Nuts and bolts of salivary gland pathology in primary Sjögren's syndrome

Primary Sjögren's syndrome (pSS) is a chronic, systemic, inflammatory autoimmune disease characterised by lymphocyte proliferation and progressive damage to exocrine glands. Salivary gland histopathology based on salivary gland biopsy is relevant for the diagnosis of pSS and therefore broadly applied in clinical practice. Tissue can be obtained from labial salivary glands (LSG) biopsy or from major salivary glands (MSG) biopsy, namely the parotid; in this latter scenario, the procedure can be either an open surgical biopsy or a US guided core needle biopsy.In this review we will: i) present the histopathological findings that may be encountered by pathologists on biopsies from pSS patients; ii) discuss the advantages and disadvantages of the surgical and/or imaging guided procedures to obtain tissues from LSG or MSG; iii) describe the histopathological features of lymphoma of MSG in pSS patients.

Secretagogue effect of PDE4 inhibitor apremilast on human salivary gland organoids obtained from primary Sjögren's syndrome patients

OBJECTIVES

The aim of the study was to culture vital salivary gland organoids obtained through labial or parotid biopsy of primary Sjögren's syndrome (pSS) patients in order to evaluate their morphological and functional features in basal condition and after stimulation with Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) activator forskolin and phosphodiesterase 4 (PDE4) inhibitor apremilast, their in vitro regenerative capacity and the immune-histological resemblance with original tissue.

METHODS

Salivary gland tissues from five pSS patients were processed to obtain vital organoids; swelling assay and cell proliferation tests were performed after forskolin and apremilast application. Immunochemistry evaluation on original salivary gland tissue and corresponding organoids was performed, and secretomics analysis was conducted to assess their functional status.

REULTS

After application of forskolin and apremilast, we observed organoid swelling after 30 minutes, compatible with a positive functional status and enhancement of saliva production. In 3 cases, apremilast induced organoid proliferation. All cases were positive for cytokeratin 14 (CK14) and most for cytokeratin 5 (CK5). All the cases were positive for amylase; its secretion, and thus functional status of organoids, was confirmed by its high concentration in the culture medium. A focal ductal differentiation was found in some cases, highlighted by epithelial membrane antigen (EMA) positivity. The more differentiated EMA positive areas were negative for the staminal marker CK14, showing a sort of "complementary staining".

CONCLUSIONS

Our data highlighted that differentiated cells and vital functional organoids that recapitulate the development of original salivary glands can be obtained from pSS epithelium. For the first time, the direct stimulating effect of PDE4 inhibitor apremilast on pSS human salivary gland organoids is reported, opening new perspectives on targeting oral dryness with drugs that combine secretagogue and immunomodulatory effects.

Predicting lymphoma in Sjögren's syndrome and the pathogenetic role of parotid microenvironment through precise parotid swelling recording

OBJECTIVE

Parotid swelling (PSW) is a major predictor of non-Hodgkin lymphoma (NHL) in primary Sjögren's syndrome (pSS). However, since detailed information on the time of onset and duration of PSW is scarce, this was investigated to verify whether it may lead to further improved prediction. NHL localisation was concomitantly studied to evaluate the role of the parotid gland microenvironment in pSS-related lymphomagenesis.

METHODS

A multicentre study was conducted among patients with pSS who developed B cell NHL during follow-up and matched controls that did not develop NHL. The study focused on the history of salivary gland and lachrymal gland swelling, evaluated in detail at different times and for different durations, and on the localisation of NHL at onset.

RESULTS

PSW was significantly more frequent among the cases: at the time of first referred pSS symptoms before diagnosis, at diagnosis, and from pSS diagnosis to NHL. The duration of PSW was evaluated starting from pSS diagnosis, and the NHL risk increased from PSW of 2-12 months to > 12 months. NHL was prevalently localised in the parotid glands of the cases.

CONCLUSION

A more precise clinical recording of PSW can improve lymphoma prediction in pSS. PSW as a very early symptom is a predictor, and a longer duration of PSW is associated with a higher risk of NHL. Since lymphoma usually localises in the parotid glands, and not in the other salivary or lachrymal glands, the parotid microenvironment appears to be involved in the whole history of pSS and related lymphomagenesis.

Risk of Cancer in Connective Tissue Diseases in Northeastern Italy over 15 Years

Objective: To evaluate cancer risk among individuals with connective tissue disease (CTD) in Friuli Venezia Giulia, northern Italy. Methods: A population-based cohort study was conducted based on data from health records available in the regional healthcare database. Demographic characteristics, hospital discharges, exemption from medical charges, drug prescriptions, were individually matched with data from the population-based cancer registry. Cancer risk was assessed in people diagnosed with the following diseases: systemic lupus erythematosus (SLE), Sjögren’s syndrome (SS), systemic sclerosis (SSc), polymyositis (PM), and dermatomyositis (DM). Results: In all, 2504 patients were followed 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), whereas the number of observed NHL cases was more than two-fold significantly higher than expected (SIR = 2.52). The subgroup analysis showed a higher risk of NHL among SS patients (SIR = 3.84) and SLE patients (SIR = 2.69). Conversely, the study population showed a decreased risk for breast cancers (SIR = 0.61) and corpus uteri (SIR = 0.21). Conclusions: The incidence of NHL was higher among patients with SS and SLE. Careful surveillance for hematological malignancies in these patients is recommended.

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

Sjögren syndrome: looking forward to the future

Primary Sjögren’s syndrome (pSS) is a heterogeneous disease characterised by a wide spectrum of manifestations that vary according to the different stages of the disease and among different subsets of patients. The aim of this qualitative literature review is to summarise the recent advances that have been reported in pSS, ranging from the early phases to the established disease and its complications. We analysed the diagnostic, prognostic, and management aspects of pSS, with a look into future clinical and research developments. The early phases of pSS, usually antedating diagnosis, allow us to investigate the pathophysiology and risk factors of the overt disease, thus allowing better and timely patient stratification. Salivary gland ultrasound (SGUS) is emerging as a valid complementary, or even alternative, tool for histopathology in the diagnosis of pSS, due to a standardised scoring system with good agreement and performance. Other promising innovations include the application of artificial intelligence to SGUS, ultrasound-guided core needle biopsy, and a wide array of novel diagnostic and prognostic biomarkers. Stratifying pSS patients through the integration of clinical, laboratory, imaging, and histopathological data; differentiating between activity-related and damage-related manifestations; and identifying patients at higher risk of lymphoma development are essential steps for an optimal management and individualised treatment approach. As new treatment options are emerging for both glandular and systemic manifestations, there is a need for a more reliable treatment response evaluation. pSS is a complex and heterogeneous disease, and many distinct aspects should be considered in the different stages of the disease and subsets of patients. In recent years, efforts have been made to improve our understanding of the disease, and certainly in the coming years, some of these novelties will become part of our routine clinical practice, thus improving the management of pSS patients.

Safety, patient acceptance and diagnostic accuracy of ultrasound core needle biopsy of parotid or submandibular glands in primary Sjögren's syndrome with suspected salivary gland lymphoma

Background

Enlargement of the major salivary glands (SGs) is a major risk factor for B-cell lymphoma among patients with primary Sjögren’s syndrome (pSS). Ultrasound-guided core needle biopsy (US-guided CNB) could be a novel technique to manage SG enlargement among patients with pSS.

Objective

Accordingly, this study’s main aim was to evaluate the safety, patient tolerance and diagnostic accuracy of US-guided CNB procedure for patients with pSS with major SG enlargement.

Methods

Patients with clinical diagnosis of pSS and a clinical indication for SG biopsy consecutively underwent US-guided CNB between September 2019 and June 2021. These patients were evaluated clinically 1, 2 and 12 weeks after US-guided CNB. Patients were asked to complete a questionnaire about postprocedural complications as well as periprocedural pain, using the Visual Analogue Scale. Complications were categorised as transient (<12 weeks) or persistent (≥12 weeks).

Results

US-guided CNB was performed on 30 major salivary glands (22 parotid glands and 8 submandibular glands). The procedure was well tolerated. Transient complications—such as haematoma, swelling—were observed among 43% of patients, and mean periprocedural pain was low. However, no persistent complications were reported during the study’s follow-up period.

Conclusion

US-guided CNB represents a novel approach for the management of patients with pSS with SG enlargement. The procedure showed remarkable patient safety and tolerance, allowing adequate glandular sampling and a definite diagnosis for almost all participating patients without long-term complications.

Sonographic features of lymphoma of the major salivary glands diagnosed with ultrasound-guided core needle biopsy in Sjögren's syndrome

OBJECTIVES

To identify ultrasound (US) features of lymphomas (L) of major salivary glands (SGs) in primary Sjögren's syndrome (pSS) patients and to differentiate US pattern of L and non-L.

METHODS

Prospectively, from September 2019 to March 2021, 27 pSS-patients with clinical findings suspicious for L of the SGs underwent US evaluation followed by US-guided core-needle biopsy (CNB). For each patient, we assessed the OMERACT score, dichotomised (0/1 "lower", 2/3 "higher"), and we compared it between L-pSS and nonL-pSS groups. For focal lesions, echogenicity, inner appearance, shape, margins, presence of septa, vascularisation and posterior acoustic features were also assessed and compared between the two groups; we planned to consider as "suspicious" features more frequently associated with L. We expected to compare frequencies at which two or more "suspicious" features were simultaneously present between L-pSS and nonL-pSS. P<0.05 were considered statistically significant.

RESULTS

L-pSS showed more inhomogeneous glandular pattern (100% vs. 69.2% higher OMERACT; p=0.0407). For focal lesions, the "suspicious" features identified were: OMERACT grade 3, very hypoechoic, homogenous, oval shape, well-defined margins, presence of septa, colour-Doppler vascularization, posterior acoustic enhancement. 6/8 and 7/8 simultaneous suspicious features were significantly higher among L-pSS patients, compared to nonL-pSS (88.9% vs. 28.6%, p=0.034 for 6/8 features; 77.8% vs. 14.3%, p=0.040 for 7/8 features).

CONCLUSIONS

L of the major SGs in pSS was always associated with OMERACT scores 2 or 3 and presented with diffuse or focal patterns. For focal lesions, the association of more "suspicious" features made the diagnosis of L increasingly more likely. This information can help to improve planning of US-guided CNB.

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.

Diagnosis and management of lung involvement in systemic lupus erythematosus and Sjögren's syndrome: a literature review

Lung involvement in systemic lupus erythematosus (SLE) and primary Sjögren's syndrome (pSS) has extensively been outlined with a multiplicity of different manifestations. In SLE, the most frequent finding is pleural effusion, while in pSS, airway disease and parenchymal disorders prevail. In both cases, there is an increased risk of pre-capillary and post-capillary pulmonary arterial hypertension (PAH) and pulmonary venous thromboembolism (VTE). The risk of VTE is in part due to an increased thrombophilic status secondary to systemic inflammation or to the well-established association with antiphospholipid antibody syndrome (APS). The lung can also be the site of an organ-specific complication due to the aberrant pathologic immune-hyperactivation as occurs in the development of lymphoma or amyloidosis in pSS. Respiratory infections are a major issue to be addressed when approaching the differential diagnosis, and their exclusion is required to safely start an immunosuppressive therapy. Treatment strategy is mainly based on glucocorticoids (GCs) and immunosuppressants, with a variable response according to the primary pathologic process. Anticoagulation is recommended in case of VTE and multi-targeted treatment regimens including different drugs are the mainstay for PAH management. Antibiotics and respiratory physiotherapy can be considered relevant complement therapeutic measures. In this article, we reviewed lung manifestations in SLE and pSS with the aim to provide a comprehensive overview of their diagnosis and management to physicians taking care of patients with connective tissue diseases.

Shared Pathogenetic Features Between Common Variable Immunodeficiency and Sjögren's Syndrome: Clues for a Personalized Medicine

Common variable immunodeficiency disorders (CVID) are a group of rare diseases of the immune system and the most common symptomatic primary antibody deficiency in adults. The “variable” aspect of CVID refers to the approximately half of the patients who develop non-infective complications, mainly autoimmune features, in particular organ specific autoimmune diseases including thyroiditis, and cytopenias. Among these associated conditions, the incidence of lymphoma, including mucosal associated lymphoid tissue (MALT) type, is increased. Although these associated autoimmune disorders in CVID are generally attributed to Systemic Lupus Erythematosus (SLE), we propose that Sjogren’s syndrome (SS) is perhaps a better candidate for the associated disease. SS is an autoimmune disorder characterized by the lymphocytic infiltrates of lacrimal and salivary glands, leading to dryness of the eyes and mouth. Thus, it is a lymphocyte aggressive disorder, in contrast to SLE where pathology is generally attributed to auto-antibody and complement activation. Although systemic lupus erythematosus (SLE) shares these features with SS, a much higher frequency of MALT lymphoma distinguishes SS from SLE. Also, the higher frequency of germ line encoded paraproteins such as the monoclonal rheumatoid factor found in SS patients would be more consistent with the failure of B-cell VDJ switching found in CVID; and in contrast to the hypermutation that characterizes SLE autoantibodies. Thus, we suggest that SS may fit as a better “autoimmune” association with CVID. Examining the common underlying biologic mechanisms that promote lymphoid infiltration by dysregulated lymphocytes and lymphoma in CVID may provide new avenues for treatment in both the diseases. Since the diagnosis of SLE or rheumatoid arthritis is usually based on specific autoantibodies, the associated autoimmune features of CVID patients may not be recognized in the absence of autoantibodies.

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

Ultrasound and Bioptic Investigation of Patients with Primary Sjögren's Syndrome

Primary Sjögren's syndrome (pSS) is a chronic and heterogeneous disorder characterized by a wide spectrum of glandular and extra-glandular features. The hallmark of pSS is considered to be the immune-mediated involvement of the exocrine glands and B-cell hyperactivation. This leads pSS patients to an increased risk of developing lymphoproliferative diseases, and persistent (>2 months) major salivary gland enlargement is a well-known clinical sign of possible involvement by B cell lymphoma. Better stratification of the patients may improve understanding of the mechanism underlying the risk of lymphoproliferative disorder. Here, we summarize the role of different imaging techniques and a bioptic approach in pSS patients, focusing mainly on the role of salivary gland ultrasonography (SGUS) and a US-guided core needle biopsy (Us-guided CNB) as diagnostic and prognostic tools in pSS patients with persistent parotid swelling.

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.

One year in review 2020: comorbidities, diagnosis and treatment of primary Sjögren's syndrome

Primary Sjögren's syndrome (pSS) is a complex and heterogeneous disorder characterised by a wide spectrum of glandular and extra-glandular features. The discovery of novel biomarkers allowed to characterise the disease not only phenotypically on the basis of clinical presentation, but also on the basis of the endotype. Moreover, a better stratification of patients has important value in the evaluation of mechanisms underlying the risk of lymphoproliferative disorders in these patients. Finally, novel targeted therapies may open new possibilities for the application of personalised medicine in pSS.