Key issues in salivary gland pathology...2016/04/11 · 1. Careful radiation treatment planning (mean dose ) 2. Salivary gland transfer 3. Amifostine (radical scavenger) 4. Pilocarpine

Arjan Vissink

Key issues in salivary

gland pathology

Saliva has many functions and although

not essential for the maintenance of life it

contributes to the efficient working and

protection of the human body

Neil Jenkins, 1978

complaints

reduced

quality of life oral pathology

diagnostics lymphoma personalized

medicine

A

B F

E

D

C

FcRL4

Topics

• Hyposalivation versus xerostomia

• Why is water not effective?

• Main causes of xerostomia:

– Drugs, radiotherapy, Sjögren’s syndrome

syndrome

• Recent progress:

– saliva diagnostics

– ultrasonography

– which biopsy?

– MALT lymphoma

Hyposalivation versus xerostomia

• People may complain of dry mouth and

have an abnormal low (<0.1 ml/min)

unstimulated whole saliva flow rate

• People can complain of oral dryness yet

have a normal whole saliva flow rate

• People may have an abnormal low flow

rate of whole saliva and not complain of

oral dryness

Hyposalivation versus xerostomia

• Discrepancy is present in 20-30% of the

subjects

• Hyposalivation = reduced flow

• Xerostomia = sensation of oral dryness

• Xerostomia ≠ hyposalivation

Vissink et al., J Dent Res 1986;65:1121-4

Why is water not effective?

better

worse

Vissink et al., J Dent Res 1986;65:1121-4

water

whole saliva

mucin solutions

Drug-related xerostomia

Don’t forget self care medications

Are side effects a problem?

Sreebny and Vissink. Dry Mouth: the malevolent symptom. Wiley-Blackwell, 2010

Sreebny and Vissink. Dry Mouth: the malevolent symptom. Wiley-Blackwell, 2010

• Not only the amount of saliva, but also the

composition of saliva and how the dryness

signal is interpreted underlie the sensation of

oral dryness

Drugs

Atkinson et al, Gerodontology 1989;8:23-26

0

0,05

0,1

0,15

0,2

0,25

0,3

ml/min

0 1 2 3 4

hour

Unstimulated parotid + SMSL flow

furosemide

placebo

• The lowest secretion rates are seen in

patients using most drugs

• But even in these patients salivary

secretion can usually be stimulated to a

sufficient level

Närhi, J Dent Res 1994;73:20-25

Drugs

0

0,2

0,4

0,6

0,8

1

1,2

1,4

1,6

1,8

0 0 1-3 4-6 >7

ml/min

number of drugs

Secretion of whole saliva

unstimulated

stimulated

• Over 1000 drugs are linked to a sensation of oral dryness

• But often there is no proof that drugs indeed reduce salivary flow

Drugs

Aliko et al., Oral Surg Oral Med Oral Pathol Oral Radiol 2015;120:185-206

Villa et al., Clin Oral Investig 2015;19:1563-80

Villa et al., Oral Dis 2015 Nov 25. doi: 10.1111/odi.12402 [Epub ahead of print]

Head and neck radiotherapy

http://www.toptenz.net/wp-content/uploads/2012/09/radiotherapy-cancer.jpg

Salivary glands are radiosensitive

1. Can radiation injury of salivary gland tissue

be prevented?

2. Can radiation damage of salivary gland

tissue be restored?

Key questions

Vissink et al, Int J Radiat Oncol Biol Phys 2010;78:983-91

Vissink et al, Oral Dis 2015;21:e1-11

Grégoire et al., J Clin Oncol 2015;33:3277-84

Jensen et al, J Natl Cancer Inst (in press)


1. Careful radiation treatment planning (mean dose )

2. Salivary gland transfer

3. Amifostine (radical scavenger)

4. Pilocarpine (enhancement of proliferation)

Valdez et al, Int J Radiat Oncol Biol Phys 1993;25:41-7

Burlage et al, Radiother Oncol 2001;61:271-74


time (weeks)

sa

livary

flo

w (

% fro

m b

ase

line)

parotid gland

submandibular gland

Prevention of salivary gland damage


Kam et al, J Clin Oncol 2007;25:4873-9

Semenenko et al, Phys Med Biol 2008;;53:737-55


Gupta et al, Radiother Oncol 2012;104:343-8


Grégoire et al, J Clin Oncol 2015;33:3277-84

Minimize exposure of the salivary glands to radiation:

- shielding and conformational field planning

- intensity modulated radiation therapy (IMRT)


A: 3D-Conformatie Radiotherapie B: Standaard IMRTC: Bestralingsbundel met

verschillende intensiteit3D conformal radiotherapy Standard IMRT


Kam et al, J Clin Oncol 2007;25:4873-9

Semenenko et al, Phys Med Biol 2008;;53:737-55


Gupta et al, Radiother Oncol 2012;104:343-8


Grégoire et al, J Clin Oncol 2015;33:3277-84




IMRT spares salivary glands

May new radiation techniques result in

less xerostomia?

• IMRT has resulted in some reduction of xerostomia

and its related complaints

• Will further demarcating the radiation portals result

in less damage to salivary gland tissue?

Konings et al, Int J Radiat Oncol Biol Phys 2005;62:1090-5



• Is parotid gland stem cell sparing radiotherapy a

reasonable thought?

Pringle et al, Stem Cells 2013;31:613-9


less xerostomia?

• parotid gland stem cell sparing radiotherapy for head

and neck cancer


less xerostomia?

van Luijk et al., Sci Transl Med 2015;7:305ra147

• parotid gland stem cell sparing radiotherapy for head

and neck cancer

van Luijk et al., Sci Transl Med 2015;7:305ra147


less xerostomia?

• IMRT has resulted in some reduction of xerostomia

and its related complaints

• Will further demarcating of the radiation portals

result in less damage to salivary gland tissue?

• Might proton radiotherapy be a solution?


less xerostomia?




Diepte in centimeters

Dosis

DO

SIS

Fotonen

Protonen Bragg-peak

"Spread Out" Bragg peak

Target

Photons

Bragg peak

Spread-out Bragg peak

Advantage protons

Advantage protons

Depth in centimetres

Do

se

Van de Water et al. Work in progress

Courtesy Hans Langendijk


less xerostomia?

IMPT

66.5 Gy

51.3 Gy

40.0 Gy

20.0 Gy

10.0 Gy

Isodose

lines:

Van de Water et al, Int J Radiat Oncol Biol Phys 2011;79:1216-24

IMRT


less xerostomia?

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 10 20 30 40 50 60 70

Gemiddelde dosis oorspeekselklieren (Gy)

Kan

s o

p d

rog

e m

on

d

Model

3D-CRT

IMRT

IMPT

Mean dose parotid glands (Gy)

Pa

tients

with

xe

rosto

mia

(%

)

Van de Water et al, Int J Radiat Oncol Biol Phys 2011;79:1216-24


less xerostomia?

• Can radiation injury of salivary gland tissue

be prevented?

• Can radiation damage of salivary gland

tissue be restored?

Key questions



Grégoire et al., J Clin Oncol 2015;33:3277-84

Jensen et al, J Natl Cancer Inst (in press)


• Few acinar cells survive radiation

• Thus, little to no primary fluid secretion will occur

• Ductal compartment, although water impermeable,

is better preserved than acinar compartment

• Introduction of a water channel (aquaporine) in

ductal cells

• Transfection with hAQP1 gene

AdhAQP1(encodes water channel protein)

Baum and O’Connell 1995

Delporte et al , Proc Natl Acad Sci USA 1997;94:3268-73

Shan et al, Mol Ther 2005;11:444-51

Is gene therapy the answer?

Baum et al, Proc Natl Acad Sci U S A 2012;109:19403-7

Baum, Oral Dis 2014;20:115-8

Baum, Oral Dis 2016;22:81-4


• Single, escalating doses of AdhAQP1 (safety)

• Assessments:

• Effectiveness of AdhAQP1 to increase parotid gland salivary

output

• Improvement of symptoms associated with irradiation-induced

parotid hypofunction

First trial in human Effect of AdhAQP1 on salivary flow in patients treated with

radiation for head and neck cancer (NCT00372320)



Baum, Oral Dis 2014;20:115-8


First results are promising


Baum, Oral Dis 2014;20:115-8


• Salivary glands can undergo renewal if enough

stem cells survive

• If too few stem cells survive, transplantation of

undamaged (donor)stem cells could enable the

gland to regenerate

• Ductal cells remain relatively intact and could

serve as a natural engraftment place for

transplanted cells

Lombaert et al, Clin Cancer Res 2006;12:1804-12

Lombaert et al, Stem Cells 2008;26:2595-601

Lombaert et al, Plos ONE 2008 Apr 30;3(4):e2063

Lombaert et al, Oral Dis 2011;17:445-9

Is stem cell therapy a reasonable

approach?

Feng et al, Radiother Oncol 2009;92:466-71

Coppes and Stokman, Oral Dis 2011;17:143-53

Pringle et al, J Vis Exp 2011;(48). pii: 2484

Nanduri et al, Radiother Oncol 2011;99:367-72




approach?

How to obtain stem cells


approach?

Single cell derived spheres form salivary gland like organoids

Feng et al, Radiother Oncol 2009;92:466-71

Coppes and Stokman, Oral Dis 2011;17:143-53

Pringle et al, J Vis Exp 2011;(48). pii: 2484




Pringle et al., Stem Cells 2016 Feb 16. doi: 10.1002/stem.2278. [Epub ahead of print]


approach?

Stem cell therapy results in partial return of secretion

Awaiting proof in human!!


approach?

Key Research Questions

Where are we?

1. Can radiation injury of salivary gland

tissue be prevented?

Yes, to a certain extent

2. Can radiation damage of salivary gland

tissue be restored?

Probably, animal and first results

in human are promising

Sjögren’s syndrome • Chronic, progressive, inflammatory and

lymphoproliferative disease

• Mononuclear cell infiltration of exocrine

glands

• Dry eyes, dry mouth, fatigue

• Female/male ratio of 9:1

• Prevalence 0.1-1.0%

Sjögren’s syndrome • Local & systemic B-cell hyperactivity

(hyper IgG, rheumatoid factor, anti-

SSA/SSB)

• Presence of CD4+ and CD8+

activated T-cells

• ≈ 7.5% of patients develop B-cell

lymphoma (frequently MALT-

lymphoma in major salivary glands)

Non Hodgkin lymphoma

Pollard et al., J Rheumatol 2011;38:2198-2208

Many other systems can be involved too

Pijpe et al., Ann Rheum Dis 2007;66:107-12

Atkinson et al., J Rheumatol 1990;17:318-22

Salivary gland function in Sjögrens’syndrome

Progression (duration of symptoms)

0

0,05

0,1

0,15

0,2

0,25

0,3

0,35

0,4

0,45

0,5

mL

/min

UWS U-SM/SL S-SM/SL S-Parotid

Healthy

<1 year

1-4 years

>4 years

AECG (<0.1 ml/min)

• early stage: reduction of the secretion of

the (sero)mucous glands

• advanced stage: reduction of parotid

glands (Par)

• early stage: nocturnal oral dryness (SM)

• advanced stage: dryness throughout the

day (SM + Par)

Sjögren’s syndrome

Pijpe et al., Ann Rheum Dis 2007;66:107-12

Topics

• Hyposalivation versus xerostomia

• Why is water not effective?

• Main causes of xerostomia:

– Drugs, radiotherapy, Sjögren’s syndrome

syndrome

• Recent progress (Sjögren’s):

– saliva diagnostics

– ultrasonography

– which biopsy?

– MALT lymphoma

Courtesy David Wong

Proteonomics primary Sjögren’s syndrome

• ‘Down-regulated’ proteins:

dermcidin, cystatin C, carbonic anhydrase VI (three isoforms),

calgranulin A, prolactin inducible protein and Von Ebner’s gland

protein

• ‘Up-regulated’ proteins:

alpha-enolase, fructose bisphosphate aldolase A, caspase 14, S100

calcium binding protein A, fatty acid-binding protein, imunoglobulins,

and beta-2-microglobulin

Hu et al., Arthritis Rheum 2007;56:3588-600

Hu et al., Arthritis Care Res (Hoboken) 2010;62:1633-8

Sjögren’s syndrome patients can be

distinguished from controls and SLE patients

Delaleu et al., Arthritis Rheumatol 2015;67:1084-95

Salivary Biomarkers for Sjögren’s Syndrome Detection –

A Multi-Center Study

(420 patients)

NIDCR Award 2 U01 DE017593

David Wong, Kathy Sivils, Arjan Vissink

Parotid gland ultrasonography

Sjögren’s syndrome healthy

sialogram

ultrasound

Parotid gland ultrasonography

• Indirectly validated (labial salivary glands)

• In need of (further) validation against

other salivary gland diseases (currently

mainly disease controls)

• In need of validation against parotid gland

function and parotid gland histopathology

Bootsma et al., Arthritis Rheum 2013;65:21-3

Delli et al., Oral Dis 2015;21:792-800

Jousse-Joulin et al., Rheumatology (Oxford) 2015 Dec 14 [Epub ahead of print]

Mossel, Delli, van Nimwegen (in progress)

Histopathology

Mostly taken from minor salivary glands (labial)

Alternatives: - parotid gland

- lacrimal gland

- submandibular gland Invasive procedure of 10 min.

Important for:

- diagnostic reasons

- prognostic reasons

- evaluation of new treatment options

- pathogenesis of the disease

Salivary glands

Lacrimal gland

Fox et al., Ann Rheum Dis 2011;70:1351-3

Theander et al., Ann Rheum Dis 2011;7-:1363-8

Bootsma et al., Arthritis Rheum 2013;65:21-3

Delli et al., Oral Maxillofac Surg Clin North Am 2014;26:23-33

Labial biopsy


Shiboski et al., Arthritis Care Res 2012;64:475-87 (ACR)

Pijpe et al., Rheumatology 2007;46:335-41 (labial versus parotid)

Vitali et al., Ann Rheum Dis 2002;61:554-8 (AECG)

Parotid biopsy


Pijpe et al., Rheumatology 2007;46:335-41

Vitali et al., Ann Rheum Dis 2002;61:554-8

Parotid versus labial biopsy

Parotid gland Labial gland

Courtesy Erlin Haacke

Delli et al., Ann Rheum Dis 2016 Jan 12 [Epub ahead of print]

Baseline number of CD20+B-cells/mm2 is

prognostic biomarker for efficacy of rituximab

Lymphoma

• ≈ 7.5% of patients develop B-cell lymphoma

• Mostly a mucosa associated lymphoid

tissue (MALT) lymphoma in major salivary

glands

Courtesy Erlin Haacke

pSS focus MALT lymphoma

MALT lymphoma

• MALT lymphomas express Fc receptor-

like 4 (FcRL4/IRTA1/CD307d)

• Normally FcRL4 is expressed on a very

small subset of mucosa-associated B-

cells

• FcRL4+B-cells might be closely related to

MALT lymphoma cells

Falini et al., Histopathology 2012;61:930-41

MALT lymphoma

• Are FcRL4+B-cells present in inflamed

parotid gland tissue?

A

B F

E

D

C

MALT lymphoma Parotid gland Labial gland

FcRL4

H&E

Haacke et al., Scand J Immunol 2015;81: 380-381

MALT lymphoma

• FcRL4+B-cells are enriched in parotid

glands compared to the labial glands

• FcRL4+B-cells are likely the cells from

which MALT lymphomas arise

Haacke et al., Scand J Immunol 2015;81:380-381

complaints

reduced

quality of life oral pathology

diagnostics lymphoma personalized

medicine

A

B F

E

D

C

FcRL4

NIH sponsored trial

Documents

Key issues in salivary gland pathology...2016/04/11 · 1. Careful radiation treatment planning (mean dose ) 2. Salivary gland transfer 3. Amifostine (radical scavenger) 4. Pilocarpine