Abstract
Sjögren’s syndrome is well known to target exocrine glands, especially lacrimal and salivary glands, which share with mammary glands anatomical, histological, and immunological features. Herein, we investigated the mammary involvement in patients with Sjögren’s syndrome and compared the histological findings with minor salivary gland involvement. We reviewed the charts of patients with Sjögren’s syndrome (followed in Montpellier University Hospital, between January 2000 and January 2015), in whom minor salivary gland and mammary tissues were available. Two expert pathologists analysed retrospectively these tissues in order to identify inflammatory patterns. Immunohistochemical stainings were performed to precise leucocyte distribution. Sixteen Sjögren’s syndrome patients with available salivary and breast tissue samples were included. All were women, with a median age of 60.1 ± 11.3 years at Sjögren’s syndrome diagnosis. Mammary biopsy was conducted because of breast symptoms in 6 patients and following imaging screening strategies for breast cancer in 10 patients. Nine patients exhibited an inflammatory breast pattern (lymphocytic infiltrates or duct ectasia), close to minor salivary gland histological findings. Immunohistochemical stainings (n = 5) revealed B and T cell infiltrates within breast tissue, with a higher proportion of T CD4+ cells, but no IgG4-secreting plasma cells were found. This is the first series to describe breast inflammatory patterns in Sjögren’s syndrome. Mastitis is in line with the classical involvement of exocrine glands in this disease. These findings are consistent with the literature data considering Sjögren’s syndrome as an “autoimmune epithelitis”.
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References
Burbelo PD, Ambatipudi K, Alevizos I. Genome-wide association studies in Sjögren’s syndrome: What do the genes tell us about disease pathogenesis? Autoimmun Rev. 2014;13:756–61. doi:10.1016/j.autrev.2014.02.002.
Kivity S, Arango MT, Ehrenfeld M, Tehori O, Shoenfeld Y, Anaya J-M, et al. Infection and autoimmunity in Sjogren’s syndrome: a clinical study and comprehensive review. J Autoimmun. 2014;51:17–22. doi:10.1016/j.jaut.2014.02.008.
Boisserie P, Poupard A, Guntz M, Lafargue JP, Boyer J, Joubaud F. Primary biliary cirrhosis, chronic pancreatitis and Gougerot-Sjögren syndrome (apropos of a case). Gastroentérol Clin Biol. 1983;7:641–2.
Barreda F, Contardo C, León A, Navarrete J, Figueroa R, Attanasio F. Primary sclerosing cholangitis associated with Sjögren’s syndrome, retroperitoneal fibrosis and chronic pancreatitis. Report of a case. Rev Gastroenterol Perú Órgano Soc Gastroenterol Perú. 1989;9:106–14.
Moutsopoulos HM. Sjögren’s syndrome: autoimmune epithelitis. Clin Immunol Immunopathol. 1994;72:162–5.
Mitsias DI, Kapsogeorgou EK, Moutsopoulos HM. The role of epithelial cells in the initiation and perpetuation of autoimmune lesions: lessons from Sjogren’s syndrome (autoimmune epithelitis). Lupus. 2006;15:255–61.
Tzioufas AG, Kapsogeorgou EK, Moutsopoulos HM. Pathogenesis of Sjögren’s syndrome: what we know and what we should learn. J Autoimmun. 2012;39:4–8. doi:10.1016/j.jaut.2012.01.002.
Vitali C, Bombardieri S, Jonsson R, Moutsopoulos HM, Alexander EL, Carsons SE, et al. Classification criteria for Sjögren’s syndrome: a revised version of the European criteria proposed by the American-European Consensus Group. Ann Rheum Dis. 2002;61:554–8.
Shiboski SC, Shiboski CH, Criswell LA, Baer AN, Challacombe S, Lanfranchi H, et al. American College of Rheumatology classification criteria for Sjögren’s syndrome: a data-driven, expert consensus approach in the Sjögren’s International Collaborative Clinical Alliance cohort. Arthritis Care Res. 2012;64:475–87.
Lwin KY, Zuccarini O, Sloane JP, Beverley PC. An immunohistological study of leukocyte localization in benign and malignant breast tissue. Int J Cancer J Int Cancer. 1985;36:433–8.
Degnim AC, Brahmbhatt RD, Radisky DC, Hoskin TL, Stallings-Mann M, Laudenschlager M, et al. Immune cell quantitation in normal breast tissue lobules with and without lobulitis. Breast Cancer Res Treat. 2014;144:539–49. doi:10.1007/s10549-014-2896-8.
Adamson TC, Fox RI, Frisman DM, Howell FV. Immunohistologic analysis of lymphoid infiltrates in primary Sjogren’s syndrome using monoclonal antibodies. J Immunol Baltim Md. 1950;1983(130):203–8.
Huguet P, Bosch JA, Raventós A, Jacas C, Sanjosé A, Vilardell M. Sjögren’s syndrome: histologic and immunohistochemical study. Ann Méd Interne. 1995;146:233–4.
Garnier A. Analyse morphologique des critères diagnostiques du syndrome de Goujerot-Sjögren sur les biopsies de glandes salivaires accessoires: a propos de 90 cas. Faculté de Médecine de Limoges. (1996).
Szabo K, Papp G, Dezso B, Zeher M. The histopathology of labial salivary glands in primary Sjögren’s syndrome: focusing on follicular helper T cells in the inflammatory infiltrates. Mediators Inflamm. 2014;. doi:10.1155/2014/631787.
Development Petherick A. Mother’s milk: a rich opportunity. Nature. 2010;468:S5–7. doi:10.1038/468S5a.
Collado MC, Laitinen K, Salminen S, Isolauri E. Maternal weight and excessive weight gain during pregnancy modify the immunomodulatory potential of breast milk. Pediatr Res. 2012;72:77–85. doi:10.1038/pr.2012.42.
Aitken SL, Corl CM, Sordillo LM. Immunopathology of mastitis: insights into disease recognition and resolution. J Mammary Gland Biol Neoplasia. 2011;16:291–304. doi:10.1007/s10911-011-9230-4.
Boullu S, Andrac L, Piana L, Darmon P, Dutour A, Oliver C. Diabetic mastopathy, complication of type 1 diabetes mellitus: report of two cases and a review of the literature. Diabetes Metab. 1998;24:448–54.
Kudva YC, Reynolds C, O’Brien T, Powell C, Oberg AL, Crotty TB. “Diabetic mastopathy”, or sclerosing lymphocytic lobulitis, is strongly associated with type 1 diabetes. Diabetes Care. 2002;25:121–6.
Kinonen C, Gattuso P, Reddy VB. Lupus mastitis: an uncommon complication of systemic or discoid lupus. Am J Surg Pathol. 2010;34:901–6. doi:10.1097/PAS.0b013e3181da00fb.
Rosa M, Mohammadi A. Lupus mastitis: a review. Ann Diagn Pathol. 2013;17:230–3. doi:10.1016/j.anndiagpath.2012.09.003.
Islam AD, Selmi C, Datta-Mitra A, Sonu R, Chen M, Gershwin ME, et al. The changing faces of IgG4-related disease: clinical manifestations and pathogenesis. Autoimmun Rev. 2015;14:914–22. doi:10.1016/j.autrev.2015.06.003.
Vasaitis L. IgG4-related disease: a relatively new concept for clinicians. Eur J Intern Med. 2016;27:1–9. doi:10.1016/j.ejim.2015.09.022.
Dite P, Novotny I, Trna J, Sevcikova A. Autoimmune pancreatitis. Best Pract Res Clin Gastroenterol. 2008;22:131–43. doi:10.1016/j.bpg.2007.10.014.
Cheuk W, Chan ACL, Lam W-L, Chow S-M, Crowley P, Lloydd R, et al. IgG4-related sclerosing mastitis: description of a new member of the IgG4-related sclerosing diseases. Am J Surg Pathol. 2009;33:1058–64. doi:10.1097/PAS.0b013e3181998cbe.
Ogura K, Matsumoto T, Aoki Y, Kitabatake T, Fujisawa M, Kojima K. IgG4-related tumour-forming mastitis with histological appearances of granulomatous lobular mastitis: comparison with other types of tumour-forming mastitis. Histopathology. 2010;57:39–45. doi:10.1111/j.1365-2559.2010.03581.x.
Herrera van Oostdam DA, Jaimes Piñón T, Martínez-Martínez MU, Oros-Ovalle C, Aléman-Sánchez N, Abud-Mendoza C. IgG4-related disease, retrospective histopathological diagnosis. Prevalence in an university hospital. Reumatol Clin. 2015;. doi:10.1016/j.reuma.2014.12.007.
Chougule A, Bal A, Das A, Singh G. IgG4 related sclerosing mastitis: expanding the morphological spectrum of IgG4 related diseases. Pathology (Phila). 2015;47:27–33. doi:10.1097/PAT.0000000000000187.
Stappaerts I, Colpaert C, Verbraecken J, Van Marck E, Vermeire P. Granulomatous mastitis as presenting sign of Wegener’s granulomatosis. Acta Clin Belg. 1999;54:207–10.
Ladefoged K, Balslev E, Jemec GB. Crohn’s disease presenting as a breast abscess: a case report. J Eur Acad Dermatol Venereol JEADV. 2001;15:343–5.
Barczyńska T, Dankiewicz-Fares I, Bilińska-Reszkowska H, Zalewska J, Jeka S. Atypical location of Wegener’s granulomatosis with breast involvement: case report. Ann Acad Med Stetin. 2011;57:70–6.
Zujić PV, Grebić D, Valenčić L. Chronic granulomatous inflammation of the breast as a first clinical manifestation of primary sarcoidosis. Breast Care Basel Switz. 2015;10:51–3. doi:10.1159/000370206.
Rahal RMS, de Freitas-Júnior R, Carlos da Cunha L, Moreira MAR, Rosa VDL, Conde DM. Mammary duct ectasia: an overview. Breast J. 2011;17:694–5. doi:10.1111/j.1524-4741.2011.01166.x.
Al-Masad JK. Mammary duct ectasia and periductal mastitis in males. Saudi Med J. 2001;22:1030–3.
Gregoir C, Hilliquin P, Acar F, Lessana-Leibowitch M, Renoux M, Menkès CJ. Acute mastitis in rheumatoid polyarthritis with Gougerot-Sjögren syndrome treated with tiopronin (Acadione). Rev Rhum Mal Ostéo Articul. 1991;58:203–6.
Valdez R, Thorson J, Finn WG, Schnitzer B, Kleer CG. Lymphocytic mastitis and diabetic mastopathy: a molecular, immunophenotypic, and clinicopathologic evaluation of 11 cases. Mod Pathol. 2003;16:223–8. doi:10.1097/01.MP.0000056627.21128.74.
Ríos G, Peredo RA. Lymphocytic mastitis preceding Sjögren’s syndrome. P R Health Sci J. 2010;29:127–9.
Chomette G, Auriol M, Labrousse F, Raphaël M, Szpirglas H, Vaillant JM. Immunopathology of the labial salivary glands in Sjögren’s syndrome and other autoimmune diseases. Rev Stomatol Chir Maxillofac. 1988;89:237–41.
Talal N, Asofsky R, Lightbody P. Immunoglobulin synthesis by salivary gland lymphoid cells in Sjögren’s syndrome. J Clin Invest. 1970;49:49–54. doi:10.1172/JCI106221.
Anderson LG, Cummings NA, Asofsky R, Hylton MB, Tarpley TM, Tomasi TB, et al. Salivary gland immunoglobulin and rheumatoid factor synthesis in Sjögren’s syndrome. Natural history and response to treatment. Am J Med. 1972;53:456–63.
Speight PM, Cruchley A, Williams DM. Quantification of plasma cells in labial salivary glands: increased expression of IgM in Sjögren’s syndrome. J Oral Pathol Med. 1990;19:126–30.
Matthews JB, Deacon EM, Wilson C, Potts AJ, Hamburger J. Plasma cell populations in labial salivary glands from patients with and without Sjögren’s syndrome. Histopathology. 1993;23:399–407.
van Woerkom JM, Kruize AA, Barendregt PJ, Kater L, Hené R, Bootsma H, et al. Clinical significance of quantitative immunohistology in labial salivary glands for diagnosing Sjogren’s syndrome. Rheumatol Oxf Engl. 2006;45:470–7. doi:10.1093/rheumatology/kei191.
Roguedas A-M, Pers J-O, Lemasson G, Devauchelle V, Tobón GJ, Saraux A, et al. Memory B-cell aggregates in skin biopsy are diagnostic for primary Sjögren’s syndrome. J Autoimmun. 2010;35:241–7. doi:10.1016/j.jaut.2010.06.014.
Yoshiiwa A, Nabata T, Morimoto S, Sakaguchi K, Yamagata H, Fukuo K, et al. A case of Hashimoto’s thyroiditis associated with renal tubular acidosis, Sjögren syndrome and empty sella syndrome. Nihon Naibunpi Gakkai Zasshi. 1992;68:1215–23.
Ashraf VV, Bhasi R, Kumar RP, Girija AS. Primary Sjögren’s syndrome manifesting as multiple cranial neuropathies: MRI findings. Ann Indian Acad Neurol. 2009;12:124–6. doi:10.4103/0972-2327.53083.
Ebert EC. Gastrointestinal and hepatic manifestations of Sjogren syndrome. J Clin Gastroenterol. 2012;46:25–30. doi:10.1097/MCG.0b013e3182329d9c.
Corsiero E, Sutcliffe N, Pitzalis C, Bombardieri M. Accumulation of self-reactive naïve and memory B cell reveals sequential defects in B cell tolerance checkpoints in Sjögren’s syndrome. PLoS ONE. 2014;. doi:10.1371/journal.pone.0114575.
Jin L, Yu D, Li X, Yu N, Li X, Wang Y, et al. CD4+ CXCR5+ follicular helper T cells in salivary gland promote B cells maturation in patients with primary Sjogren’s syndrome. Int J Clin Exp Pathol. 2014;7:1988–96.
Varin M-M, Guerrier T, Devauchelle-Pensec V, Jamin C, Youinou P, Pers J-O. In Sjögren’s syndrome, B lymphocytes induce epithelial cells of salivary glands into apoptosis through protein kinase C delta activation. Autoimmun Rev. 2012;11:252–8. doi:10.1016/j.autrev.2011.10.005.
Routsias JG, Tzioufas AG. Autoimmune response and target autoantigens in Sjogren’s syndrome. Eur J Clin Invest. 2010;40:1026–36. doi:10.1111/j.1365-2362.2010.02342.x.
Kyriakidis NC, Kapsogeorgou EK, Tzioufas AG. A comprehensive review of autoantibodies in primary Sjögren’s syndrome: clinical phenotypes and regulatory mechanisms. J Autoimmun. 2014;51:67–74. doi:10.1016/j.jaut.2013.11.001.
Gong Y-Z, Nititham J, Taylor K, Miceli-Richard C, Sordet C, Wachsmann D, et al. Differentiation of follicular helper T cells by salivary gland epithelial cells in primary Sjögren’s syndrome. J Autoimmun. 2014;51:57–66. doi:10.1016/j.jaut.2013.11.003.
Ittah M, Miceli-Richard C, Eric Gottenberg J-, Lavie F, Lazure T, Ba N, et al. B cell-activating factor of the tumor necrosis factor family (BAFF) is expressed under stimulation by interferon in salivary gland epithelial cells in primary Sjögren’s syndrome. Arthritis Res Ther. 2006;8:R51. doi:10.1186/ar1912.
Barrera MJ, Bahamondes V, Sepúlveda D, Quest AFG, Castro I, Cortés J, et al. Sjögren’s syndrome and the epithelial target: a comprehensive review. J Autoimmun. 2013;42:7–18. doi:10.1016/j.jaut.2013.02.001.
Mostafa S, Seamon V, Azzarolo AM. Influence of sex hormones and genetic predisposition in Sjögren’s syndrome: a new clue to the immunopathogenesis of dry eye disease. Exp Eye Res. 2012;96:88–97. doi:10.1016/j.exer.2011.12.016.
Czerwinski S, Mostafa S, Rowan VS, Azzarolo AM. Time course of cytokine upregulation in the lacrimal gland and presence of autoantibodies in a predisposed mouse model of Sjögren’s Syndrome: the influence of sex hormones and genetic background. Exp Eye Res. 2014;128:15–22. doi:10.1016/j.exer.2014.09.001.
Tsinti M, Kassi E, Korkolopoulou P, Kapsogeorgou E, Moutsatsou P, Patsouris E, et al. Functional estrogen receptors alpha and beta are expressed in normal human salivary gland epithelium and apparently mediate immunomodulatory effects. Eur J Oral Sci. 2009;117:498–505. doi:10.1111/j.1600-0722.2009.00659.x.
Manoussakis MN, Tsinti M, Kapsogeorgou EK, Moutsopoulos HM. The salivary gland epithelial cells of patients with primary Sjögren’s syndrome manifest significantly reduced responsiveness to 17β-estradiol. J Autoimmun. 2012;39:64–8. doi:10.1016/j.jaut.2012.01.005.
Katsiougiannis S, Tenta R, Skopouli FN. Endoplasmic reticulum stress causes autophagy and apoptosis leading to cellular redistribution of the autoantigens Ro/Sjögren’s syndrome-related antigen A (SSA) and La/SSB in salivary gland epithelial cells. Clin Exp Immunol. 2015;181:244–52. doi:10.1111/cei.12638.
Kang YK, Jung SY, Qin J, Li C, Tsai SY, Tsai M-J, et al. E2/Estrogen receptor/sjogren syndrome-associated autoantigen relieves coactivator activator-induced G1/S arrest to promote breast tumorigenicity. Mol Cell Biol. 2014;34:1670–81. doi:10.1128/MCB.01564-13.
Acknowledgments
We owe a special thank to Dr A. Garnier (Pathological laboratory, Montpellier), Pr Jean-Emmanuel Kahn (Internal Medicine, Foch Hospital, Suresnes, France), Pr Marc Michel (Internal medicine department, Mondor Hospital, Crétéil, France), all the Pathological department laboratory technicians (Montpellier Hospital) and A Nadaradjane for their kindly help in this work.
Authors Contribution
Radjiv Goulabchand (RG) and Philippe Guilpain (PG) conceived this study. Radjiv Goulabchand (RG), Assia Hafidi (AH), and Hélène Perrochia (HP) performed the histological analysis and captures. Radjiv Goulabchand (RG), Assia Hafidi (AH), Hélène Perrochia (HP), and Philippe Guilpain (PG) conducted interpretation and analysis. Radjiv Goulabchand (RG), Hélène Perrochia (HP), Assia Hafidi (AH), and Philippe Guilpain (PG) contributed to drafting the manuscript. Philippe Guilpain, Ingrid Millet, Jacques Morel, Cédric Lukas, Sébastien Humbert, Sophie Rivière, Christian Gény, Christian Jorgensen, and Alain Le Quellec have taken part in recruiting patients and collecting data. All authors have taken part in drafting the article or revising it critically for important intellectual content and final approval of the version to be published.
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Goulabchand, R., Hafidi, A., Millet, I. et al. Mastitis associated with Sjögren’s syndrome: a series of nine cases. Immunol Res 65, 218–229 (2017). https://doi.org/10.1007/s12026-016-8830-x
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DOI: https://doi.org/10.1007/s12026-016-8830-x