Maladaptive autophagy in the pathogenesis of autoimmune epithelitis in Sjӧgren's Syndrome

OBJECTIVE

Salivary gland epithelial cells (SGECs) are key cellular drivers in the pathogenesis of primary Sjӧgren's Syndrome (pSS); however, the mechanisms sustaining SGECs activation in pSS remain undetermined. The aim of this study is to determine the role of autophagy in the survival and activation of SGECs in pSS.

METHODS

Primary SGECs isolated from minor salivary glands (SG) of patients with pSS or sicca syndrome were evaluated by flow-cytometry, immunoblotting, and immunofluorescence to assess autophagy (autophagic-flux, LC3IIB, p62, LC3B+/LAMP1+ staining), apoptosis (annexin V/PI, Caspase-3) and activation (ICAM, VCAM). Focus score and germinal centers presence was assessed in SG from the same patients to correlate with histological severity. Human salivary gland (HSG) cells were stimulated in vitro with PBMCs and serum from pSS patients in the presence or absence of autophagy inhibitors to determine changes in autophagy and epithelial cell activation.

RESULTS

SGECs from pSS patients (n=24) exhibited increased autophagy (autophagic-flux p=0.001; LC3IIB p=0.02; p62 p=0.064; LC3IIB/LAMP1+ staining), increased expression of anti-apoptotic molecules (Bcl2 p=0.006), and reduced apoptosis (Annexin-V/PI p=0.002, Caspase-3 p=0.057) compared to sicca (n=16). Autophagy correlated with histologic disease severity. In vitro experiments on HSG cells stimulated with serum and PBMCs from pSS patients confirmed activation of autophagy and expression of adhesion molecules, which was reverted upon pharmacologic inhibition of autophagy.

CONCLUSIONS

In pSS SGECs, inflammation induces autophagy and pro-survival mechanisms, which promote SGEC activation and mirror histological severity. These findings indicate that autophagy is a central contributor to the pathogenesis of pSS and a new therapeutic target.

“Nudge” in Lucca’s Hospital: separate waste collection improvement and cigarettes dumping reduction

Background

Positive behaviour and user's collaboration improved by using choices orientation techniques; in Lucca's Hospital (North-West Tuscany Sanitary Authority) this approach has improved separate waste collection execution and has decreased cigarettes dumping in commons areas.

Objectives

Phase 1 (May 2019): amendment of choices architecture recyclable waste bins in commons areas and into the wards were boosted, with “islands” clearly visible from any point of common paths; in the transit areas were installed exclusively multi-material and paper bins, equipped with signs that clearly indicate which products deliver; residual waste bins were allowed exclusively in certain points.ashtrays at the hospital entrances were eliminated and replaced with signage indicating smoking cessation benefits and the presence of areas “put your cigarette out” along the structure approach routes.

Phase 2 (scheduled for May 2020): “nudge” action

Spreading in community (using press and social-media) and locally (using poster) of the slogan “In San Luca we are taking a step forward: don't lag behind!”. This message stimulate the perception of an ongoing change to join.

Results

A decrease in residual waste collection and in instances of non-compliance in separate waste collection was detected. Decorum in the outdoor environments improved, with a reduction of user's reports and extra-cleaning interventions.

Conclusions

The described actions have improved user's collaboration, management efficiency of waste disposal and cleaning service, perceived quality and cost.

Key messages

Imitating a social model appears to be successful motivator of virtuous behaviours. Choices architecture and “nudge” techniques may improve citizens’ care pathways governance.

THU0265 THYMIC STROMAL LYMPHOPOIETIN (TSLP) AS A BIOMARKER OF PRIMARY SJÖGREN’S SYNDROME (PSS) AND RELATED LYMPHOMA: VALIDATION IN INDEPENDENT COHORTS

Background:

Thymic stromal lymphopoietin (TSLP) has been implicated in primary Sjögren’s syndrome (pSS) and related B-cell lymphoproliferation/lymphoma (NHL) by tissue studies on salivary glands (SG) (1). It resulted significantly higher in the serum of pSS patients compared to non-pSS sicca and to healthy subjects, with the highest levels found in NHL.

Objectives:

The purpose of this work was to confirm that serum TSLP is elevated in pSS by the study of independent cohorts.

Methods:

Serum TSLP levels were measured by ELISA in 91 pSS patients (F=86, 94.5%; mean age 57.2 years, 25-80) from the Udine cohort (cohort 1, UD), Italy. One additional multicentre cohort (cohort 2) from the Italian SS Study Group (GRISS) was studied, including 125 pSS patients from the Universities of Roma (RO), L’Aquila (L’AQ), Pisa (PI) and Perugia (PG). pSS patients with active NHL (n=12 in cohort 1; n=1 in cohort 2) were excluded from comparative analyses to avoid bias. Secondly, additional serum samples from pSS-related NHL in stable and complete remission, from both cohort 1 and 2, were analysed in a separate subgroup (n = 12). Thirdly, a preliminary evaluation of serum TSLP was performed in pSS patients from a different geographical area (University of Athens, Greece; cohort 3).

Results:

Cohort 2 included 125 pSS patients (F=114, 91.2%; mean age 58.1 years, 23-84): 124 benign, 1 with NHL. In this cohort, serum TSLP levels were confirmed to be high (mean 30.26 pg/mL, 0.41-95.21) and comparable to cohort 1 (mean 33.81 pg/mL, 0-140.8; p=ns). No difference was found by the separate analysis of pSS from each single Centres (RO n=49, mean 33.21, 1.4-95.21; L’AQ n=34, mean 38.6, 16.31-85.11; PI n=28, mean 20.23, 0.41-56.67; PG n=13, mean 19.39, 1.03-68.38; p=ns), and vs cohort 1 (p=ns). The only patient in cohort 2 with NHL showed serum TSLP of 160.91 pg/mL, comparable to the mean TSLP in the 12 UD pSS-NHL (151.96 pg/mL). Importantly, in pSS-related NHL in stable remission, serum TSLP resulted undetectable (7/13) or detectable at very low levels (6/13) (mean 10.46, 0-38.5), and significantly lower than in benign pSS patients from the two cohorts (n=203, mean 31.48, 0-140.8; p=0.0022). Metachronous samples from one patient, at the stage of NHL activity and then at NHL remission, showed a decrease in TSLP from 128.04 pg/mL to undetectable levels. Finally, TSLP levels were increased also in the Greek cohort (mean 54.9, 26.72-78.95), and significantly higher than the two Italian cohorts (p=0.0085 and p<0.0001, vs cohort 1 and 2, respectively).

Conclusion:

Serum TSLP levels are increased in pSS, as herein confirmed in independent cohorts. TSLP might be important in the disease pathophysiology and mirrors the course of pSS-related B-cell lymphoproliferation itself. It may thus represent a novel important biomarker.

References:

[1]Gandolfo S. et al, Clin Exp Rheumatol. 2019 May-Jun;37 Suppl 118(3):55-64.

Disclosure of Interests:

Saviana Gandolfo: None declared, Cinzia Fabro: None declared, Serena Colafrancesco: None declared, Francesco Carubbi Speakers bureau: Francesco Carubbi received speaker honoraria from Abbvie and Celgene outside this work., Francesco Ferro: None declared, Elena Bartoloni Bocci: None declared, Efstathia Kapsogeorgou: None declared, Andreas Goules: None declared, Luca Quartuccio Consultant of: Abbvie, Bristol, Speakers bureau: Abbvie, Pfizer, Roberta Priori: None declared, Alessia Alunno: None declared, Guido Valesini: None declared, Roberto Giacomelli Grant/research support from: Actelion, Pfizer, Speakers bureau: Abbvie, Roche, Actelion, BMS, MSD, Ely Lilly, SOBI, Pfizer, Roberto Gerli: None declared, Chiara Baldini: None declared, Athanasios Tzioufas: None declared, Salvatore De Vita Consultant of: Roche, Human Genome Science, Glaxo Smith Kline and Novartis

FRI0149 THE CLINICAL FEATURES OF SJÖGREN’S SYNDROME PATIENTS WITH EARLY AND LATE DISEASE ONSET

Background:

Sjögren’s syndrome (SS) affects mainly individuals of the 4thor 5thdecade of life, although patients with early (≤35 years old) or late (≥65 years old) disease onset have been described in the literature. The clinical spectrum of the disease extends from mild dryness to severe systemic vasculitis and lymphoproliferative disorders. The phenotypic diversity of SS is defined by many factors, including age, since many parameters related to age may affect the clinical expression of the disease. Few studies have been conducted to study the effect of age on the clinical phenotype of SS, though with limited number of patients. Large and well-defined groups of SS are required to address such questions.

Objectives:

To study the clinical phenotype of SS patients with early and late disease onset and to explore the association of age with lymphoma development in a unified multicenter cohort.

Methods:

From a total cohort of 1997 consecutive SS patients who fulfill the 2016 EULAR/ACR criteria and are followed up in 5 clinical centers ([Universities ofUdine,Pisa andAthens,Harokopio andIoannina, (UPAHI)], those with either early (≤35 years) or late (≥65 years) disease onset were identified and matched according to gender and disease duration with middle aged controls whose disease onset was at the 4thor 5thdecade of life. Glandular manifestations, extra-glandular manifestations, serologic characteristics and histologic features were compared between the 2 age groups and the middle-aged control groups. Statistical analysis for categorical variables was performed by Fisher exact or chi-square tests and for continuous variables with t test or Mann-Whitney accordingly.

Results:

Three hundred seventy-nine (19%) SS patients with early and 293 (15%) with late disease onset were identified and compared with 353 and 285 middle aged SS controls respectively. The median disease duration of patients with early onset was 12 years (range:0-68) and for those with late disease onset was 5 years (range: 0-27). SS patients with early disease onset had statistically significant higher frequency of Raynaud’s phenomenon, lymphadenopathy, hypergammaglobulinemia, anti-Ro/SSA, anti-La/SSB, rheumatoid factor, salivary gland enlargement, low C4 complement levels, leukopenia and lymphoma (10,3% vs 5,7%, p= 0.03, OR= 1,91, 95% CI: 1,11-3,27) while SS patients with late disease onset had more frequently dry mouth, interstitial lung disease and lymphoma (6,8% vs 2,1%, p=0,01, OR= 3,4. 95%CI: 1,35-1,81).

Conclusion:

In a multicenter cohort of 1997 consecutive SS patients, those with early and late disease onset comprise more than one third of the total SS population. Patients with early disease onset, exhibit robust B cell responses with traditional risk factors for lymphoma as opposed to patients with late disease onset. Both age groups have increased lymphoma prevalence but presumably for different reasons, since late onset patients lack classical predictors of lymphoma. Therefore, these predictors deserve further study in different disease subsets.

Disclosure of Interests:

Andreas Goules: None declared, Ourania Argyropoulou: None declared, Vasileios Pezoulas: None declared, Francesco Ferro: None declared, Saviana Gandolfo: None declared, Valentina Donati: None declared, Marco Binutti: None declared, Sara Zandonella Callegher: None declared, Loukas Chatzis: None declared, Aliki Venetsanopoulou: None declared, Evangelia Zampeli: None declared, Maria Mavromati: None declared, Paraskevi Voulgari: None declared, Clio Mavragani: None declared, Chiara Baldini: None declared, Fotini Skopouli: None declared, Dimitris Fotiadis: None declared, Salvatore De Vita Consultant of: Roche, Human Genome Science, Glaxo Smith Kline and Novartis, Haralampos M. Moutsopoulos: None declared, Athanasios Tzioufas: None declared

THU0294 THE DIFFERENCES IN THE CLINICAL SPECTRUM OF CRYOGLOBULINEMIC VASCULITIS BETWEEN SJÖGREN’S SYNDROME AND HCV HEPATITIS

Background:

Cryoglobulinemic vasculitis (CV) is a serious complication of Sjögren’s syndrome (SS) and is closely associated with type II IgMk cryoglobulins. CV has been well documented in HCV patients without SS, and shares common features with CV in SS. So far, few studies have described the clinical picture of CV in HCV negative SS, but the number of studied patients was rather small and CV was not well defined. To better describe the clinical spectrum of CV in SS and explore the differences compared to HCV-related CV, a large cohort of well characterized patients is required.

Objectives:

To study the clinical phenotype of CV in HCV-negative SS patients, in a large cohort of well characterized patients, after applying stringent classification CV criteria and in comparison with the classical CV of HCV patients.

Methods:

From a total cohort of 1997 consecutive SS patients who fulfill the 2016 EULAR/ACR criteria and are followed up in 5 clinical centers ([Universities ofUdine,Pisa andAthens,Harokopio andIoannina, (UPAHI)], those who fulfil the 2011 classification criteria for CV were identified and compared with matched HCV-CV patients according to age and gender. Glandular, extra-glandular manifestations and serologic features were compared between the 2 CV groups. Statistical analysis for categorical variables was performed by Fisher exact or chi-square tests and for continuous variables with t test or Mann-Whitney accordingly.

Results:

Among the 1083 SS patients who have been evaluated for cryoglobulins, 114 (9,8%) were found positive. Seventy-one (6,5%) SS patients met the 2011 CV criteria while 44 patients presented with type II IgMk cryoglobulinemia without CV. Sixty nine of 71 (97%) SS related CV patients were females and 2 of 71 (3%) males. Forty eight of 71 (68%) had SS disease onset >35 and <65 years old while 14/71 (19,7%) and 9/71 (12,7%) had SS disease onset <35 and >65 years old respectively. The most common clinical manifestations of CV among SS patients were purpura (90%) followed by arthralgias (70%), fatigue (59%), Raynaud’s phenomenon (48%), lymphadenopathy (31%), peripheral neuropathy (22,3%), vasculitic ulcer (11,3%) and glomerulonephritis (11,3%). Interestingly, almost 50% of SS related CV patients developed lymphoma and displayed high frequency of strong predictors including purpura, low C4 complement (88,6%) and salivary gland enlargement (SGE). Compared to HCV-CV patients, SS-CV patients had higher frequency of sicca manifestations, SGE, fatigue, arthritis, Raynaud’s phenomenon, lymphadenopathy, type II IgMk cryoglobulins and lymphoma.

Conclusion:

The prevalence of cryoglobulinemia and CV among SS patients is about 10% and 6-7% respectively. SS-CV patients are mainly middle-aged females with purpura as the main clinical manifestation, and up to one half of them may develop lymphoma, which is rarer in HCV-CV. Compared to HCV-CV patients, SS patients with CV have more frequently sicca symptoms, SGE and type II IgMk cryoglobulins.

Disclosure of Interests:

Ourania Argyropoulou: None declared, Vasileios Pezoulas: None declared, Luca Quartuccio: None declared, Francesco Ferro: None declared, Saviana Gandolfo: None declared, Valentina Donati: None declared, Aliki Venetsanopoulou: None declared, Loukas Chatzis: None declared, Evangelia Zampeli: None declared, Maria Mavromati: None declared, Paraskevi Voulgari: None declared, Clio Mavragani: None declared, Chiara Baldini: None declared, Fotini Skopouli: None declared, Dimitris Fotiadis: None declared, Massimo Galli: None declared, Salvatore De Vita Consultant of: Roche, Human Genome Science, Glaxo Smith Kline and Novartis, Haralampos M. Moutsopoulos: None declared, Andreas Goules: None declared, Athanasios Tzioufas: None declared

Microbiopsy a first-level diagnostic test to rule out oral dysplasia or carcinoma in general dental practice

OBJECTIVES

Diagnostic delay in oral oncology could be improved if general dentists had a reliable and easy-to-use first-level diagnostic test to rule out the presence of oral dysplasia or carcinoma. Microbiopsy has been proved to have high sensitivity and high negative predictive value in a clinical setting characterized by high prevalence of disease. Moreover, it has been proved to be easily performed by general dentists. This study aimed to determine the negative predictive value of microbiopsy in routine dental practice: a clinical setting characterized by low prevalence of disease.

METHODS

Within the frame of a previous study, general dentists from the Metropolitan Area of Turin performed microbiopsy for each oral mucosal lesion detected during their practice. The clinical outcome of 129 lesions negative at microbiopsy was checked by a query performed through the database of the Piedmont Cancer Registry, covering the population of the Metropolitan Area of Turin, with particular reference to cancer involving the mouth (ICD-10:C03-06). This allowed us to define "true negative" cases and to calculate the negative predictive value of microbiopsy.

RESULTS

In a mean follow-up of 7.5 years (range 7-9 years), with a dropout rate of 7.7%, no case of tumour involving the mouth was observed, thus revealing a negative predictive value approaching 100%.

CONCLUSIONS

Microbiopsy represents an easy-to-use and reliable first-level test able to aid general dentists to select patients requiring an oral medicine assessment in a short time and definitely to avoid diagnostic delay in oncologically relevant oral mucosal lesions.

Efficacy of intravenous cyclosporine in a case of cytophagic histiocytic panniculitis complicated by haemophagocytic syndrome after visceral leishmania infection

Cytophagic histiocytic panniculitis (CHP) is a rare panniculitis characterized by systemic features, due to histiocytic infiltration along with haemophagocytosis, which may also appear in bone marrow, spleen, lymph nodes, and liver. Haemophagocytic lymphohistiocytosis (HLH) is a group of autoinflammatory disorders, which include macrophage activation syndrome, sometimes observed in the course of systemic autoimmune diseases, such as juvenile chronic polyarthritis, systemic lupus erythematosus or vasculitis, and infection-associated haemophagocytic syndrome; if not promptly recognised and treated, HLH can be fatal. Visceral leishmaniasis (VL) is a systemic disease caused by different forms of Leishmania spp., an intracellular protozoa. VL is endemic in tropical countries such as in the Middle East and the Mediterranean. The typical clinical and laboratory features are fever, hepato-splenomegaly, hypergammaglobulinaemia and pancytopenia. The features of VL may mimic some haematologic diseases. We report a case of cytophagic histiocytic panniculitis and HLH, triggered by a previous visceral leishmania infection. Cyclosporine was quickly effective in this case, after failure of high-dose glucocorticoids, anakinra and etoposide.

Oral proliferative verrucous leucoplakia: are there particular features for such an ambiguous entity? A systematic review

Proliferative verrucous leucoplakia (PVL) is a distinct, particularly aggressive form of oral leucoplakia. Given the low prevalence of PVL, data are sparse and are mostly from case reports, case series and only a few case-control studies, meaning that the literature is able to provide only weak evidence. The present systematic literature review aims to collate the available evidence on the following issues: patient demographics, aetiology, lesion location(s), malignant potential, location and histopathological features of transformed lesions, disease-specific survival rates and treatment response. Electronic databases were searched for studies in the English language reporting original data from at least 10 patients with PVL on the target issues of the present review. The retrieved data were merged and a descriptive analysis performed. The 20 studies selected indicated that PVL does not seem to be correlated with the major risk factors for oral carcinoma (tobacco, alcohol and/or areca nut/betel leaf chewing). The disorder affects mainly adult/elderly women and has a very high malignant transformation rate, particular site distribution and particular location and histopathological features of transformed lesions. The present results may be limited by some articles being unintentionally excluded as they were not found during the electronic search, a lack of worldwide accepted diagnostic criteria for PVL, and overlapping data from multiple studies performed in a limited number of centres. Despite these potential drawbacks, the present results demonstrate that PVL does have particular features.

Genomic aberrations in normal appearing mucosa fields distal from oral potentially malignant lesions

OBJECTIVES

Oral fields of visually normal and non-dysplastic mucosa (ODFs) may represent the precursors of oral potentially malignant lesions (OPMLs). Aim of the study was to provide new evidence for the concept of the "field carcinogenesis" model by comparing the ODF and OPML genomic aberration profiles obtained by high resolution DNA flow cytometry (hr DNA-FCM) and array-Comparative Genomic Hybridization (a-CGH). A second aim was to investigate if specific CGH aberrations were associated with DNA aneuploidy.

METHODS

Nineteen patients with single OPMLs were recruited for the study. In parallel with obtaining samples of OPML tissue from 11 leukoplakias without dysplasia (nd-OPMLs) and 8 with dysplasia (d-OPMLs), we also obtained samples from distant ODFs. DNA aneuploid nuclei detected by hr DNA-FCM were physically separated, based on DNA content, from the DNA diploid components with a DNA-FCM-Sorter. These relatively pure subpopulations of epithelial nuclei were then submitted to DNA extraction and a-CGH for a genome-wide analysis of DNA copy number aberrations (CNAs).

RESULTS

The frequencies of DNA aneuploidy (DI ≠ 1) among ODFs and OPMLs were respectively 5.3% and 32%. The DI aneuploid values of ODFs and nd-OPMLs were all near-diploid (DI ≠ 1 and DI ≤ 1.4), while for d-OPMLs were high-aneuploid (DI > 1.4) in 40% of the cases. CNA averages were 1.9 in ODFs and 6.5 in OPMLs. The gain of the chromosomal region 20q13.33-qter was observed in 37% of both ODFs and corresponding OPMLs. Additional common regions included 7p22.2-pter, 11p15.5-pter and 16p13.3-pter where gains were observed. Furthermore, gains of 20q13.31-q13.33 and of 5p13.33-pter and loss of 9p21.3 were detected at high frequency (respectively, at 62.5%, 50% and 50%) only in d-OPMLs. In particular, loss at 9p21.3, gain at 5p13.33-pter and gain of 20q13.31-q13.33 were associated with DNA aneuploidy (p = 0.00004; p = 0.0005; p = 0.01).

CONCLUSIONS

ODFs and OPMLs showed common CNAs in specific chromosomal regions suggesting that they may represent early events of the natural history of oral carcinogenesis according to the field effect cancerization and may contribute to the ODF-OPML transition. In addition, loss at 9p21.3 and gains at 5p13.33-pter and 20q13.31-q13.33 may contribute to DNA aneuploidization.

Vascular endothelial growth factor genetic polymorphisms and haplotypes in female patients with bisphosphonate-related osteonecrosis of the jaws

OBJECTIVE

To investigate the polymorphisms of the vascular endothelial growth factor (VEGF) gene in relation to female patients who developed bisphosphonate-related osteonecrosis of the jaws (BRONJ).

METHODS

Test subjects were 30 Italian female patients with BRONJ (Group A). Control subjects were 30 female patients with a history of intravenous bisphosphonate use without any evidence of osteonecrosis (Group B) and 125 unrelated healthy volunteers (Group C). Three single-nucleotide polymorphisms were investigated: -634 G>C, occurring in 5' untranslated region (UTR); +936 C>T, occurring in 3' UTR; and -2578 C>A of the promoter region.

RESULTS

The frequency of the VEGF CAC (+936/-2578/-634) haplotype was increased in patients with BRONJ, compared with female disease-negative controls [odds ratio (OR) = 2.76, 95% CI = 1.09-4.94, P = 0.039; corrected P value: P(c) = 0.117], and was also increased compared with female healthy controls (OR = 2.11, 95% CI = 1.14-3.89, P = 0.024; corrected P value: P(c) = 0.072). The CC homozygotes of -634G>C of VEGF gene and AA homozygotes of -2578C>A have also been significantly correlated in female patients who developed BRONJ compared with healthy controls (OR = 2.04, 95% CI = 1.12-3.70, P = 0.008; corrected P value: P(c) = 0.024).

CONCLUSIONS

These results suggest a possible haplotype effect of VEGF polymorphisms expression in BRONJ Italian female patients. Studies with different and larger populations possibly using TagSNP to represent all haplotypes within the VEGF gene are needed to further delineate the genetic contribution of this gene to BRONJ.

Course of oral lichen planus: a retrospective study of 808 northern Italian patients

OBJECTIVES

To undertake a retrospective inspection of the general features, clinical presentation and outcome of 808 Italian patients with oral lichen planus (OLP), followed up from 6 months to 17 years.

RESULTS

The mean age was 61 years for women (n = 493) and 58 years for men (n = 315). More than 20% of the total cases had liver abnormalities (n = 164) of which 83.5% infected with hepatitis C virus (n = 137). The reticular and plaque form were the predominant type, affecting almost 60% of patients. 12.3% of patients had also extraoral manifestation, taking into account the skin (n = 63) and genital (n = 24). Symptoms were present in 40% of the total patients. Only less than 2.47% of patients underwent remission, whereas 78% still had oral lesions at the end of the follow-up period. Treatment was directed towards almost 42% of the patients, mainly using topical corticosteroids. Oral squamous cell carcinoma developed in 15 patients, commonly arising on the lateral border of the tongue.

CONCLUSION

This is one of the largest groups of OLP patients with such long a follow-up ever reported. We confirm the chronic nature of this disorder, rarely remissive and the treatment intend for alleviating symptoms. OLP is established to be a disease with small frequency of malignant transformation.

Topical clobetasol in the treatment of atrophic-erosive oral lichen planus: a randomized controlled trial to compare two preparations with different concentrations

Oral lichen planus (OLP) is a chronic inflammatory disease that can be painful, mainly in the atrophic and erosive forms. Numerous drugs have been used with dissimilar results, but most treatments are empirical and do not have adequate control groups or correct study designs. However, to date, the most commonly employed and useful agents for the treatment of LP are topical corticosteroids. A randomized, double-blind, placebo-controlled trial has been designed to compare the efficacy and safety of two different formulations of clobetasol, a very potent topical steroid, in the topical management of OLP and to evaluate which gives the longest remission from signs and symptoms. Thirty-five consecutive patients were divided into two groups: the first received clobetasol propionate 0.025% and the second was given clobetasol propionate 0.05%. Both drugs were placed in 4% hydroxyethyl cellulose bioadhesive gel. Anti-mycotic prophylaxis was also added. After the end of therapy, patients received a 2-month follow-up. In all, 14 of the 15 clobetasol 0.025% patients (93%) and 13 of the 15 clobetasol 0.05% patients (87%), had symptoms improvement after 2 months of therapy (P = 0.001 in both groups). Also, 13 of the 15 clobetasol 0.025% patients (87%) and 11 of the 15 clobetasol 0.05% patients (73%) had clinical improvement after 2 months of therapy (P < 0.05 in both groups). No statistical differences were found in comparing the two different formulations. A larger concentration of the active molecules cannot further improve the therapeutic findings or optimize the obtained results in a significant manner.

Verrucous oral carcinoma: clinical findings and treatment outcomes in 74 patients in Northwest Italy

AIM

Oral squamous cell carcinoma (OSCC) is an extremely invasive tumour of stratified squamous epithelium that spreads throughout degradation of the basement membrane (BM) and extracellular matrix (ECM). Oral verrucous carcinoma (VC) is a rare low-grade variant of OSCC. VC has a different clinical behaviour from classical OSCC and the optimal treatment is controversial. This report analyses the clinical features and outcomes in patients undergoing treatment for oral VC.

METHODS

A group of 74 Northern Italian patients were studied; for each patient, agreement of histological diagnosis, age and gender, risk factors, tumor site, T classification, treatment, outcome and survival rate were examined and analysed statistically.

RESULTS

The survival rate was 93.65% at 5 years and 83.44% at 10 years. Retrospective analysis showed no risk of cervical lymph node metastasis and surgical treatment results were good.

CONCLUSION

Our survival rates showed a good prognosis, with no risk of cervical lymph node metastases, suggesting that most cases can be controlled by surgery alone.

The impact of liquid-based oral cytology on the diagnosis of oral squamous dysplasia and carcinoma

OBJECTIVE

Even though diagnostic oral exfoliative cytology is a useful, economical and practical tool in the diagnosis of oral dysplasia and carcinoma, it is not yet extensively used. The results of conventional exfoliative and liquid-based diagnostic cytology in oral potentially malignant lesions (PML) are herein reported and compared with the histological diagnosis.

METHODS

Either conventional (89) or liquid-based (384) exfoliative cytology was used for the diagnosis of oral dysplasia/carcinoma in 473 subjects and the results were compared with scalpel biopsy histology. Cells were collected using a Cytobrush device for conventional smears and with a dermatological curette for the liquid-based cytology. The 'curette technique' also allowed for the collection of 'accidental' tissue fragments, utilized as microbiopsies.

RESULTS

Histological diagnosis was squamous carcinoma in 96 of 473 cases, high-grade dysplasia (oral intraepithelial neoplasia two to three) in 24 and other lesions in 353 cases. The smears in the conventional cytology group were inadequate in 12.4%, with an 85.7% sensitivity and a 95.9% specificity. There were 8.8% of inadequate specimens in the liquid-based cytology group; sensitivity was 95.1% and specificity was 99.0%.

CONCLUSIONS

Although conventional cytology is useful when diagnosing oral PML (better sensitivity and predictive positive value if compared with the cervical smear test with similar specificity) and can improve the accuracy of histological diagnosis, liquid-based cytology gives better results, as it not only enhances both sensitivity and specificity, but also provides material for further investigation (AgNORs, DNA, microbiopsies, etc.).

Implant supported prostheses with Bone System implant system: a retrospective study with follow-up period up to 13-years about 1021 fixtures

AIM

To analyze the data collected in 13 years of clinical controls in patients with oral rehabilitation on Bone System dental implant systems and to evaluate the success, failure and complications in daily implant dentistry, without strict inclusion criteria, in order to define the success or survival or failure of dental implants.

METHODS

A total of 477 patients (231 men and 246 women) received dental implants for oral rehabilitation in 3 different private dental offices in Piedmont, Italy. A total of 1 021 fixtures were implanted from 1992 to 2004; patients were followed up for a maximum of 13 years. Surgery was performed by the same operator using the same dental implant system (Bone System, Italy), with manufacturer modifications and improvements to the system as it evolved during the study period. Treatment planning and oral reconstruction on the inserted implants were carried out by 3 different specialists in prosthesis dentistry and 4 dental laboratory technicians. In the follow-up period, clinical success was defined as the degree of patient satisfaction and as the survival of restorations on dental implants.

RESULTS

The survival rate of the fixtures was 95.9%; the clinical effectiveness was 92.8%; the failure rate was 4.1%. Complications included peri-implantitis, implant fractures and technical complications related to implant components and prostheses. Long-term implant survival and clinical success were not influenced by anatomic site (maxilla or mandible).

CONCLUSION

Dental implant therapy is a viable option for oral rehabilitation; if correctly managed, it may provide predictable results.

Ciclosporin vs. clobetasol in the topical management of atrophic and erosive oral lichen planus: a double-blind, randomized controlled trial

BACKGROUND

Oral lichen planus (OLP) is a chronic inflammatory disease that can be painful, especially in the atrophic and erosive forms. Several drugs have been used with varying results, but most treatments are empirical, and do not have adequate control groups or correct study designs.

OBJECTIVES

To compare the effectiveness of clobetasol and ciclosporin in the topical management of OLP and to evaluate which is more cost-effective and which gives the longest remission from signs and symptoms.

METHODS

A randomized, comparative, double-blind study was designed. Forty consecutive patients were divided into two groups to receive clobetasol propionate or ciclosporin for 2 months. Both drugs were placed in 4% hydroxyethyl cellulose bioadhesive gel. Antimycotic prophylaxis was also given. After the end of therapy, patients underwent a 2-month follow-up.

RESULTS

Eighteen of 19 clobetasol-treated patients (95%) improved after 2 months of therapy, while 13 of 20 ciclosporin-treated patients (65%) had a clinical response (P = 0.04). Symptomatology improved in 18 clobetasol-treated patients (95%) and in 17 ciclosporin-treated patients (85%) (not statistically significantly different). Two months after the end of therapy, 33% of clobetasol-treated patients and 77% of ciclosporin-treated patients were stable (P = 0.04). Clobetasol produced significantly more side-effects than ciclosporin (P = 0.04). The daily cost of ciclosporin treatment was 1.82 compared with 0.35 for clobetasol therapy.

CONCLUSIONS

Clobetasol is more effective than ciclosporin in inducing clinical improvement, but the two drugs have comparable effects on symptoms. Conversely, clobetasol gives less stable results than ciclosporin when therapy ends and has shown a higher incidence of side-effects. The daily cost of ciclosporin is more than five times higher than clobetasol.

Non-neoplastic salivary gland diseases

A wide range of non neoplastic disorders can affect the salivary glands, although the more common are: mumps, acute suppurative sialadenitis, Sjögren's syndrome and drug-induced xerostomia. Salivary dysfunction is not a normal consequence of old age, and can be due to systemic diseases, medications or head and neck radiotherapy. Diagnosis of salivary disorders begins with a careful medical history, followed by a cautious examination. While complaints of xerostomia may be indicative of a salivary gland disorder, salivary diseases can present without symptoms. Therefore, routine examination of salivary function must be part of any head, neck, and oral examination. Health-care professionals can play a vital role in identifying patients at risk for developing salivary dysfunction, and should provide appropriate preventive and interventive techniques that will help to preserving a person's health, function, and quality of life. The present work provides an overview of most of the non neoplastic disorders of the salivary glands, in which the general presentation, pathology, and treatments are discussed.

Localized oral amyloidosis of the palate

BACKGROUND

Amyloidosis is a rare disease with multifactorial pathogenesis. Localized amyloidosis affecting the head and neck region is an uncommon and benign process, which has almost no clinical consequences. The most reported characteristic features of localized oral amyloidosis appear as multiple soft nodules of the tongue, lip and cheek.

METHODS

We report the case of a 68-year-old woman suffering from a primary localized amyloidosis presenting as a purple patch on the palate.

CONCLUSIONS

The presence of systemic amyloidosis or underlying plasma cell dyscrasia have to be ruled out in patients presenting with a diagnosis of amyloidosis of the oral mucosa. If a primary localized amyloidosis is proven, the surgical therapy may be useful to eliminate a functional impairment.

Hepatitis C virus-associated oral lichen planus: is the geographical heterogeneity related to HLA-DR6?

BACKGROUND

The association between hepatitis C virus (HCV) and oral lichen planus (OLP) is more common in the Mediterranean area and Japan, possibly because of immunogenetic factors.

METHODS

Intermediate-resolution HLA-DRB typing by hybridization with oligonucleotide probes was performed in 31 Italian OLP patients with HCV infection, in 45 Italian OLP and in 48 British OLP patients without HCV infection. As healthy controls we included data from 145 unrelated Italian and 101 unrelated British bone marrow donors.

RESULTS

Italian HCV+ve OLP patients possessed the HLA-DR6 allele more frequently than Italian and British OLP patients without HCV infection (51.6% vs. 17.7% vs. 16.7%; P corrected = 0.028 and 0.017, respectively). There was no difference in the frequency of the HLA-DR6 allele between Italian and British control subjects.

CONCLUSIONS

The present data suggest that HLA-DR6 may be responsible for the peculiar geographic heterogeneity of the association between HCV and OLP.

Proliferative verrucous vs conventional leukoplakia: no significantly increased risk of HPV infection

Proliferative verrucous leukoplakia (PVL) is a very aggressive form of oral leukoplakia (OL) with high morbidity and mortality rates, hypothesised to be linked to HPV infection. This study aimed to determine the presence of HPV DNA in PVL in comparison with OL, and in relation to social-demographical variables (age, gender, smoking and drinking habits) in an Italian multi-centric hospital-based study. The study group consisted of 58 cases of PVL and 90 cases of OL as controls (47 homogeneous (H) and 43 non-homogeneous (non-H) form), both recruited from four Italian cohorts. HPV DNA was identified in exfoliated mucosal cells by nested PCR (nPCR) with MY09/MY11 and GP5+/GP6+ primer pairs and the HPV genotype determined by direct DNA sequencing. HPV DNA was found in 24.1% (14/58)of PVL and in 25.5% (23/90) of OL; there was thus no significant difference found between PVL and OL (both forms) for risk of HPV infection (OR=0.93; 95% IC:0.432-1.985). Similarly, in both groups of PVL and OL lesions, no statistic association was found between any demographical variable considered and HPV infection. HPV-18 was the most frequently detected genotype in all tissues, being found in 78.5% and 60.8% of HPV+ve PVL and OL, respectively. Other more rarely detected genotypes were HPV-16 (28.6% in PVL and 13% in OL), HPV-6 (17.4% in OL) and HPV-53 (8.8% in OL). PVL does not appear more likely to be associated to HPV infection than conventional OL lesions.

Oral acanthosis nigricans, tripe palms and sign of leser-trélat in a patient with gastric adenocarcinoma

Acanthosis nigricans (AN), tripe palms (TP) and the sign of Leser-Trélat (LT) may be seen with the presence of malignancy. Acanthosis nigricans may have a mucocutaneous localization involving the oral mucosa with papillomatous and verrucous lesions usually on the lips and buccal mucosa. These paraneoplastic dermatoses are generally linked with intra-abdominal malignancy, most often gastric adenocarcinoma. Improvement of the associated dermatoses after the treatment of the malignancy has been frequently observed. We report the case of a 53-year-old man suffering from advanced gastric adenocarcinoma, in which metastases seemed to sustain all three paraneoplastic dermatoses. To the best of our knowledge this is the first case of a patient showing manifestations of all three paraneoplastic dermatoses. Patients presenting with this set of dermatoses should be suspected to harbor an occult malignancy, or have persistence of a known malignancy.

Risk of oral squamous cell carcinoma in 402 patients with oral lichen planus: a follow-up study in an Italian population

The most important complication of oral lichen planus (OLP) is the development of oral squamous cell carcinoma (OSCC) but this is a very controversial matter. The aim of the study was to estimate in a Northern Italian cohort of OLP patients the risk for OSCC. Four hundred and two patients with histologically confirmed OLP diagnosed from January 1988 to July 1999, were followed-up to the end of February 2001. The standardized incidence ratio (SIR) of OSCC was calculated for the entire cohort and specific for gender, type of OLP, therapy for OLP and hepatitis C virus (HCV) infection. The relative risk (RR) of OSCC according to HCV infection was also estimated in the cohort. During the follow-up period, two men (1.3%) and seven women (2.9%) developed an OSCC. The SIR was 44.9 (95% CI: 20.5-85.2), being higher among women, but statistically significant in both genders. The RR of OSCC for patients with HCV as compared with those without HCV infection was 3.16 (0.8-12.5). Patients with OLP had a significantly increased risk of OSCC, irrespective of the clinical type of OLP and therapy. HCV infection apparently increased the risk for OSCC although this result could reflect the role of confounders, such as liver cirrhosis.

[Usefulness of oral exfoliative cytology for the diagnosis of oral squamous dysplasia and carcinoma]

AIM

It is well known that diagnostic oral exfoliative cytology, even if a useful, economical and practical tool in the diagnosis of oral dysplasia and carcinoma, is not yet used so extensively as is cervico-vaginal cytology.

METHODS

Exfoliative cytology was used for the diagnosis of oral dysplasia and carcinoma, and the results compared to the histological examination. Cytological smears were taken from 89 patients with oral lesions suspicious for neoplasia (in particular erythro- and leukoplakia and lichen). All patients were also subjected to oral biopsy and histological examination.

RESULTS

Out of 89 cases studied, histology showed the presence of an invasive squamous carcinoma in 32, dysplasia in 17, phlogosis in 15 and other types of lesions (2 of which malignant non-epithelial tumours) in 25. The cytological smear was inadequate for diagnosis in 11/89 cases (12.4%). In cytologically adequate and histologically positive cases, cytology confirmed the histological diagnosis of dysplasia and/or carcinoma in 38/45 cases (sensitivity 86.5%, accuracy 89.6%). Moreover, 1 case which was histologically negative at the onset, proved positive at cytology. There were 2 false-positive cytology results (specificity 94.3%, predictive positive value 95.7%).

CONCLUSIONS

Despite the small number of cases in the cohort, oral cytology can improve the accuracy of histology, and may be a useful screening tool for the diagnosis of oral neoplasia/dysplasia.

Systemic and topical corticosteroid treatment of oral lichen planus: a comparative study with long-term follow-up

BACKGROUND

Topical corticosteroids are the mainstay treatment for oral lichen planus (OLP), but some authors suggest that systemic corticosteroid therapy is the only way to control acute presentation of OLP.

METHODS

Forty-nine patients with histologically proven atrophic-erosive OLP were divided into two groups matched for age and sex. The test group (26 patients) was treated systemically with prednisone (50 mg/day), and afterwards with clobetasol ointment in an adhesive medium plus antimicotics, whereas the control group (23 patients) was only treated topically with clobetasol plus antimycotics.

RESULTS

Complete remission of signs was obtained in 68.2% of the test group and 69.6% of the control group, respectively (P = 0.94). Similar results were obtained for symptoms. Follow-up showed no significant differences between the two groups. One-third of the patients of the test group versus none in the control group experienced systemic side-effects (P = 0.003).

CONCLUSIONS

The most suitable corticosteroid therapy in the management of OLP is the topical therapy, which is easier and more cost-effective than the systemic therapy followed by topical therapy.

Oral diseases possibly associated with hepatitis C virus

Morbidity associated with hepatitis C virus (HCV) infection can involve a variety of extrahepatic conditions, including lichen planus (LP) and sialadenitis, predominantly or exclusively involving the oral region, conditions which have been largely neglected in reviews. The literature suggests that HCV-infected patients may frequently have Sjögren-like sialadenitis with mild clinical symptoms, whereas oral LP may be significantly associated with HCV infections in Southern Europe and Japan but not in Northern Europe. These geographical differences could be related to immunogenetic factors such as the HLA-DR6 allele, significantly expressed in Italian patients with OLP and HCV. Analysis of experimental data suggests that HCV could be involved in the pathogenesis of both these diseases. Moreover, parotid lymphoma may arise in patients with sialadenitis, mainly with type II cryoglobulinemia. Little attention has been paid to oral health needs in HCV-infected patients and the variable effect of interferon-alpha therapy on oral tissues. Further research is needed, because of the potentially great influence of oral diseases possibly linked to HCV on the quality of life of millions of patients.

Oral mucosal dysplastic lesions and early squamous cell carcinomas: underdiagnosis from incisional biopsy

OBJECTIVES

To evaluate the degree and causes of underdiagnosis of incisional biopsy in oral potentially malignant lesions (PML).

DESIGN

Cross-sectional retrospective study.

MATERIALS AND METHODS

All pathology slides (incisional biopsy and resection specimen) from 46 patients with oral PML were reviewed and scored blind. The provisional diagnosis was considered in order to provide underdiagnosis or overdiagnosis according to whether this score was lower or higher than the final diagnosis.

MAIN OUTCOME MEASURES

Concordance between the scores for provisional and final diagnoses was compared for reviewed and unreviewed assessments.

RESULTS

Upon review, underdiagnosis significantly decreased from 23.9% to 4.4% (P=0.016, chi-square with the Yates' correction). As the underdiagnosis ratio was not significantly influenced by intra- or inter-observer variability, it is likely to be related to pathologists' interpretation difficulties when examining incisional biopsy specimens.

CONCLUSIONS

The good quality of incisional biopsy samples was demonstrated, but clinicians should be conscious of the possible underdiagnosis by incisional biopsy when planning therapy in suspected early oral squamous cell carcinoma lesions.

Lichen planus and hepatitis C virus infection

In the last 20 years an increasingly strong association between lichen planus (LP) and chronic hepatic disease has been suggested, mainly in Southern Europe and in patients with oral LP (OLP) of the erosive type. When sensitive hepatitis C virus (HCV) assays became available, several studies have supported the link between LP and HCV infection. The aim of this paper is to review the literature on LP and liver disease, especially caused by HCV. Pub-Med on line Medline data searches were carried up for the years 1966-2001 to identify literature on liver diseases, HCV infection and LP. All the paper found were critically reviewed. The available literature suggests that LP, mainly, OLP may be significantly associated with HCV infections in Italy, Spain, Japan, USA whereas controversial data are coming from France and Germany and in Holland and UK the OLP studied patients did not have signs of HCV infection. These geographical differences could be related to immunogenetic factors as the allele HLA-DR6 has been found to be significantly expressed in Italian patients with OLP and HCV infection. However a high prevalence of OLP has been found in UK-HCV infected patients suggesting that in countries with low HCV prevalence, LP should be probably better identify in HCV-infected patients rather than seeking to find HCV infection in LP patients. HCV viral sequences have been found in oral samples of patients with and without LP strongly suggesting the possibility that HCV may be involved in the development of the oral lesions. probably via an immunological still unknown pathway.

Malacoplakia of the tongue. A case report and review of the literature

Our aim is to present a singular case of malacoplakia of the tongue and a review of the literature. Malacoplakia (from the Greek "malacos", soft, and "placos", plaque) is a granulomatosis initially described in 1902. It has the clinical aspect of a yellow-brown, soft plaque of variable size, characterized by a central navel or ulcer and an intense peripheral hyperaemia, usually located in the urogenital and gastrointestinal tract. The mortality rate is higher than 50% if vital organs are involved. In the world literature there are 16 cases of the head and neck region and particularly only 2 of them are located on the tongue. In these 2 cases the lesion caused some distress to the patients who referred to a medical observation for this motive. Conversely we report a case of asymptomatic lingual malacoplakia occurring in a 57-year-old woman, diagnosed by chance during a stomatological examination in the Department of Oral Medicine and Periodontology of Turin University. In this case the outcome was quite plain and our patient did not need any supporting medical therapy. Nevertheless the potential danger of malacoplakia should underline the importance of a more careful histological assessment of submucosal nodules of the oro-pharyngeal region. Moreover the histopathological characteristic, the present etiopathogenetic hypothesis and the therapeutic pattern of malacoplakia suggested in the literature are discussed.

Lack of association between hepatotropic transfusion transmitted virus infection and oral lichen planus in British and Italian populations

BACKGROUND

A possible association between oral lichen planus (OLP) and chronic hepatic disease has been found in some populations, although this is probably geographically influenced. In 1997 a new hepatotropic virus, transfusion transmitted virus (TTV), was identified but has not been studied in relation to OLP.

OBJECTIVE

The present investigation evaluated the genoprevalence of TTV DNA in the sera of British and Italian patients suffering from OLP using two different sets of primers to identify TTV subgenomic DNA.

METHODS

Study groups comprised 40 adult subjects (21 British, 19 Italian) with OLP. For each country, two control groups, a disease-control group and a healthy-control group, were included. The presence of TTV DNA in the sera of patients and control subjects was assessed using two different polymerase chain reactions (PCR) and DNA sequence analysis.

RESULTS

Statistical analysis did not reveal evidence of any association between TTV infection and OLP or country of residence.

CONCLUSION

An association between TTV and OLP is unlikely.

HLA-DQB1 alleles in Italian patients with mucous membrane pemphigoid predominantly affecting the oral cavity

BACKGROUND

Mucous membrane pemphigoid (MMP) used to be considered as a single entity but it is now evident that a range of variants exists. Among them, pure ocular cicatricial pemphigoid (OCP) and pure oral pemphigoid (OP) appear to be very different subsets. Previous immunogenetics studies have found increased occurrence of the DQB1*0301 allele mainly in patients with OCP whereas in patients with OP the data are more open to doubt.

OBJECTIVES

To analyse HLA predisposition in a group of Italian patients with MMP predominantly affecting the oral cavity.

METHODS

We carried out high-resolution typing of HLA-DQB1 alleles in 28 patients with MMP predominantly affecting the oral cavity and in 97 geographically matched, healthy controls. All were Italian caucasians.

RESULTS

The frequency of HLA-DQB1*0301 was significantly increased in the MMP patients compared with the controls (96% vs. 48%; corrected P, Pc = 0.001; relative risk, RR = 28.73). A strong association with DQB1*0301 was also evident in patients with OP compared with the controls (95% vs. 48%; Pc = 0.01; RR = 20.21). There was no significant difference in DQB1*0301 frequency between patients with OP and with MMP not restricted to the oral cavity. Patients with MMP were more frequently homozygous for DQB1*0301 than the controls (43% vs. 8%; Pc < 0.001; RR = 8.34).

CONCLUSIONS

Our data suggest that Italian patients with MMP lesions predominantly affecting the oral cavity present the same genetic predisposition linked to HLA-DQB1*0301 previously reported mainly in patients with OCP.

Increased frequency of HLA-DR6 allele in Italian patients with hepatitis C virus-associated oral lichen planus

BACKGROUND

Recent controlled studies have confirmed that hepatitis C virus (HCV) is the main correlate of liver disease in patients with lichen planus (LP), mainly in southern Europe and Japan. However, a low prevalence of HCV infection has been found in LP patients in England and northern France, and significant differences in serum HCV RNA levels or HCV genotypes have not been found between LP patients and controls. Thus host rather than viral factors may be prevalent in the pathogenesis of HCV-related LP. The HLA-DR allele may influence both the outcome of HCV infection and the appearance of symptoms outside the liver.

OBJECTIVES

To assess whether major histocompatibility complex class II alleles play a part in the development of HCV-related LP.

METHODS

Intermediate-resolution DRB typing by hybridization with oligonucleotide probes was performed in 44 consecutive Italian oral LP (OLP) patients with HCV infection (anti-HCV and HCV RNA positive), in an age, sex and clinically comparable disease control group of 60 Italian OLP patients without HCV infection (anti-HCV and HCV RNA negative), and in 145 healthy unrelated Italian bone marrow donors without evidence of liver disease or history of LP and with negative tests for HCV.

RESULTS

Patients with exclusive OLP and HCV infection possessed the HLA-DR6 allele more frequently than patients with exclusive OLP but without HCV infection (52% vs. 18%, respectively; Pc (Pcorrected) = 0.028, relative risk = 4.93). We did not find any relationship between mucocutaneous LP, HCV infection and HLA-DR alleles.

CONCLUSIONS

HCV-related OLP therefore appears to be a distinctive subset particularly associated with the HLA class II allele HLA-DR6. This could partially explain the peculiar geographical heterogeneity of the association between HCV and LP.