contribute to variability across pathologic evaluations of the same specimen, including non-homogenous distribution of the inflammatory infiltrates and the small size of some biopsy specimens. Small specimens (less than 5 glands) or those in which the glands remain embedded in a connective tissue block may lead to unreliable focus score values [32]. For instance, in a study that reevaluated lip biopsy specimens several years after the first assessment, the grading system had been applied incorrectly during the initial interpretation in 45% of specimens. This resulted in misdiagnoses in 10% of the cases and non-diagnoses in 34% [46]. Other studies have demonstrated that the grade of infiltration varied within the same biopsy depending on the depth of tissue examined. The lack of reproducibility and standardization with regard to the interpretation of labial salivary gland biopsies has hampered progress in SS [47].

A variety of strategies have been proposed to improve the reliability of salivary gland biopsies. Multiple tissue levels should be evaluated in order to maximize the number of foci, the glandular area, and the technical quality of the material. One expert group suggested that within a single 4 mm2 biopsy, a minimum of three tissue levels separated by a minimum of 200 nm should be evaluated, thereby insuring the detection of independent foci on each section [48]. Another group suggested that the histopathological evaluation should be performed with multilevel sectioning as well as with the assessment of a cumulative focus score (cFS). Thus, for each patient, the total number of foci at all three levels and the total surface area measured at all levels are used to calculate this cFS. This approach in a study of 120 SS patients altered the baseline classification in 6% of the patients and increased the specificity of the AECG criteria from 84.5% to 94.4% [49].

Cigarette smoking has been linked with a reduced glandular focus score in lower lip biopsies of patients primary SS [50]. It has also been proposed that cigarette smoking reduces the production of anti-Ro and anti-La antibodies by lowering the accumulation of lymphocytes within salivary glands [50].

Finally, it must be remembered that focal sialadenitis can occur in conditions other than SS. Focal or diffuse inflammatory infiltration has been reported in cases of sialolithiasis cases [51], other connective tissue diseases, in the elderly, in chronic hepatitis C virus infections, and in sarcoidosis. Moreover, focus score >1 has been found in 15% of healthy asymptomatic volunteers without correlation with age, smoking, serologic findings, or salivary flow [52]. This type of infiltrate has also been reported in postmortem series of submandibular glands from subjects who had no clinical evidence of SS during life [53].

27.7 Is There an Alternative to Labial Salivary Gland Biopsy?

Some studies have sought to identify adequate surrogates of minor salivary gland biopsy in order to spare patients this invasive procedure. Subjects with both sicca symptoms and positive serology (elevated anti-SSA or anti-SSB) have been reported more likely to have strongly positive lip biopsies [54, 55]. Similarly, more widespread glandular inflammatory changes have been observed in the presence of multiple systemic extraglandular manifestations and disease-specific autoantibodies

[56, 57]. Two studies of patients with sicca symptoms reported that high serum levels of IgG were associated with biopsy results [58, 59]. Although the specificity and positive predictive values of elevated serum IgG were both 97%, the sensitivity was only 40%. Conversely, another study found that neither the symptoms nor the serology could predict the result of the biopsy [46].

In conclusion, biopsy of the minor salivary gland is valuable in the diagnosis of SS. However, the diagnosis requires additional findings, such as abnormal immunologic essays, the presence of keratoconjunctivitis sicca, and demonstration of salivary gland hypofunction. For some authors, patients who have typical presentations of SS, including positive assays for anti-Ro or –La antibodies, do not derive additional benefit from a lip biopsy. In contrast, labial salivary gland biopsy may contribute importantly to the evaluation of patients with equivocal symptoms and/or negative serological testing [54].

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Chapter 28

Immunological Tests in Primary Sjögren

Syndrome

Soledad Retamozo, Pilar Brito-Zerón, Myriam Gandía, Lucio Pallarés, and Manuel Ramos-Casals

S. Retamozo • P. Brito-Zerón • M. Ramos-Casals (*)

Spanish Group of Autoimmune Diseases (GEAS), Spanish Society of Internal Medicine (SEMI), Sjögren Syndrome Research Group (AGAUR), Laboratory of Autoimmune Diseases Josep Font, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS),

Department of Autoimmune Diseases, ICMD Hospital Clínic, Barcelona, Spain

M. Gandía

Sjögren Syndrome Research Group (AGAUR), Laboratory of Autoimmune Diseases Josep Font, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Department of Autoimmune Diseases, ICMD Hospital Clínic, Barcelona, Spain

Rheumatology Department, Hospital Puerta del Mar, Cadiz, Spain

L. Pallarés

Autoimmune Diseases Unit, Hospital Son Espases, Palma de Mallorca, Spain