Establishment of Sialoscintigraphy Reference Values in Obstructive Sialadenitis

1. Establishment and Utilization ofSialoscintigraphy Reference ValuesUsing Patients withObstructive Sialadenitis Chen, Yen-Chun, MD, TMUH Hung, Shih-Han, MD PhD, TMUH 2018.11.04

2. Salivary excretory portion • Restingsaliva: • Subm gland:65% • Parotid: only 20% • Sublingualgland: 7-8% • Stimulatedsaliva: • Parotid:50% • Remaining50%:othersalivaryglandsandgingivalcrevicularfluid Reference: Dawes C. Editors Edgar, WM and O’Mullane, DM. 2nd edition. British Dental Association, London, 1996.

3. Diseases of salivary glands & Evaluation • Anatomical evaluation • Sialography • Sonography • CT/MRI • Functional evaluation • Questionnaire • Sialometry • Sialoscintigraphy • Biopsy • Non-neoplastic • Functional disorders • Obstructive disorders • Infectious disorders • Neoplastic

4. Salivary scintigraphy 0 min 20th min 35th min TMUHprotocol Complete 7 mCi 99mTc-O4(pertechnetate), IV Secretion stimulation:20ml 100% concentratedlemon juice PO Counts/sec Time (min) ROI: region of interest Time-activity curve

5. Former interpretation History: 42 y/o male, right parotid swelling during foot intake for 5 years Impression: Excretory dysfunction of right parotid gland is noted. Counts/sec Time (min)

7. Features of sialoscintigraphy • Non-invasive • Functional evaluation • But lack of reference values • Healthy volunteers • Previous studies: low subject number • Adverse reaction • Thyroid scan • Different protocol • Female predominance

8. Objectives • To evaluate the feasibility of establishing clinically applicable reference values for sialoscintigraphic data in unaffected glands in patients who present with uniglandular obstructive sialadenitis. • Values further validated from patients with confirmed Sjogren’s syndrome.

9. Subjects acquisition

10. b TA3 TA1 c a TA4 TA2 TA6 TA5 Time (min) Quantitativeanalysis Counts/sec Tmax Tmin

11. Statistical analysis • Mean ± standard deviation (SD) • Unpaired t-tests • Mann-Whitney U test: non-parametric comparisons • ROC curves and AUC analysis • P value of < 0.05 as statistically significant • SAS 9.4 (SAS Institute Inc., Cary, North Carolina, USA)

12. Establishment of reference scintigraphic values 93 patients with uniglandular obstructive sialadenitis, average 45.9 y/o, ♀: ♂= 1.38: 1 a The Mann-Whitney U test was used to calculate the P-value.

13. ROCcurvesandvaluesofAUCfor diagnostic accuracy of obstructive sialadenitis ParotidME,AUC=0.61 Submandibular UR,AUC=0.68 Submandibular MA,AUC=0.58 Submandibular ME,AUC=0.82

14. Validationofreferencevalueswith confirmed Sjogren’ssyndrome 53 patients fulfilled criteria of Sjogren’s syndrome, average 54.2 y/o, ♀: ♂= 50: 3 a The Mann-Whitney U test was used to calculate the P-value.

15. ROCcurvesandvaluesofAUCfor diagnostic accuracy of Sjogren’s syndrome ParotidME,AUC=0.62 ParotidTmin,AUC=0.66 Submandibular UR,AUC=0.77 Submandibular MA,AUC=0.61

16. ROCcurvesandvaluesofAUCfor diagnostic accuracy of Sjogren’s syndrome Submandibular ME,AUC=0.81 Submandibular Tmax,AUC=0.61 Submandibular Tmin,AUC=0.62

17. Discussion • Potential as reference values • from the unaffected glands of patients with uniglandular obstructive sialadenitis • Li et al. (2007): in patients of HN cancer receiving irradiation which affects one side of the parotid gland, there is no evidence of overcompensation on the opposite side of the parotid gland Li Y., et al. Int J Radiat Oncol Biol Phys, 2007

18. Limitations of the study • The reference values of the unaffected glands might not be considered the true normal values. • Provide an applicable clinical methodology, with further validation with patients of Sjogren’s syndrome. • No parameter is perfect. • Institutions need to select their own cut-off values.

19. Conclusion • Scintigraphic data from the unaffected glands of patients with uniglandular obstructive sialadenitis • Could potentially be used as reference values in the evaluation of salivary gland diseases • ME (maximal excretion): maybe a good indicator • Distinguishing normal glands from glands with obstructive diseases or Sjogren’s syndrome • For both the parotid and submandibular glands

20. Thank You For Your Attention