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: 7.87). 01/2003; 48(1):64-71. DOI: 10.1002/art.10747
Source: PubMed

ABSTRACT 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.

Download full-text


Available from: Richard J Wakefield, Aug 16, 2015
1 Follower
  • Source
    • "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]. "
    [Show abstract] [Hide abstract]
    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
  • Source
    • "In two small studies of early RA patients, MRI BME at baseline was the strongest individual predictor of MRI erosions at 1 and 2 years' follow-up [54] [57]. MRI synovitis showed a clear relationship with the development of subsequent MRI erosive damage in another study, but this study did not include conventional radiographs, generally regarded as the gold standard for assessing structural damage [58]. Haavardsholm et al. showed that according to the Outcome Measures in Rheumatology Clinical Trials (OMERACT) RA MRI Scoring system (RAMRIS) the MRI BME score was an independent predictor of structural progression on CR and MRI in an inception cohort of 84 early RA patients [42]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: With recent improvements in the treatment of rheumatoid arthritis (RA), remission has become an achievable goal for a large proportion of RA patients, and remission is now a defined target in current RA guidelines. However, studies have shown that progression of radiographic joint damage may occur in clinical remission, regardless of the choice of remission definition. Sub-clinical inflammation detected by modern imaging techniques such as ultrasonography and magnetic resonance imaging is present in the majority of patients in clinical remission, and is associated with progressive joint damage and disease activity flare in these patients. This chapter aims to assess the importance of imaging findings in RA patients in clinical remission and to discuss the possible role of modern imaging in future remission criteria.
    Best practice & research. Clinical rheumatology 12/2012; 26(6):767-85. DOI:10.1016/j.berh.2012.10.004 · 3.06 Impact Factor
  • Source
    • "Radiographs visualize the late disease manifestations such as bone erosions and joint space narrowing. However, radiographs do not show changes in synovial tissue and bone marrow [7], which occur much earlier than erosions. Recent research demonstrates that synovial and bone marrow changes can be detected months to years before an erosion develops [8] [9]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: The international consensus on treatment of rheumatoid arthritis (RA) involves early initiation of disease modifying anti-rheumatic drugs (DMARDs) for which a reliable identification of early disease is mandatory. Conventional radiography of the joints is considered the standard method for detecting and quantifying joint damage in RA. However, radiographs only show late disease manifestations as joint space narrowing and bone erosions, whereas it cannot detect synovitis and bone marrow oedema, i.e., inflammation in the synovium or the bone, which may be visualized by magnetic resonance imaging (MRI) months to years before erosions develop. Furthermore, MRI allows earlier visualization of bone erosions than radiography. In order to allow early treatment initiation and optimal guidance of the therapeutic strategy, there is a need for methods which are capable of early detection of inflammatory joint changes. In this review, we will discuss available data, advantages, limitations and potential future of MRI in RA.
    European journal of radiology 06/2009; 71(2):189-96. DOI:10.1016/j.ejrad.2009.04.048 · 2.16 Impact Factor
Show more