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About the Focus Score
The focus score is a semiquantitative method to assign a probabilistic risk category for patients
undergoing evaluation for Sjogren's syndrome.
Some basic rules for interpretation apply:
- Minimum adequacy should be at least 4 lobules and at a minimum, 8 mm^2 of acinar surface area (EULAR recommendatin)
- One should only score minor salivary lobules without pre-existing chronic or fibrosing injury
- Do not score lobules with pre-existing atrophic or fibrotic changes (look for dilated ducts with periductal fibrosis)
- A significant focus is one with greater than 50 lymphocytes (+/- minor plasma cell component) around a duct or acinus. Foci with few sparse cells or uniformly plasma cell infiltrates don't count
- Try to keep the entire patches of inflammatory foci as one focus
- In florid cases, it can be hard to separate one focus from another. Some recommendations includ counting entire lobules as a focus and this finding can be qualified in a comment
Normal salivary lobule
Focal lymphocytic sialadenitis
Non-specific chronic sialadenitis lobule
Sclerosing chronic sialadenitis
How to calculate the Focus Score
How to estimate acinar surface area:
For an Olympus BX41 (or similar) scope with 10x objective and 10 eyepiece:
- A 100x field is nearly 4 mm2 surface area
- Position each lobule to fill the 100x field, and count full fields as 4 mm2
- Estimate partial fields as best you can
- Fudge the total area down 1 or 2 mm2 for excess connective tissue
- * Ignore atrophic or fibrotic/injured lobules *
Some caveats
- At least 8 mm^2 of good quality glandular tissue be available to evaluate
- Cut several serial sections to follow foci through levels
- Non-specific chronic inflammation (NSCS) should be quantified and generally not counted in the FS, unless areas with unequivocally uninjured glands are nearby
- In partially atrophic/fibrotic glands, all of the gland surface area is counted in the denominator, but only FLS in uninjured acini are counted towards the focus score
The calculation
(Total # of inflammatory foci / total surface area) * 4 = Focus Score
Original Reference:
Greenspan JS, et. al., "The histopathology of Sjorgren's syndrome in labial salivary gland biopsies", Oral Surgery 37(2):217-229, Feb. 1974.
Up to date consensus guidelines:
Sjögren's histopathology workshop group from ESSENTIAL (EULAR Sjögren's syndrome study group), et al. Standardisation of labial salivary gland histopathology in clinical trials in primary Sjögren's syndrome. Ann Rheum Dis. 2016 Dec 13.
Greenspan JS, et. al., "The histopathology of Sjorgren's syndrome in labial salivary gland biopsies", Oral Surgery 37(2):217-229, Feb. 1974.
Up to date consensus guidelines:
Sjögren's histopathology workshop group from ESSENTIAL (EULAR Sjögren's syndrome study group), et al. Standardisation of labial salivary gland histopathology in clinical trials in primary Sjögren's syndrome. Ann Rheum Dis. 2016 Dec 13.
Histomorphometry
Number of lobules in biopsy
Number of atrophic lobules
Estimated acinar surface area (mm^2)
Acinar Histologic Findings (if adequate sampling)
Qualifiers
Lymphocytic Inflammation
Additional biopsy findings
Focus Score
Use this for NSCS or SCS
Final Diagnoses
Add a New Case Reference ID
Site by Chandra Krishnan with
Studio Riehl
. Updated April 2020.