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It develops a wide spectrum of clinical manifestations and has a specific autoantibody (Ab) profile. Antinuclear antibodies are the most commonly detected Ab, with anti-Ro/SS-A being the most specific, and cryoglobulins and C3, C4 hypocomplementemia the main prognostic markers.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Sjögren's syndrome prevails in the clinical setting and translates into an immuno-mediated gland involvement, accompanied by fatigue, musculoskeletal pain and a systemic condition in a significant percentage of patients, occasionally complicated by lymphoma in 2–5% of patients.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In addition to the observed sex differences compared to several European cohorts, the key histological pattern is the focal infiltration of the exocrine glands by lymphocytes, observed in the minor salivary gland biopsy (MSGB).<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> Despite the fact that there are different recommendations on the use of topical, immunosuppressant and biological therapies for the treatment of SjS, the reality is that, today, the effective therapy available is, at the very least, insufficient.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The diagnosis of the disease is not easy, different classification criteria have been proposed. From the first ones by Fox et al.,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> to the widely accepted American-European Consensus Group (AECG) by Vitali et al. of 2002,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> with new proposals in 2012 and 2016.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> None have determined the diagnostic reliability of glandular disease detected by imaging techniques such as ultrasound.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Throughout the history of this disease, an objective and non-invasive technique has been sought to help confirm the diagnosis in a specific way. In 1992, Vitali et al. began to study the application of high-resolution ultrasound on the parotid and submandibular glands, with the aim of implementing this technique in clinical practice for the diagnosis of SjS. The authors established a glandular lesion ultrasound severity <span class="elsevierStyleItalic">score</span> with mixed results, summarized in a recent review.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Other more current studies have compared glandular lesion ultrasound detection with magnetic resonance imaging and sialography.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,12</span></a> One of the limitations of these studies is the absence of technique standardization, which is why Jousse-Joulin et al. propose a consensus on how to standardize the evaluation of key ultrasound salivary gland findings and their reliability, which includes: echogenicity, homogeneity, hyperechogenic bands, number of hypoechogenic areas, location of these areas in the gland, number of abnormal lymphoid nodules in the gland, calcifications, visible posterior margin; all bilaterally, in the parotid and submandibular glands. Based on these ultrasound findings, the experts confirmed the diagnostic suspicion, ruled out SjS, or assessed it as undetermined. The final conclusion of this international group was that, after evaluating the reliability of the images, the typical glandular pattern of SjS patients with lack of glandular homogeneity with hypoechogenic/anechoic areas in its parenchyma observed on ultrasound images, could be used concomitantly by experts in salivary gland ultrasound along with the other classification criteria in the diagnosis of SjS to reach greater final diagnostic certainty.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">However, the ultrasound indices described so far show disparate results due to: a) heterogeneity of the studied patients, b) differences in the ultrasound equipment used, c) different indices used and d) being ultrasonographer-dependent. Cornec et al.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> evaluated the role of glandular ultrasound in the diagnosis of SjS, concluding that its addition to the classification criteria of the American College of Rheumatology (ACR) and CETA in clinical practice would increase sensitivity and reduce the number of MSGB, suggesting the performance of MSGB only in those patients with an ultrasound (US) not suggestive of SjS.</p><p id="par0025" class="elsevierStylePara elsevierViewall">It is from this growing interest in the incorporation of ultrasound as a patient bedside tool that the introduction of new ultrasound methods in diagnosis has been considered, including elastography.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Elastography is a non-invasive ultrasound method that allows the “in vivo” measurement of the elasticity and stiffness of the parenchyma after subjecting it to deforming forces. It provides a quantitative/qualitative measurement and a dynamic visualization of tissue stiffness in a wide variety of clinical structures, especially in soft tissue examinations: breast, thyroid, muscle and salivary gland. The different elastography modalities are based on the fact that different pathological processes may be inflammatory, fibrotic or tumoral, and can cause changes in tissue elasticity. On the basis of this hypothesis, when a force is applied to a tissue, the soft tissues will be deformed more than the hard tissues. The quantitative transient elastography (TE) FibroScan™, which uses an external controlled mechanical vibration to generate waves, is specifically used to study the degree of liver fibrosis. While both the Acoustic Radiation Force Impulse (ARFI) imaging, as well as the different shear wave elastography (SWE) techniques, which increases when the stiffness of the evaluated tissue increases, use acoustic radiation force(ARF). ARFI imaging only provides qualitative information, analysing tissue displacement after applying ARF. Elastography is a reproducible tool, it measures differences in parenchymal stiffness and offers high precision in measurements integrated into a colour spectrum (elastography <span class="elsevierStyleItalic">score</span>). At the same time pressure ratios are obtained in numerical values thanks to a specific <span class="elsevierStyleItalic">software</span>.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15,16</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The applicability of elastography in the study of liver, muscle or breast tissue has been progressively extended, but there are currently very few studies that have sought to highlight the role that the diagnosis of SjS glandular involvement may have. Kimura-Hayama et al. evaluated the submandibular and parotid glandular stiffness of 26 patients using elastography, and attempted to correlate the ultrasound findings with the symptoms, unstimulated whole saliva flow and serological study of C3 and C4 levels, anti-Ro/La antibodies, the presence of different cytokines and the presence of fibrosis in the minor salivary gland. Their results demonstrated a correlation between SWV (Shear Wave Velocity), ultrasound B mode, and glandular and systemic involvement in patients with SjS. Furthermore, interferon-gamma-induced protein 10 (CXCL10), an inflammatory cytokine, was associated with a higher degree of chronic inflammation, rather than with the existence of fibrotic changes.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Using a similar specific <span class="elsevierStyleItalic">software</span>, ARFI (virtual quantification <span class="elsevierStyleItalic">software</span>) both Samier-Guérin et al., in 10 patients, as well as Turnaoglu et al. in 25 patients, observed that abnormal structural findings assessed by a series of impulses in an area of interest suggests an increasing role of elastography in SjS.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18–20</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In our experience, in the context of the diagnostic study of systemic autoimmune diseases, and specifically SjS, an ultrasound study in patients with and without parotid enlargement is useful for obtaining clinical information on the stage of their disease and the possible asymptomatic involvement of the parotid and submandibular glands. The grayscale (GS) and colour (CD) or Power Doppler (PD) ultrasound study offers detailed information on the structural lesion of the gland according to the most widely accepted <span class="elsevierStyleItalic">score</span>.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> Likewise, our growing interest and the novel applicability of elastography in other areas and specialties, makes us believe that GS/CD/PD ultrasound will be, in a short period of time, an essential tool in the diagnosis and monitoring of patients with SjS. We think that, in the medium term, it will probably be included as a recommended tool to reduce, if viable, MSGB, as it has happened in other immune-mediated diseases, such as the case of ultrasound of the temporal artery for the diagnosis of giant cell arteritis.</p><p id="par0045" class="elsevierStylePara elsevierViewall">From this point on, we currently do not know the role that minor salivary gland elastography will play, although being an inexpensive, non-invasive, accessible, fast and useful diagnostic tool for both diagnosis and monitoring, the recent data, even though limited, should support its clinical use. If parotid gland involvement is a characteristic feature of SjS, we suspect that elastography together with conventional GS/CD/PD ultrasound could be essential in diagnostic sensitivity improvement, enhanced glandular structure definition, description of the inflammatory versus fibrotic pattern and in the improvement of monitoring while reducing the number of MSGB.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Corominas H, de Agustín J. Ecografía y elastografia en el diagnóstico de síndrome de Sjögren. 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Journal Information
Vol. 155. Issue 6.
Pages 254-255 (September 2020)
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Vol. 155. Issue 6.
Pages 254-255 (September 2020)
Editorial article
Ultrasound and elastography in Sjögren's syndrome
Ecografía y elastografia en el diagnóstico de síndrome de Sjögren
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