerated, no long-term complications were reported in the follow-up period (mean 9.5 ±5.7 months). Only transient complications were noticed in 11 patients (55%). In particular, two cases of local swelling at the biopsy site lasting no more than 6 days, one case of local bleeding and subsequently hematoma of the submandibular area, one case of transient facial paresis (lasting less than one hour), seven cases of post-procedural mild local pain, that resolved within 10 days without the need of analgesics (Table 1). The procedure was well tolerated, with a very low reported intra-operative pain (mean VAS 1.74 ±2.49) and a mean post-operative pain VAS of 1.39 (±2.33). The biopsy sampling was diagnostic in 19/20 patients (95%).

Conclusion:

US-guided CNB represents a novel approach for the management of pSS patients with SGs enlargement. This procedure shows a remarkable patient safety and tolerance, allowing an adequate glandular sampling and definite diagnosis in almost all the studied patients.

References:

[1]Zabotti A, Zandonella Callegher S, Lorenzon M, Pegolo E, Scott CA, Tel A, et al. Ultrasound-guided core needle biopsy compared with open biopsy: a new diagnostic approach to salivary gland enlargement in Sjögren’s syndrome? Rheumatology (Oxford) 2020.

[2]Shiboski CH, Shiboski SC, Seror R, Criswell LA, Labetoulle M, Lietman TM, Rasmussen A, Scofield H, Vitali C, Bowman SJ, Mariette X; International Sjögren’s Syndrome Criteria Working Group. 2016 American College of Rheumatology/European League Against Rheumatism Classification Criteria for Primary Sjögren’s Syndrome: A Consensus and Data-Driven Methodology Involving Three International Patient Cohorts. Arthritis Rheumatol. 2017 Jan;69(1):35-45. doi: 10.1002/art.39859. Epub 2016 Oct 26. PMID: 27785888; PMCID: PMC5650478.

Table 1.

Description of complications

Complications of US-guided CNBPatients presenting complications, n/N (%)11/20 (55%)Description of transient complicationsSwelling at biopsy site, n2Bleeding, n1Hematoma, n1Local Pain, n7Local infection, n0Sialocele or fistula, n0Anaesthesia/paraesthesia, n0Transient facial palsy (< 1 hour), n1No persistent complications reported

All the above specified complications were transient (< 12 weeks). No persistent complications were reported in the follow up.

Figure 1.

Post-biopsy complication Questionnaire

Disclosure of Interests:

Alen Zabotti Speakers bureau: UCB, Novartis, Janssen, Paid instructor for: Amgen, Consultant of: Janssen, Ivan Giovannini: None declared, Sara Zandonella Callegher: None declared, Valeria Manfrè: None declared, Michele Lorenzon Consultant of: not relevant for this study, Enrico Pegolo: None declared, Cathryn Ann Scott: None declared, Alessandro Tel: None declared, Massimo Robiony Consultant of: not relevant for this study, Grant/research support from: not relevant for this study, Chiara Zuiani Consultant of: not relevant for this study, Grant/research support from: not relevant for this study, Salvatore De Vita Consultant of: GSK, Roche, Grant/research support from: not relevant for this study

Autologous micrografts and methotrexate in plantar erosive lichen planus: healing and pain control. A case report

Erosive lichen planus is an uncommon variant of lichen planus. We report a case of longstanding and refractory plantar ELPs causing disabling and opiate-resistant pain treated with ‘classic’ meshed skin graft combined with Rigenera^® micrografts. After approximately 9 months follow-up, no clinical recurrence or pain were observed. Erosive lichen planus (ELP) is an uncommon variant of lichen planus, involving oral cavity and genitalia and, less often plantar areas, where it usually presents with chronic erosions of the soles, along with intense, disabling pain and progressive loss of toenails. An abnormal immune cellular response (CD8+ lymphocytes and macrophages) and the consequent altered production of multiple mediators (interleukin-12, interferon-γ, tumor necrosis factor-α, RANTES and MMP-9), seem to play a crucial role in the pathogenesis, although the etiology remains uncertain. From a histological point of view, ELP shows keratinocyte apoptosis, intense inflammatory response and basal epithelial keratinocytes TNF-α overexpression. Several therapies have been proposed, with variable and controversial results. While topical corticosteroids and topical calcineurin inhibitors are the treatments of choice for localized forms, short pulses of systemic glucocorticoids, phototherapy, and systemic immunosuppressants are recommended for generalized cases. Surgery has been reported as a possible therapeutic option in refractory and stable cases with localized lesions, either alone or with cyclosporine. Herein, we report a case of longstanding and refractory plantar ELPS causing disabling and opiate-resistant pain treated with ‘classic’ meshed skin graft combined with Rigenera® micrografts.