Elucidation of the relationship between synovitis and bone damage - A randomized magnetic resonance imaging study of individual joints in patients with early rheumatoid arthritis

University of Leeds, Leeds, England, United Kingdom
Arthritis & Rheumatology (Impact Factor: 7.76). 01/2003; 48(1):64-71. DOI: 10.1002/art.10747
Source: PubMed


To simultaneously image bone and synovium in the individual joints characteristically involved in early rheumatoid arthritis (RA).
Forty patients with early, untreated RA underwent gadolinium-enhanced magnetic resonance imaging (MRI) of the second through fifth metacarpophalangeal joints of the dominant hand at presentation, 3 months, and 12 months. In the first phase (0-3 months), patients were randomized to receive either methotrexate alone (MTX) or MTX and intraarticular corticosteroids (MTX + IAST) into all joints with clinically active RA. The MTX-alone group received no further corticosteroids until the second phase (3-12 months), when both groups received standard therapy.
In the first phase, MTX + IAST reduced synovitis scores more than MTX alone. There were significantly fewer joints with new erosions on MRI in the former group compared with the latter. During the second phase, the synovitis scores were equivalent and a similar number of joints in each group showed new erosions on MRI. In both phases, there was a close correlation between the degree of synovitis and the number of new erosions, with the area under the curve for MRI synovitis the only significant predictor of bone damage progression. In individual joints, there was a threshold effect on new bone damage related to the level of synovitis; no erosions occurred in joints without synovitis.
In early RA, synovitis appears to be the primary abnormality, and bone damage occurs in proportion to the level of synovitis but not in its absence. In the treatment of patients with RA, outcome measures and therapies should focus on synovitis.

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    • "Moreover, early signs of arthritis are joint effusion, hypervascularization and synovial hypertrophy. In particular, vascularization has been shown to correlate with arthritis' destructive behavior [3], whereas clinical improvement does not imply a stop of the erosion process or of the disease activity [4]. From an aetiopathological point of view, a crucial event in the pathogenesis of arthritis, and rheumatoid arthritis (RA) in particular, is the onset of pannus[5]: new blood vessel formation is a very early feature of synovial hyperplasia[6], which promotes the destruction of cartilage and bone[7]. "
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    ABSTRACT: Inflammatory rheumatic diseases are leading causes of disability and constitute a frequent medical disorder, leading to inability to work, high comorbidity and increased mortality. The gold-standard for diagnosing and differentiating arthritis is based on patient conditions and radiographic findings, as joint erosions or decalcification. However, early signs of arthritis are joint effusion, hypervascularization and synovial hypertrophy. In particular, vascularization has been shown to correlate with arthritis' destructive behavior, more than clinical assessment. Contrast Enhanced Ultrasound (CEUS) examination of the small joints is emerging as a sensitive tool for assessing vascularization and disease activity. The evaluation of perfusion pattern rely on subjective semi-quantitative scales, that are able to capture the macroscopic degree of vascularization, but are unable to detect the subtler differences in kinetics perfusion parameters that might lead to a deeper understanding of disease progression and a better management of patients. Quantitative assessment is mostly performed by means of the Qontrast software package, that requires the user to define a region of interest, whose mean intensity curve is fitted with an exponential function. We show that using a more physiologically motivated perfusion curve, and by estimating the kinetics parameters separately pixel per pixel, the quantitative information gathered is able to differentiate more effectively different perfusion patterns. In particular, we will show that a pixel-based analysis is able to provide significant markers differentiating rheumatoid arthritis from simil-rheumatoid psoriatic arthritis, that have non-significant differences in clinical evaluation (DAS28), serological markers, or region-based parameters.
    SPIE Medical Imaging 2014, San Diego (CA, USA); 02/2014
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    • "Rheumatoid arthritis is largely a synovial based disease with the potential for severe joint destruction, but it often has systemic manifestations. Some authors have suggested that synovitis might be secondary to a more basic disease process first occurring within medullary bone as primary inflammatory infiltrate [4–7], but this is subject to debate and not universally accepted [8]. Intriguingly, Ostendorf and co-workers [6, 9] found that bone scintigraphy has demonstrated increased bone turnover in some patients with rheumatoid arthritis without correlating magnet resonance imaging (MRI) findings, while in most patients bone scintigraphic uptake correlated well with MRI changes. "
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    ABSTRACT: Imaging in rheumatology was in the past largely confined to radiographs of the hands and sacroiliac joints (SIJs) helping to establish the diagnosis and then monitoring disease progression. Radiographs are not very sensitive for early inflammation in inflammatory rheumatic disorders and the demand on imaging services was therefore limited. However, over the last 10–15 years new drugs and new technologies have brought new challenges and opportunities to rheumatology and radiology as specialties. New drug treatments allow more effective treatment, preventing many complications. Early diagnosis and disease monitoring has become the challenge for the rheumatologist and radiologist alike. The best possible patient outcome is only achieved if the two specialties understand each other’s viewpoint. This article reviews the role of imaging—in particular radiography, magnet resonance imaging, computer tomography, ultrasound and nuclear medicine—for the diagnosis and monitoring of rheumatological disorders, concentrating on rheumatoid arthritis, inflammatory spondylarthropathies and gout. Teaching Points • New drugs for the treatment of inflammatory disorders has led to greatly improved outcomes. • Imaging often allows for earlier diagnosis of inflammatory disorders. • Early diagnosis and treatment can often prevent the development of crippling disease manifestations. • Tailored imaging examinations are best achieved by consultation of rheumatologist and radiologist.
    Insights into Imaging 10/2013; 4(6). DOI:10.1007/s13244-013-0293-1
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    • "Experiences from comparative studies of CR, US, MRI and CT have shown that CT is the most sensitive imagine technique for the detection of bone erosions [2,3,34-38] and, therefore, can be considered the gold standard for the evaluation of wrist anatomical damage in RA. Difficulties of CR for a detail evaluation of wrist joints are mainly due to a projectional superimposition of bones in this complicated anatomical area, high irregularities of the bone margins (e.g. at level of ligaments attachment) and the presence of nutritive foramina that can appear like erosions. "
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    ABSTRACT: To investigate the performance of conventional radiography (CR) for the detection of bone erosions of wrist in rheumatoid arthritis (RA) using multidetector computed tomography (CT) as the reference method and to evaluate the validity of a computer-assisted manual segmentation (outlining) technique to quantify erosion volume on CT scans. Twenty five RA patients and six controls underwent CT and radiographic evaluation of the dominant wrist on the same day. CT was performed by using a64 GE light Speed VCT power. Wrists images were evaluated separately and scored for the presence of erosions according to the Outcome Measures in Rheumatology Rheumatoid Arthritis MRI Scoring System (RAMRIS) and the Sharp/van der Heijde scoring method. Measurements of bone erosion volumes were obtained using OsiriX medical imaging software. The mean value of the volumes of the CT bone erosions detected at two readings was used to calculate inter-rater agreement. The overall sensitivity, specificity and accuracy of radiography for detecting erosions were 25.5%, 98.3% and 70.1%, respectively. Using computer-assisted manual segmentation (outlining) technique, erosion volume on CT measurements per subject was ranged from 0.001 cm3 to 2.01 cm3. Spearman's RAMRIS score of each wrist bones in all subjects (n = 25) were correlated with the total erosion volume on CT (p < 0.0001), with the ratio between erosion volume and the corresponding bone volume on a percentage basis (p < 0.0001). The total Sharp/van der Heijde erosion score of the all wrist bones was correlate with the RAMRIS score (p = 0.008). The intraclass correlation coefficients (ICC) for manual segmentation showed high agreement (ICC = 0.901). Considering CT as the reference method, CR showed very low sensitivity. A close correlation with CT erosion volumes supports the OMERACT RAMRIS erosion score as a semiquantitative measure of joint damage in RA. Although the computer-assisted manual segmentation can be beneficial for diagnostic decision in cross-sectional CT examinations of the wrist in RA, this technique will require further evaluation in terms of responsiveness.
    BMC Musculoskeletal Disorders 09/2013; 14(1):265. DOI:10.1186/1471-2474-14-265 · 1.72 Impact Factor
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