Yukinori Takagi

Salivary gland ultrasonography: can it be an alternative to sialography as an imaging modality for Sjögren's syndrome?

Objectives Salivary ultrasonography (US) was evaluated as an alternative imaging modality to sialography for Sjögrens syndrome (SS). Methods Parotid sialography and parotid and submandibular US were performed in 360 patients (188 with SS and 172 non-SS) who were suspected of SS and had fulfilled the American-European criteria (AEC) for SS or had received ≥3 of the objective examinations that were considered minimal requirements for classifying non-SS and had undergone both the imaging examinations. The glands were considered positive for SS if they exhibited peripheral sialoectatic changes on sialography and/or hypoechoic areas, echogenic streaks and/or irregular gland margins on US. The images obtained were independently rated as SS-positive or SS-negative by three radiologists in a blind fashion and the final decision was made by consensus. Interobserver and intermodality agreement was evaluated using κ values for sialography and parotid and/or submandibular US. Results Average κ values for the interobserver agreement were 0.81, 0.80 and 0.82 in sialography, parotid and submandibular US, respectively, indicating very good or good agreement. The κ value for intermodality agreement between sialography and parotid US was 0.81 and between sialography and submandibular US was 0.76, indicating very good and good agreement, respectively. The diagnostic ability of parotid US was significantly lower than that of sialography (p<0.001, McNemar test). However, the diagnostic ability of submandibular US was comparable to that of sialography (p=0.153). Conclusions Submandibular US is a promising technique that can be used as a practical alternative to sialography in the classification of SS.

Corticosteroid irrigation of parotid gland for treatment of xerostomia in patients with Sjögren’s syndrome

OBJECTIVE To determine the efficacy of corticosteroid irrigation of the parotid gland in relieving salivary flow deficiency in patients with Sjögren’s syndrome. METHODS The parotid glands of 31 patients with primary (24) or secondary (seven) Sjögren’s syndrome were irrigated either with saline solution followed by corticosteroid solution, or with saline solution alone. Salivary function was assessed by Saxon test. RESULTS Corticosteroid irrigation significantly increased the salivary flow rate in patients with Sjögren’s syndrome (p< 0.0001), with clinical improvement detectable 3.7 (2.4) weeks (mean (SD)) after initial corticosteroid irrigation. The extent of improvement in salivary function was reciprocal to the clinical severity of the disease, with patients at the early stages obtaining 1.20 (0.57) g net increase in salivary flow rate, and patients at the most advanced stages obtaining 0.20 (0.47) g net increase. Repeated corticosteroid irrigations did not evoke corticosteroid refractoriness of the salivary gland; similar levels of net increase in salivary flow rate were observed after the second to fourth challenge of the corticosteroid in these patients. The sustained period was 8.4 (3.5) months (mean (SD)). CONCLUSION These findings suggest the clinical usefulness of corticosteroid irrigation therapy in relieving xerostomia in patients with Sjögren’s syndrome.

Sonography as a replacement for sialography for the diagnosis of salivary glands affected by Sjögren's syndrome

Recently, it has been suggested that sonographic evaluation of the salivary glands is useful in the diagnosis of Sjogrens syndrome. Kawamura et al and, more recently, Ariji et al , showed that descriptive and quantitative assessment of the salivary glands by sonography efficiently differentiated between diseased and normal glands in patients with Sjogrens syndrome.1,2 They showed that the proposed sonographic gradings correlated well with the sialographic gradings. These findings suggest that sonography might be an alternative diagnostic tool for Sjogrens syndrome. Here, we attempted to determine whether sonography can take the place of sialography as an alternative technique for the assessment of salivary gland involvement in Sjogrens syndrome. Sialography and sonography were performed on 294 patients who presented with sicca syndrome (171 positive and 123 negative for Sjogrens syndrome). We diagnosed patients with Sjogrens …

Fast and high-resolution MR sialography using a small surface coil

To establish a fast and high‐resolution MR sialographic technique that provides fast and high‐resolution imaging.

Ultrasonography as an additional item in the American College of Rheumatology classification of Sjögren’s syndrome

OBJECTIVE In this study we evaluated US as an additional classification item in the ACR classification of SS. METHODS Of 581 patients classified as either SS (n = 364) or non-SS (n = 217) based on the minimum requirements of the American-European Consensus Group (AECG) classification, 184 patients (102 SS and 82 non-SS) who had scored two or more positive or two or more negative results according to the ACR criteria were selected. The AECG classification was used as the gold standard. A parotid and/or submandibular gland that was assigned a score ≥G1 was designated as SS positive. We evaluated US alone or with varying combinations of the ACR classification items in the diagnosis of SS. RESULTS The ACR criteria diagnosed the 184 patients with 91% sensitivity, 90% specificity and 91% accuracy. US alone diagnosed the 184 ACR patients with 79% sensitivity, 90% specificity and 83% accuracy, which was comparable to the results of US diagnosis in the AECG cohort (81%, 86% and 83%, respectively). Incorporating the US criteria as an alternative to one of the three ACR classification items achieved 89-91% sensitivity, 87-96% specificity and 89% or 92% accuracy, which was comparable to that of the original ACR classification. Furthermore, kappa analysis indicated that the results of the original ACR and US-replaced ACR classifications matched completely (κ = 0.960-0.974). CONCLUSION These results suggest that US can be used as an alternative to any of the three ACR classification items.

MR Imaging of Labial Glands

BACKGROUND AND PURPOSE: The labial salivary gland is a site of occurrence of tumors and cysts, and it serves as the biopsy site for the diagnosis of Sjögren syndrome. However, its imaging features have not been well understood. Here we attempted to depict the labial gland by high-resolution MR imaging. MATERIALS AND METHODS: The labial glands from 89 patients without Sjögren syndrome, 14 patients with Sjögren syndrome, and 3 patients with tumor or cyst of the lips were imaged by using a 1.5T MR imager with a 47- or 110-mm surface coil. RESULTS: The upper and lower labial glands consisted of 1–3 layers of gland clusters, each of which had high signal intensity on T1-weighted and fat-suppressed T2-weighted images and was readily enhanced after gadolinium injection. The posterior parts of the glands were thicker than the anterior parts. The gland areas in the lower lips (186 ± 64 mm2 in women and 192 ± 68 mm2 in men) were greater than those in the upper lips (140 ± 46 mm2 in women and 162 ± 66 mm2 in men). We did not find any significant age-related changes or sex differences in the gland area. The labial gland areas were smaller in the patients with Sjögren syndrome than in patients without Sjögren syndrome, though the difference was significant only in the upper lips (104 ± 53 mm2). CONCLUSION: This is the first report describing imaging features of the labial salivary glands. High-resolution MR imaging can readily delineate the labial glands.

Prevalence of Sjogren syndrome among Nagasaki atomic bomb survivors.

Objectives: Through a comprehensive epidemiological study, we determined Sjögren syndrome (SS) prevalence and examined the association between SS and ionising radiation dose. Methods: A total of 1008 atomic bomb survivors in Nagasaki agreed to undergo the tests comprising a questionnaire for xerophthalmia and xerostomia, Schirmer-I test, Saxon test, and tests of anti-SS-A/Ro and anti-SS-B/La antibodies, and, if necessary, Rose Bengal stain test, salivary ultrasonographic and MRI examination from November 2002 through October 2004. Diagnosis of SS was based on the American–European Consensus Group criteria, or a modified version thereof. Results: Among the 1008 participants (male 398, female 610, average age 71.6 years), 154 participants (15.3%) complained of xerophthalmia, and 264 (26.2%) of xerostomia. Reduced tear flow as assessed by the Schirmer-I test was detected in 371 of 992 participants (37.4%) and reduced saliva flow as assessed by the Saxon test in 203 of 993 participants (20.4%). Among all participants, 38 (3.8%) and 10 (1.0%) participants tested positive for anti-SS-A/Ro and anti-SS-B/La antibodies, respectively. Taking into consideration all the results, 23 participants were diagnosed with SS (primary 20, secondary 3), yielding a prevalence of 2.3%. Although the association between SS and radiation dose was not significant, radiation dose was significantly associated with hyposalivation. Conclusions: The present comprehensive epidemiological study reveals that the prevalence of SS was 2.3% among Nagasaki atomic bomb survivors and was not associated with radiation dose. The association between radiation dose and hyposalivation supported the possibility that radiation exposure damaged salivary gland function.

Salivary gland ultrasonography as a primary imaging tool for predicting efficacy of xerostomia treatment in patients with Sjögren’s syndrome

OBJECTIVE To evaluate ultrasonography (US) grading of salivary gland disease as a predictor of treatment efficacy for impaired salivary function in xerostomia patients with or without Sjögrens syndrome (SS). METHODS We retrospectively analysed the prognostic importance of salivary US grading in 317 patients (168 with SS and 149 without SS). US images of the parotid and submandibular glands in each patient were individually categorized into grades 0-4 based on the extent of damage to the gland; and the sum total grade of the two gland types on either side was assigned a US score of 0-8 for each patient. The relative importance of US score and demographic and clinical variables was assessed using stepwise multiple regression analysis after various durations of xerostomia treatment. RESULTS Multiple regression analysis indicated that the baseline US score before treatment was the most important factor [standardized regression coefficient (β) = -0.523, t-statistic (t) = -7.967, P < 0.001] in predicting negative outcomes in SS patients. Treatment duration (β = 0.277, t = 4.225, P < 0.001) was also a significant but less important positive variable. On the other hand, US grading did not effectively predict treatment outcomes in non-SS patients, with treatment duration (β = 0.199, t = 2.486, P = 0.014) and baseline salivary flow rate before treatment (β = -0.172, t = -2.159, P = 0.032) being significant but weak predictors of positive and negative outcome, respectively. CONCLUSION Salivary gland US grading may help to predict outcomes of treatment for impaired salivary function in patients with SS.

A single centre retrospective analysis of AECG classification criteria for primary Sjögren’s syndrome based on 112 minor salivary gland biopsies in a Japanese population

OBJECTIVE To assess the usefulness and performance of the American European Consensus Group (AECG) criteria based on minor salivary gland biopsy (MSGB) in Japanese patients with primary SS. METHODS Among 208 MSGB cases, we retrospectively selected 112 subjects who satisfied the complete set of AECG classification criteria. Of the 112 subjects studied, 63 primary SS patients and 49 non-SS group subjects were classified according to the AECG criteria. The contribution of subjective and objective components was statistically analysed. RESULTS Sex, dry eye, Saxon test, Schirmers test, anti-SSA/Ro antibody, MSGB grading and sialography statistically contributed to the diagnosis. Multiple logistic regression analysis showed that positive MSGB [odds ratio (OR) 105; 95% CI 13, 849), positive anti-SSA/Ro antibody (OR 96; 95% CI 10, 923), a positive Saxon test (OR 46; 95% CI, 6, 340) and the existence of dry eye (OR 8, 95% CI 2, 43) were associated with the diagnosis of primary SS. Among the components of the AECG criteria, MSGB and anti-SSA/Ro antibody were very strong contributors. Furthermore, the abnormal-finding positive rate in sialography significantly correlated with MSGB grading (P-value for trend = 0.0006), although other subjective and objective components were not associated with MSGB grading. CONCLUSION The usefulness of the AECG criteria for Japanese primary SS patients was confirmed.

Parotid irrigation and cevimeline gargle for treatment of xerostomia in Sjögren's syndrome.

To the Editor: Xerostomia may be associated with a wide range of diseases including autoimmune diseases such as Sjögren’s syndrome (SS)1. Cholinergic agents such as pilocarpine and cevimeline have been recently applied to relieve xerostomia in patients with SS. However, adverse effects such as abdominal pain, nausea, diarrhea, and ocular symptoms were major shortcomings in the use of the drugs2,3. Corticosteroid irrigation of the affected salivary glands has been successfully applied to patients with SS4. Further, a preliminary study showed that cevimeline gargle was effective in treating some patients with severe SS who were refractory to treatment with corticosteroid irrigation5...