Yttrium radiosynoviorthesis in the treatment of knee arthritis in rheumatoid arthritis: a systematic review

OBJECTIVE

To consider the question: How strong is the evidence in favour of yttrium synovectomy in chronic knee arthritis in patients with rheumatoid arthritis in comparison with placebo and intra-articular steroid treatment?

METHODS

A systematic review of the literature was performed using Medline and the Embase database.

RESULTS

Initially, seven papers were identified, but only two met the inclusion criteria. Neither study showed evidence in favour of yttrium synovectomy.

CONCLUSION

From the point of view of evidence based medicine it should be seriously questioned whether yttrium synovectomy deserves a place in clinical practice.

MRI findings in haemophilic joints treated with radiosynoviorthesis with development of an MRI scale of joint damage

We hypothesized that magnetic resonance imaging (MRI) scans taken prior to radiosynoviorthesis may be predictive of response to the procedure in persons with haemophilia. Specifically, response would be inversely related to the severity of synovial hyperplasia. Radiosynoviorthesis was administered to 21 joints with recurrent haemorrhage (target joints). A detailed self-report of haemorrhage history, joint evaluation with scoring according to the World Federation of Haemophilia orthopaedic joint and pain scales, plain radiographs, and MRI studies of the joints were performed pre- and post-radiosynoviorthesis. To augment comparison of the MRI findings to those assessed using the Arnold-Hilgartner and Pettersson scales, a provisional MRI scale for evaluation of haemophilic arthropathy was designed. We found the MRI findings prior to the procedure were not predictive of clinical response; independent of the severity of synovial hyperplasia, most joints bled less and showed improvement by the WFH orthopaedic score. There was generally no change in the severity of synovial hyperplasia after the procedure. We conclude that MRI evaluation is not routinely indicated prior to radiosynoviorthesis.

Preparation of rhenium-188-tin colloid as a radiation synovectomy agent and comparison with rhenium-188-sulfur colloid

As a generator-produced beta-emitting radionuclide, the importance of 188Re for radionuclide therapy is increasing rapidly. We prepared 188Re-tin colloid and compared its properties with 188Re-sulfur colloid. Labeling efficiencies reached >98% for tin colloid at 2 h and 89-94% for sulfur colloid at 3 h. All the preparations were stable for 72 h in water, serum, and synovial fluid. If labeled at higher temperature, the particle size of tin colloid increased. The residual radioactivity of 188Re-sulfur colloid in disposable polypropylene syringes after injecting mice was high (62.0+/-7.0%) due to its hydrophobic nature, while that of 188Re-tin colloid was low (2.9+/-1.6%). Although both 188Re-tin colloid and 188Re-sulfur colloid might be useful for radionuclide therapy, we conclude that 188Re tin colloid is more advantageous over 188Re sulfur colloid, due to higher labeling efficiency, control of the particle size, and lower residual activity in the injection syringes.

Samarium 153-labeled hydroxyapatite microspheres for radiation synovectomy in the horse: a study of the biokinetics, dosimetry, clinical, and morphologic response in normal metacarpophalangeal and metatarsophalangeal joints

OBJECTIVE

To determine the effects of Samarium-153 bound to hydroxyapatite microspheres (153SmM) when injected into the metacarpophalangeal and metatarsophalangeal joints of horses.

STUDY DESIGN

- Horses were injected with 153SmM in metacarpophalangeal and metatarsophalangeal joints with the diagonal contralateral joints used as untreated controls.

ANIMALS OR SAMPLE POPULATION

Twelve adult horses without pre-existing disease involving the metacarpo/metatarsophalangeal joints.

METHODS

Horses were divided into three groups: high-dose Samarium-153 (12.5 to 17.0 millicurie [mCi]), intermediate dose (6.5 to 12.0 mCi), and low dose (3.5 to 6.0 mCi). Horses were examined daily for 7 days postinjection for clinical abnormalities, lameness, and surface and systemic radiation levels. One horse from each group was euthanatized at 14, 30, and 60 days postinjection and the effects of the 153SmM examined microscopically in the cartilage and synovial membrane.

RESULTS

Intraarticular(153)SmM caused inflammation characterized by lameness, effusion, and regional edema for 48 to 72 hours. Minimal levels of active 153SmM were identified in the blood or urine and were well below the maximal tolerance of 1 mCi. Microscopically the radiation caused no effects on the articular cartilage. The synovectomy created was good but not ideal in that some areas did have necrosis into the subintimal regions and a few islands of intact intimal cells persisted.

CONCLUSIONS

The use of 153SmM is an effective means of targeting the synovial intimal cells with minimal extrasynovial leakage of radiation.

CLINICAL RELEVANCE

The metacarpophalangeal and metatarsophalangeal joints of the horse can be safely treated with 153SmM without damage to the cartilage or significant extracapsular leakage.

[Radiosynoviorthesis in inflammatory joint diseases]

The use of beta-(beta) emitting radionuclides for radiosynoviorthesis (RSO) has been a well established therapy for inflammed joints for more than 40 years. Radionuclides are often applied to patients with rheumatoid arthritis as local therapy. The choice of the radionuclide is empirical. The evaluation of the therapeutic success is mainly based on the improvement of the joint motion. MRI and other radiological examinations have not been proved to be reliable for diagnosis of the therapeutic success. The aims of this manuscript are to familiarize physicians with the different radionuclides, to explain the therapeutic success which can be expected due to dosimetric data, and to present the three phase bone scintigraphy as a valuable instrument for the evaluation of the therapeutic success.

Development and construction of a neutron beam line for accelerator-based boron neutron capture synovectomy

A potential application of the 10B(n, alpha)7Li nuclear reaction for the treatment of rheumatoid arthritis, termed Boron Neutron Capture Synovectomy (BNCS), is under investigation. In an arthritic joint, the synovial lining becomes inflamed and is a source of great pain and discomfort for the afflicted patient. The goal of BNCS is to ablate the synovium, thereby eliminating the symptoms of the arthritis. A BNCS treatment would consist of an intra-articular injection of boron followed by neutron irradiation of the joint. Monte Carlo radiation transport calculations have been used to develop an accelerator-based epithermal neutron beam line for BNCS treatments. The model includes a moderator/reflector assembly, neutron producing target, target cooling system, and arthritic joint phantom. Single and parallel opposed beam irradiations have been modeled for the human knee, human finger, and rabbit knee joints. Additional reflectors, placed to the side and back of the joint, have been added to the model and have been shown to improve treatment times and skin doses by about a factor of 2. Several neutron-producing charged particle reactions have been examined for BNCS, including the 9Be(p,n) reaction at proton energies of 4 and 3.7 MeV, the 9Be(d,n) reaction at deuteron energies of 1.5 and 2.6 MeV, and the 7Li(p,n) reaction at a proton energy of 2.5 MeV. For an accelerator beam current of 1 mA and synovial boron uptake of 1000 ppm, the time to deliver a therapy dose of 10,000 RBEcGy ranges from 3 to 48 min, depending on the treated joint and the neutron producing charged particle reaction. The whole-body effective dose that a human would incur during a knee treatment has been estimated to be 3.6 rem or 0.75 rem, for 1000 ppm or 19,000 ppm synovial boron uptake, respectively, although the shielding configuration has not yet been optimized. The Monte Carlo design process culminated in the construction, installation, and testing of a dedicated BNCS beam line on the high-current tandem electrostatic accelerator at the Laboratory for Accelerator Beam Applications at the Massachusetts Institute of Technology.

[Activity leakage and radiation exposure in radiation synovectomy of the knee: influence of different therapeutic modalities]

In rheumatic diseases, radiation synovectomy is a reliable method. Meanwhile, radiation synovectomy is an outpatient therapy. In addition, combination with arthroscopic synovectomy is an increasing therapeutic modality. In comparison to the hitherto inpatient modality, a greater lymphatic emigration of the radionuclide and, therefore, a higher radiation exposure is possible. In 35 patients we found radionuclide emigration in 17 cases by whole body scintigraphy, resulting in a 50%-percentile with 68.27%-confidence interval of 1.8 (0.45-4.78)% of the injected yttrium-90-activity. Comparison of 3 groups with the above mentioned therapy modalities resulted in no statistical difference (p>0.05). Because of the found radionuclide emigration, a radiation dose of 0. 1 (0.05-0,18) mSv in women and 0.2 (0.1-0.38) mSv in men was calculated. For lymph nodes, liver, spleen and whole body radiation doses of 619 (154-1644) mSv, 62 (15-165) mSv, 62 (15-165) mSv and 37 (9-99) mSv were calculated. Gonadal radiation dose can be neglected and the morbidity rate for tumors because of the whole body radiation dose is low with a value of 0.4 per thousand. Therefore, radiation synovectomy can be used unlimited by patients age and independent of the therapeutic modality.

Correlation between radiation dose, synovial thickness, and efficacy of radiosynoviorthesis

OBJECTIVE

To correlate the therapeutic efficacy of radiosynoviorthesis (RSO) to radiation doses achieved.

METHODS

In 20 patients with known rheumatoid arthritis, radiosynoviorthesis was performed in 36 joints. Arthritis disease activity was assessed by "blood pool scintigraphy" (n = 29) score after injection of 370 MBq 99mTc-MDP, before and at 1, 2, and 5 months after the RSO in 12 patients. For semiquantitative measurements, a region-of-interest technique was applied. Synovial thickness and response to the RSO were evaluated by joint ultrasonography. Pain levels were evaluated semiquantitatively. Dosimetry (n = 20) was calculated using planar quantification according to the MIRD scheme.

RESULTS

The mean radiation absorbed dose of 186Re-sulfate to the whole body was 5.3+/-2.7 cGy, liver 10.0+/-8.1 cGy, spleen 20.3+/-22.9 cGy, kidneys 9.4+/-11.4 cGy, and at the injected joints of the shoulder 120.5+/-32.2 Gy, hand 130.0+/-12.6 Gy, elbow 83.6+/-38.7 Gy, and talar/subtalar joint 84.1+/-30.7 Gy. In 7 cases, where mandatory immobilization of the joint was not possible, the dose to the lymph nodes (n = 25) was 25.9+/-53.8 Gy (maximum 189 Gy) and to single lymph nodes 14.6+/-11.2 Gy (maximum 63 Gy). The reduced doses to the synovia (at 40% leakage) were: 169Er-citrate 73.10+/-25.25 Gy; 90Y-citrate 59.25+/-46.45 Gy; 186Re-sulfate 65.40+/-32.55 Gy. In cases of complete immobilization, the dose to the lymph nodes was negligible: 169Er-citrate (n = 7), whole body dose 0.4 cGy, lymph nodes 2.3 Gy, finger joints 132.3+/-34.3 Gy; 90Y-citrate (n = 6), whole body dose 15.5 cGy, liver dose 26.5 cGy, splenic dose 11.9 cGy, kidney dose 67 cGy, joint knee joint dose 130.1 Gy. Regarding therapeutic effect, mean reduction of the 99mTc-MDP blood pool activity was 41% at first month, 48% at second month, 48% at the fifth month, 48% in larger joints, and 63% in finger joints. Three and 6 months after RSO, sonography showed a mean reduction in synovial swelling: in the knee joint 1.67 and 4.38 mm, respectively; in the larger joints (shoulder, elbow, hand, talar/subtalar) 0.88/1.93 mm; and in finger joints 0.53/1.76 mm. Clinically, best results were observed in the finger joints.

CONCLUSION

1. We observed a significantly higher radiation absorbed dose to the lymph nodes and lower dose to the synovia in the absence of joint immobilization. Immobilization of the joint is essential. 2. At 2 months after treatment, a significant reduction of blood pool activity and synovial swelling was observed, with further improvement in the following months, especially in the finger joints. 3. There is a strong correlation between the reduction of blood pool activity, synovial swelling, and improvement of pain.

[The effects of low-dose Co-60 irradiation on the course of aseptic arthritis in a rabbit knee joint]

PURPOSE

Numerous clinical observations demonstrate the efficacy of low radiation doses in the treatment of painful osteoarthritis. Experimental investigations remain scarce. We investigated the effects of locally daily 5 times 1.0 Gy 60-Co irradiation on an artificially induced aseptic gonarthritis in rabbits.

MATERIAL AND METHODS

Three separate experiments (EV) were performed (10 rabbits per experiment, 5 treated/5 controls; duration: EV1: 18 days; EV2: 6 days; EV3: 29 days). An aseptic arthritis in the right knee joint of rabbits was induced by intraarticular injection of 0.5 ml papain solution (3%, 30,000 USP/mg) on day 0. The arthritic knee joint of the anesthesized animals was irradiated daily from day 1 to 5 with 5 times 1.0 Gy. The controls were sham-irradiated under the same conditions. The time course of arthritis in treated animals and sham-treated controls was evaluated by clinical, laboratory-chemical and histological criteria. The clinical investigation was performed daily, the puncture of the knee-joints was carried out several times in EV1, and at the end of experiments in EV2 and EV3. At the end of the observation period, animals were killed and the knee joints excised for histological analysis.

RESULTS

The intraarticular injection of papain caused a peracute inflammatory response in all animals. After 1 week the chronic stage was reached, and the experimental arthritis resolved slowly within several weeks. Local irradiation accelerated the decrease of inflammatory joint swelling, being significant by day 4. On day 6 the volume of synovial fluid in irradiated knee-joints was significantly smaller. The morphometric data indicated a reduction in thickness of synovial membrane, a decrease in number of synovial cell layers, and a decrease in distance between capillaries and the synovial membrane surface following irradiation of arthritic joints. Due to considerable individual variability, the morphometric data partially did not reach statistically significance.

CONCLUSION

The experiments provide evidence for an antiphlogistic effect of irradiation with 5 times 1.0 Gy in vivo. They support the clinical observations of the efficacy of anti-inflammatory radiotherapy.

Efficacy of radiosynovectomy of the knee in rheumatoid arthritis: evaluation with magnetic resonance imaging

The intra-articular injection of a radiopharmaceutical agent (radiosynovectomy) produces a reduction of the synovial inflammatory process. The inflammed synovial membrane can be identified with magnetic resonance imaging after the intravenous administration of gadolinium (MRI-Gd). A 6-month prospective study was carried out in 10 patients with rheumatoid arthritis after radiosynovectomy of the knee. The efficacy was evaluated with clinical parameters and MRI-Gd. A progressive amelioration of synovial effusion, pain, articular range of mobility, total leucocytes count in synovial fluid and synovial membrane thickness through MRI-Gd was observed. The global efficacy was considered to be good in six patients, fair in three and bad in one. The study shows for the first time that MRI-Gd allows the evaluation of the response of the synovial membrane to radiosynovectomy.

Rhenium-188 microspheres: a new radiation synovectomy agent

Radiation synovectomy is efficacious in controlling the symptoms of rheumatoid arthritis. However, the procedure is not widely used because of concerns about leakage of radiopharmaceuticals from the treated joints. Leakage can be minimized by selecting particles of an appropriate size. In this study, we labelled microspheres with 188Re and analysed its biodistribution after intra-articular injection in rabbits with antigen-induced arthritis. Gamma camera imaging was performed to quantify the mean retention of 188Re in the knees. The mean retention of 188Re was 98.7, 94.6 and 93.6% at 1, 24 and 48 h, respectively. The biodistribution data revealed very low radioactivity in all organs at different times, which suggests the leakage of radiotracer from the knee was negligible. Our preliminary results indicate that 188Re microspheres are a potentially effective radiopharmaceutical for radiation synovectomy.

Nonsurgical synovectomy in the treatment of arthropathy in Von Willebrand's Disease

Von Willebrand's disease is the most common inherited bleeding disorder, with an overall prevalence in the general population of 0.8% to 1.3%. Hemarthrosis occurs mainly in the severest forms of the disease (type III), with a frequency of 3.5% to 11%, and can cause severe arthropathy similar to that seen in hemophilia. We retrospectively reviewed our experience with nonsurgical synovectomy in the treatment of recurrent hemarthrosis with arthropathy in patients with von Willebrand's disease. Four of our six patients had type III disease and the remaining two had type II disease. The age range was 13 to 63 years. The frequency of hemarthrosis prior to synovectomy was one to four per month. One (n = 2) or both (n = 1) knees were treated in 4 cases, one (n = 1) or both (n = 1) ankles in 3 cases and an elbow in one case. We used yttrium 90 in a dose of 5 mCi for one knee, rhenium 186 in a dose of 2 mCi for two ankles and the elbow and osmic acid for two knees and one ankle. Clinical and radiological results were evaluated six months after synovectomy using the World Federation of Hemophilia score. Radiologic lesions remained stable and clinical manifestations improved in every case (p < 0.05). Five patients achieved a complete remission. Safety was satisfactory. The clinical efficacy of synovectomy done, using radiocolloids or osmic acid in arthropathy due to von Willebrand's disease, seems similar to that in hemophilia.

Photodynamic synovectomy using benzoporphyrin derivative in an antigen-induced arthritis model for rheumatoid arthritis

Experimental photodynamic therapy (PDT) has recently been adapted for the treatment of inflammatory and rheumatoid arthritis. The biodistribution of benzoporphyrin derivative monoacid ring A (BPD-MA) and the effect of percutaneous light activation via intra-articular bare cleaved optical fibers was investigated using a rabbit-antigen-induced arthritis model. Qualitative evaluation of intra-articular photosensitizer clearance was performed with laser-induced fluorescence from 0 to 6 h following intravenous injection. The compound was rapidly taken up within the joint and then cleared steadily over the 6 h interval. Biodistribution was determined by fluorescence microscopy and spectrofluoroscopic extraction techniques 3 h following intravenous injection of 2 mg/kg BPD-MA. The biodistribution study demonstrated elevated levels of BPD-MA in synovium (0.35 microgram/g) and muscle (0.35 microgram/g). Fluorescence microscopy demonstrated presence of the compound within pathologic synovium but absence of the photosensitizer within meniscus, ligament, bone and articular cartilage. Tissue effects were evaluated histologically at 2 and 4 weeks posttreatment. BPD-MA-mediated PDT caused synovial necrosis in the region of light activation in 50% of treatment knees at 2 weeks and 43% at 4 weeks. No damage to nonpathologic tissues was observed. These studies indicate that selective destruction of synovium can be achieved by the light-activated photosensitizing agent BPD-MA without damage to articular cartilage or periarticular soft tissues. PDT needs to be further evaluated to optimize treatment parameters to provide for a new minimally invasive synovectomy technique.

Radiochemical synovectomy

Radiochemical synovectomies have been used for nearly fifty years for the treatment of persistent monoarticular synovitis refractory to antiinflammatory drugs, disease modifying drugs, and intraarticular corticosteroids. It is a therapeutic alternative to surgical synovectomy. There are controversies concerning safety, choice of appropriate agent, and logistics of administration. These concerns are discussed in addition to reviewing some of the more recent trials examining the efficacy of radiochemical synovectomy. It is clear that in properly selected patients this procedure is safe and beneficial.

Radiosynovectomy's clinical applications and cost effectiveness: a review

It is apparent that from the work of the authors and many others, including the work of Rivard, Sledge, Zuckerman, among others, that radiosynovectomy has an important role to play in providing effective treatment of affected joints associated with rheumatoid arthritis and other forms of arthritis as well as the hemophiliac joint. The treatment offers relief from the effects of recurrent joint effusion with an approximately 60% to 66% favorable response and from recurrent hemarthrosis in the hemophiliac joint with an approximately 75% to 80% favorable response. The impact of providing radiosynovectomy as an alternative to surgical synovectomy is seen, where postoperative side effects such as joint stiffness are avoided, improved quality of life is repeatedly documented, and the cost savings in health care dollars, particularly evident in the hemophiliac joint in this relatively small population, are potentially enormous. With almost two million people in the United States suffering from rheumatoid arthritis, the potential savings in health care dollars is also enormous. As with any use of in vivo radiopharmaceuticals, the potential for radiation-induced damage exists. However, with a 25 plus year record of use, more optimally configured radiopharmaceuticals, and the addition of maneuvers to minimize potential joint leakage, the risk of radiation induced damage appears to be minimal. It appears as though radiosynovectomy is an effective as well as cost-effective alternative to surgical synovectomy and is becoming the procedure of choice particularly in the hemophiliac patient with recurrent hemarthrosis and synovitis who has failed medical therapy. It is also the procedure of choice in patients for whom surgery is contraindicated because of the presence of clotting factor inhibitors.

[Chronic polyarthritis and radiosynoviorthesis: a prospective, controlled study of injection therapy with erbium 169 and rhenium 186]

The aim of this prospective study was to evaluate the efficiency of radiation synovectomy with rhenium-186 or erbium-169 in rheumatoid arthritis. In the control groups articulosynovitis was treated by injection of triamcinolonhexacetonid. Follow-up time was 3 years. Patients of the study had to fulfill the following criteria: rheumatoid arthritis (ARA criteria 1988), patient age above 40 years, standardized medical treatment with methotrexate, (started at least 6 month prior to injection therapy, given for the entiry study time), prednisolon < or = 7.5 mg/d and diclofenac < or = 150 mg/ d, and no previous surgery or injection therapy on this/these joint/s. Shoulder, elbow, wrist, and ankle joints were treated in group 1 by injection of rhenium-186 combined with triamcinolonhexacetonid, in group 2 by injection of triamcinolonhexacetonid alone. Each treatment group included 50 joints. Digital joints underwent injection of erbium-169 combined with triamcinolonhexacetonid (group 3 = 131 joints) or triamcinolonhexacetonid (group 4 = 86) alone. During the follow up period, the joints were assessed for pain, synovial swelling, joint motion, and stage of radiological destruction (Larsen-Dale-Eek). After 3 years follow-up, 228 joints met the above named criteria: group 1 = 41 joints, group 2 = 21 joints, group 3 = 131 joints, group 4 = 53 joints. Significantly better clinical results were achieved with the combined injection of rhenium-186 or erbium-169 and triamcinolonhexacetonid. Results for PIP joints were worse than for other joints, which is explained by better immobilization of the latter ones after injection. The progression in radiological joint destruction according to the stages of Larsen-Dale-Eek during the follow-up time of 3 years (= stage at 3 years minus stage prior to treatment) corresponded to the clinical results and was significantly slower in groups 1 and 3: group 1 = 0.62; group 2 = 1.7; group 3 = 0.75; group 4 = 1.43 Therefore, we recommend radiosynovectomy with erbium-169 or rhenium-168 in combination with triamcinolonhexacetonid and consequent immobilization after injection.

Monitoring of the biodistribution and biokinetics of dysprosium-165 ferric hydroxide with a shadow-shield whole-body counter

Radiation synovectomy is indicated when conventional pharmacological treatment of chronic synovitis has proved insufficient. In these cases dysprosium-165 ferric hydroxide (DFH) has been demonstrated to be clinically effective. After application of the agent, blood activity measurements and monitoring of activity distribution by gamma camera imaging over the local lymph nodes and the liver are commonly performed for control of possible leakage. In addition, we have used a shadow-shield whole-body counter with a profile facility to evaluate the biokinetics and biodistribution of 165Dy-DFH. Fifteen intra-articular injections were performed in 13 patients who received a median activity of 6.8 GBq (range 0.5-9.9 GBq) 165Dy-DFH. Activity profiles were obtained with the whole-body counter 2, 4 and 6 h after injection of 165Dy-DFH. The doses to non-target organs were calculated using the software MIRDOSE 3. In 10 of 15 treatments, absence of any leakage could be demonstrated. The effect of scattered rays could be observed in 14 measurements. In three patients small amounts of activity could be detected in the urinary bladder and in three patients activity was detected in the local inguinal lymph nodes, while no leakage could be detected by camera imaging. In these cases the individual doses to the bladder were 15 Gy, 65 mGy and 50 mGy, and those to the lymph nodes, 0.54 Gy, 0.89 Gy and 2.41 Gy. The whole-body counter also enabled the monitoring of activity profiles related to more complex pathological structures. In conclusion, using a whole-body counter activity leakage could be detected with much higher sensitivity than by using a gamma camera. The biodistribution of 165Dy-DFH could be determined, and leakage could be localised and related to organs. These results encourage the use of a whole-body counter to identify the site and extent of activity leakage.

[Arthroscopic synovectomy and radiosynoviorthesis]

Both procedures, radiosynoviorthesis and arthroscopic synovectomy, are well established in the local treatment of rheumatically deformed joints. By combining the two minimal invasive procedures one can increase the radicality and still decrease traumatization. A prospective study by Herresthal indicates the superiority of the combined therapy over the single nuclide therapy of knee joints in rheumatoid arthritis. This is due to the lesser traumatization as compared to the open synovectomy and to the possibility to remove fibrinous plaques which may impair the efficiency of radiosynoviorthesis. Histology, method and the respective indications regarding the joints of the upper and lower limbs are discussed.

In vitro synthesis of prostaglandin E2 by synovial tissue after helium-neon laser radiation in rheumatoid arthritis

This paper reports the effect of helium-neon laser radiation (power of 5 mW and 632.8 nm wave length) on the synthesis of PGE2 in vitro in synovial tissue of biopsy samples of knee joints in patients with chronic rheumatoid arthritis stages II or III. Twelve patients were studied. Each patient received 15 applications of He-Ne laser. Eleven points for He-Ne laser applications were selected in one of the affected knees. The energy density used was 8 J/cm2 per application point. The He-Ne laser therapy reduced the synthesis of PGE2. The analysis of the data revealed a statistically significant difference between the levels of the synthesis of PGE2 before treatment (17.69 +/- 2.65 ng mg-1 of dry tissue h-1) and after treatment (13.85 +/- 2.73 ng mg-1 of dry tissue h-1), with p < 0.01 comparing mean values. This was also accompanied by relief of pain (91.6%), and a favorable subjective report from the patient. We conclude that PGE2 is a quantifiable parameter that could explain what causes pain relief in patients with rheumatoid arthritis that are treated with He-Ne laser.

Radioactive synoviorthesis in hemophilic hemarthrosis: materials, techniques, and dangers

Radioactive synoviorthesis with 198Au, 90Y, 186Re, and 31P would seem to be the treatment of choice for recurrent hemarthroses in hemophilia. The clinical results, obtained by different centers, show a definite diminution of hemarthroses in 88% of cases. The advantages of radioactive synoviorthesis compared with surgical synovectomy are: better results, the requirement of substantially reduced antihemophilic factor, the possibility of performing the procedure on multiple cases concurrently on an ambulatory basis, no interference with articular range of movement, and the low cost of the procedure. In cases of failure, the procedure can be repeated after 6 months, and on as many as 3 occasions. Studies performed on the chromosomal changes that could be attributed to the radioactive material show the disappearance of these alterations a few years after treatment. No physical changes have been found that could be attributed to cytogenic alteration (hematologic or other) in any reported patients.

Comparison of the efficacy of nonsurgical synovectomy (synoviorthesis) and joint lavage in knee osteoarthritis with effusions

OBJECTIVE

Radioactive or chemical synovectomy (synoviorthesis) is widely used as local therapy for inflammatory joint disease in France. The objective of this retrospective study was to compare the efficacy of osmic acid or radiation synovectomy with that of joint lavage for the treatment of knee osteoarthritis with effusions.

PATIENTS AND METHODS

All study patients met American College of Rheumatology criteria for knee osteoarthritis, which was symptomatic despite conservative therapy including local corticosteroid injections. Fifty-four patients were treated by synoviorthesis (osmic acid, n = 16; yttrium 90, n = 76) and 45 by joint lavage (total 67 lavages).

RESULTS

Thirty two per cent of the patients in the synoviorthesis group had a good or excellent outcome after six months. Results were better with yttrium 90 than with osmic acid. Improvements were most marked in patients with chondrocalcinosis. Efficacy was negatively correlated with the femorotibial lesions but not with the patellofemoral lesions. Patients with knee alignment disorders had poorer outcomes. In the joint lavage group, 30% of the knees showed improvements after three months and results were significantly better after three and six months when the lavage was followed by an injection of triamcinolone hexacetonide. No side effects were recorded.

CONCLUSION

Our data suggest that chemical or radiation synovectomy or joint lavage followed by injection of a delayed-action steroid may be useful for the treatment of knee osteoarthritis with chronic or recurrent effusions.

Innovative treatment approaches for rheumatoid arthritis. Non-surgical synovectomy

Rheumatoid patients with intractable knee effusions may benefit from medical or radio-isotopic synoviorthesis. These offer more convenient, less costly alternatives to surgery with similar long-term outcome. Temporary symptomatic relief may be obtained, but disease progression is unaffected. Potential adverse effects include development of osteoarthrosis with osmic acid and teratogenicity and mutagenicity with alkylating agents and radioisotopes.

A survey of radiation synovectomy in Europe, 1991-1993

The prevalence of radiation synovectomy practice is unknown. As new particulate radiopharmaceuticals offering many potential advantages are being developed, it seems prudent to appraise the extent, frequency and variation in radiation synovectomy practice. We have evaluated radiation synovectomy practice in Europe over the period 1991-1993 by means of a postal questionnaire. More than 2300 European members of the European Association of Nuclear Medicine were questioned about the number of treated patients and joints, disease prevalence in their patients and the use of radiopharmaceuticals. Overall, 119/490 (24%) of centres replying to the survey practised radiation synovectomy during the 3 years. There were 13,450 different joint injections in 8578 patients. Rheumatoid arthritis was the most prevalent disease in patients treated (71%) and the most frequently treated joints were knee (46%) and finger joints (20%). Eight different radiopharmaceuticals were employed. Yttrium-90 colloids were most frequently and widely (100/119 centres) used, mainly employed for knee synovectomy but were also used to treat most appendicular joints. Erbium-169 colloid was almost exclusively used to treat finger joints (31/33 centres). Corticosteroid was routinely co-injected in 36/60 (60%) centres. Radiation synovectomy was widely practised throughout Europe during 1991-1993. There are variations in practice illustrated by the diversity of treated arthritides and injected joints and by the use and application of different radiopharmaceuticals.

Beta-particle dosimetry in radiation synovectomy

Beta-particle dosimetry of various radionuclides used in the treatment of rheumatoid arthritis was estimated using Monte Carlo radiation transport simulation coupled with experiments using reactor-produced radionuclides and radiachromic film dosimeters inserted into joint phantoms and the knees of cadavers. Results are presented as absorbed dose factors (cGy-cm2/MBq-s) versus depth in a mathematical model of the rheumatoid joint which includes regions of bone, articular cartilage, joint capsule, and tissue (synovium) found in all synovial joints. The factors can be used to estimate absorbed dose and dose rate distributions in treated joints. In particular, guidance is provided for those interested in (a) a given radionuclide's therapeutic range, (b) the amount of radioactivity to administer on a case-by-case basis, (c) the expected therapeutic dose to synovium, and (d) the radiation dose imparted to other, nontarget components in the joint, including bone and articular cartilage.

Rhenium-188 sulphur colloid as a radiation synovectomy agent

Radiation synovectomy has been shown to be an effective treatment for the rheumatoid arthritic knee. In this study, we evaluated the suitability of rhenium-188 as a radiation synovectomy agent. In addition, we were successful in labelling sulphur colloid with 188Re. In vitro stability tests revealed that more than 95% of the 188Re remained in colloid form over a 3-day period. Intra-articular injection of 188Re sulphur colloid into arthritic rabbit joints was followed by gamma camera imaging to quantify the leakage. The mean retention percentages of 188Re colloid in arthritic knees were 93.7% (+/- 1.4%), 90.8% (+/- 1.7%) and 87.2% (+/- 0.6%) at 1 h, 1 day and 2 days, respectively. A biodistribution study of the arthritic rabbits revealed that the highest activity outside the knees was in the liver and the kidneys. Our preliminary results indicate that 188Re sulphur colloid may be an effective radiopharmaceutical for radiation synovectomy.

[Radiation synovectomy with yttrium 90 and rhenium 186 in rheumatoid arthritis, long term follow-up and effects on synovial membrane]

Despite the progress in the treatment of rheumatoid arthritis (RA), many patients continue to suffer from persistent and painful synovitis. We assessed the clinical results of 64 intraarticular injections of Yttrium 90 in the knee and 56 injections of Rhenium 186 in the wrist in 71 patients with RA, older than 40 years, without relief of synovitis after six months of systemic or local treatment and with a radiological stage I or II of their joints. We obtained good results in 75% of knees and 100 of wrists during a follow up period of 8 to 60 months. A repeated histological examination of the synovial membrane of 14 joints in which good results were obtained disclosed a reduction in inflammation and transitory synovial cell hyperplasia that ended in a dense fibrosis. It is concluded that radiation synovectomy continues to be an effective therapy for selected patients with RA and synovitis. The observed histopathological changes may aid the interpretation of magnetic resonance imaging of the treated joints.

Synoviorthesis with colloidal 32P chromic phosphate for the treatment of hemophilic arthropathy

Between 1977 and 1992, we performed ninety-two synoviortheses (destruction of synovial tissue by intra-articular injection of a radioactive agent) on forty-eight patients who had a severe congenital disorder of hemostasis and chronic hemophilic synovitis that was resistant to conventional treatment. Colloidal 32P chromic phosphate was injected intra-articularly: 1.0 millicurie for knees and 0.5 millicurie for other joints. The duration of follow-up ranged from one to fifteen years. The frequency and importance of bleeding decreased in most of the patients. The range of motion of half of the joints remained stable or improved and that of the other half continued to decrease. Radiographic scores worsened progressively despite the decreased frequency of hemarthrosis. In most patients, the extra-articular leakage of the radioactive agent was slight. Chromosome breakages were observed almost exclusively in patients who were seropositive for human immunodeficiency virus and in whom the CD4-lymphocyte count was decreased from normal. The patients' level of satisfaction with the results was high.

Yttrium synovectomy in haemophilic arthropathy

Between 1987 and 1991 we performed Yttrium-90 (Y-90) silicate radionuclide synovectomies on 40 joints of 20 haemophiliac patients with haemophilic arthropathy. All were male, their mean age was 31 yr and 15 of the 20 (75%) were HIV antibody positive. The number of joint bleeds and amount of factor (VIII and IX) replacement given in the 6 months pre- and 6 and 12 months post-radionuclide synovectomy was compared. Y-90 silicate synovectomy was shown significantly to reduce both the number of joint bleeds (P < 0.001) and factor usage (P < 0.001) in the 6 months after the procedure, a result maintained up to 12 months. Depot methyl prednisolone was co-administered with Y-90 but thought unlikely to contribute to joint response beyond 6 months. The reduction of joint bleeds and factor usage was even more dramatic in the 6- to 12-month period post-synovectomy although this was not reflected by the P value (P < 0.001). The reduction of joint bleeds and factor consumption post-synovectomy was most obvious in elbow joints, although the other joints as a group showed a significant reduction. Patients who were HIV antibody positive showed considerable improvement up to 12 months post-treatment, both in reduction of joint bleeds and as a consequence factor consumption. This improvement was seen to a lesser extent in the smaller HIV-negative group.

Hemarthrosis and synovitis associated with hemophilia: clinical use of P-32 chromic phosphate synoviorthesis for treatment

PURPOSE

To evaluate the clinical usefulness of phosphorus-32 chromic phosphate synoviorthesis in patients with hemophilia, recurrent hemarthrosis, and synovitis.

MATERIALS AND METHODS

Forty-four P-32 colloid synoviorthesis procedures were performed in 38 patients with these abnormalities. P-32 colloid was injected intramuscularly in a dose of 1.0 mCi (37.0 MBq) in adult knees and 0.5 mCi (18.5 MBq) in adult elbows. A thin-window Geiger-Müller counter was used to survey treated joints, lymph nodes, and liver in order to detect leakage from the joint. Follow-up extended to a maximum of 4 years after treatment.

RESULTS

No evidence of clinically significant leakage was seen. Twenty-two of 28 treatments (78%) with longer than 6 months follow-up were associated with improvement in range of motion and frequency of hemorrhage. Of 15 treatments with longer than 2 years follow-up, 10 (67%) were associated with improvement in range of motion; 12 (80%), with improvement in frequency of hemorrhage; and 12 (80%) with improvement in quality-of-life activities.

CONCLUSION

P-32 colloid synoviorthesis is a clinically useful out-patient procedure in patients with hemophilia, recurrent hemarthrosis, and synovitis in whom hemostatic therapy has failed.

Histological studies on the rheumatoid synovial membrane irradiated with a low energy laser

The beneficial effects of low energy laser irradiation on rheumatoid arthritis (RA) joints have been reported, but the mechanisms of action of low energy lasers in RA are unclear. The synovial membrane in cases of RA was studied histologically to observe the effects of low energy laser irradiation. Fourteen knee joints of RA cases, which had been scheduled for arthroplasty, were irradiated with a gallium-aluminium-arsenide (Ga-Al-As) laser (790 nm in wavelength and 10 mW of output power) prior to the surgical operation, at six points of the external aspect of the knee joint for 80 seconds at each points once a day for 6 days. On the day following the last irradiation, pieces of synovial membrane from the lateral irradiated area and from the median nonirradiated area as a control were resected during the arthroplasty. The histological findings of the irradiated synovial membrane showed flattening of epithelial cells, decreased villous proliferation, narrowed vascular lumen, and less infiltration of inflammatory cells compared with those of nonirradiated synovia. The evaluation of slides was done in a blinded manner, and significant differences was seen by Wilcoxon's t-test (P < 0.01). Histological findings suggested that the low energy laser irradiation induced suppression of inflammation in the synovial membrane of RA.

Re-evaluating the need for hospitalization following synovectomy using Yttrium-90 silicate

In 51 patients treated with Yttrium-90 (Y-90) synovectomy for rheumatoid (inflammatory) arthritis (IA) and OA of the knee we found that decreased retained knee activity (RKA) and increased extra-articular activity in lymph nodes and liver are more likely to be found in IA than OA and following bilateral knee injections. Joint inflammation, as assessed by radionuclide blood pool scan but not by SF white cell count, correlates with decreased RKA and increased activity in lymph nodes. Intra-articular steroid had no significant effect on retention or extra-articular uptake. Strict hospital immobilization improves RKA of Y-90 in IA but not in OA. Y-90 synovectomy in OA shows good RKA and low extra-articular uptake. We recommend strict immobilization following Y-90 synovectomy, particularly in IA patients and/or those with high joint blood flow.

Radiation synovectomy revisited

Radiation synovectomy is a potential weapon in the therapeutic armamentarium of nuclear medicine. It is an attractive alternative to surgical or chemical synovectomy for the treatment of rheumatoid arthritis. In this article the clinical results obtained with radiation synovectomy from the 1950s through 1992 are summarized and reviewed. Even after taking into account the paucity of well-controlled trials and rigorous clinical follow-up, it is clear that radiation synovectomy is efficacious in controlling the symptoms of rheumatoid arthritis. However, the procedure is not widely used because of concerns about leakage of radioactivity from the treated joint, and the resulting high doses that can be delivered to nontarget organs. New approaches to the preparation of radiolabeled particles for use in radiation synovectomy promise to minimize this leakage and thus allow the full potential of this important radiotherapy to be realized.

Chemistry and biological behavior of samarium-153 and rhenium-186-labeled hydroxyapatite particles: potential radiopharmaceuticals for radiation synovectomy

Hydroxyapatite (HA), a natural constituent of bone, was studied as a particulate carrier for beta-emitting radionuclides in radiation synovectomy. Particles were radiolabeled with 153Sm or 186Re and their in vivo safety was investigated following intra-articular injection into knees of normal rabbits and rabbits with antigen-induced arthritis (AIA). Radiolabeling efficiency was greater than 95%; in vitro studies showed minimal (< or = 1%) loss of activity from particles over a 6-day period with 153Sm-labeled HA and about 5% loss of activity over a 5-day period with 186Re-labeled HA. The total cumulative extra-articular leakage of 153Sm over 6 days was 0.28% in normal rabbits and 0.09% in AIA rabbits. Leakage of 186Re from the joint was 3.05% over a 4-day period with 80% of extra-articular activity found in the urine. Histopathological evaluation of treated knees showed that HA particles are distributed throughout the synovium, embedded in the synovial fat pad. The ease and efficiency with which this HA carrier is labeled, coupled with observed extremely low leakage rates from the joint, make radiolabeled HA particles an attractive candidate as a radiation synovectomy agent for evaluation in rheumatoid arthritis patients.

Long term follow up of radiosynovectomy with yttrium-90 silicate in haemophilic haemarthrosis

OBJECTIVES

The aim of this study was to evaluate the long term effect of radiation synovectomy with yttrium-90 silicate in haemophiliac patients with recurrent haemarthrosis.

METHODS

The bleeding frequency and the mobility of the joint were recorded in 16 joints of 14 patients 1 year before radiosynovectomy and during follow up, which ranged from 3 to 6 years. Patients evaluated the effect of their own treatment by completing a questionnaire. Radiographs of the joints were scored by an independent radiologist before treatment.

RESULTS

A satisfactory reduction of the frequency of haemorrhage was achieved in 94% of joints during the first year after treatment and was maintained in 63% until the end of the follow up period. In general there was no decrease in mobility attributable to radiosynovectomy, and the patients' own evaluations agreed with the evaluations based on the frequencies of haemarthrosis in 75%. Patients who had only minor, or no, radiological abnormalities of the joints before treatment showed the best results. One patient developed synovitis as a complication of the radiosynovectomy.

CONCLUSION

Radiosynovectomy is an effective and safe treatment for recurrent haemarthrosis in haemophiliac patients, especially in those who have joints with no or minor radiological damage.

[Radiosynoviorthesis]

Intraarticular therapy using radionuclides seems to be the best conservative local treatment of chronic synovitis as a generally accepted alternative to surgical synovectomy. If the indication is carefully considered and the technique properly applied, the success rate of treatment is as high as it is with surgery, whereas the risk involved is comparatively low.

Yttrium synovectomy: a meta-analysis of the literature

BACKGROUND

Yttrium synovectomy for chronic synovitis of the knee enjoys widespread usage in Australia with approximately 400 patients receiving yttrium-90 in 1991. Despite abundant anecdotal evidence of its efficacy there is a paucity of controlled trials and those that have been done have produced conflicting results and have been of insufficient sample size.

AIMS

To critically and quantitatively evaluate the published English literature on comparative trials of yttrium-90 therapy for chronic synovitis of the knee.

METHODS

The technique of meta-analysis was utilised. The literature search was carried out using the MeSH terms of synovectomy and knee; and yttrium. This was augmented by referring to reviews, current textbooks and back-references. Outcome measures varied between trials but could be grouped as treatment success. The Peto modification of Mantel and Haenszl was used for statistical pooling of data yielding a pooled odds ratio (OR).

RESULTS

The literature search revealed ten controlled trials of which two were excluded from further analysis. Yttrium was superior to placebo (OR 2.42, 95% CI 1.02-5.73) but this result should be interpreted with caution due to possible publication bias. Yttrium was not superior to triamcinolone (OR 1.89, 95% CI 0.81-10.55) or other active modalities (OR 1.04, 95% CI 0.72-1.52). Further research comparing yttrium with other modalities is necessary to properly determine its place in rheumatological practice.

Calculation of beta dosimetry in radiation synovectomy using Monte Carlo simulation (EGS4)

Using the EGS4 Monte Carlo code, absorbed dose rate factors were estimated for four radionuclides of interest in radiation synovectomy, an intra-articular radiation therapy to treat rheumatoid arthritis. The treatment consists of the injection of a beta-emitting radionuclide into the joint capsule in order to eliminate diseased synovium through irradiation. The radionuclides investigated are 32P, 90Y, 165Dy, and 198Au. Calculations reveal the absorbed dose factor (cGy cm2/MBq s) as a function of distance (mm) in an EGS4 model of the rheumatic joint. The model incorporates bone, articular cartilage, joint capsule, and tissue (synovium) components found in all synovial joints, with dimensions in the model corresponding to dimensions typically found in larger joints, e.g., the knee, shoulder, or hip. Results are compared with previous, analytical approaches to beta dosimetry in radiation synovectomy. In addition, radiation backscatter due to the presence of bone is investigated and determined to have a negligible enhancement effect on absorbed dose to synovium.

Long term follow up of haemophilic arthropathy treated by Au-198 radiation synovectomy

Intra-articular injection of Au-198 (gold synoviorthesis) has been used in the treatment of repeated haemarthroses of the elbows, knees, or ankles in 64 haemophiliacs. These patients had continued to have joint haemorrhages despite appropriate, episodic, substitutive therapy over a period of more than six months. Follow-up for an average period of 14 years in one knee in 38 male haemophiliacs showed 8 good, 23 fair, and 7 poor results with regard to their joint scores. It is concluded that Au-198 is an effective agent for radiation synovectomy, particularly in the early stages of the disease with minimal radiographic changes. It appears to reduce the incidence of haemarthrosis and to slow the rate of evolution of radiographic changes.

Absorbed dose profiles for radionuclides of frequent use in radiation synovectomy

Absorbed dose profiles are presented for radionuclides of frequent or potential use in radiation synovectomy, an intraarticular technique aimed at treating rheumatoid arthritis through direct and highly selective irradiation of inflamed synovium. The radionuclides investigated were 198Au, 165Dy, 32P, 186Re, 90Y, and 166Ho. These profiles reveal the absorbed dose imparted per unit activity of injected radionuclide (Gy/mCi) as a function of penetration distance (mm) to major components of the arthritic synovial joint. Their usefulness is twofold: they can be employed to select the radionuclide best suited to achieving the proper depth of penetration in tissue (approximating the thickness of the inflamed synovium) and to determine, a priori, the necessary dose of radioactivity (delivering an absorbed dose sufficient to effectively treat all the diseased tissue). The extent of radiation of other synovial joint components, such as bone and articular cartilage, and how the advancing rheumatoid arthritis can be expected to alter the extent and pattern of absorbed dose penetration in the joint are also discussed.

[Synoviorthesis--an alternative to synovectomy?]

In the treatment of inflammatory rheumatic diseases with chronic course, operative and respectively arthroscopic synovectomy on the one hand and synoviorthesis on the other hand come into question. Synoviorthesis by corticosteroids has a very large indication if the corresponding measures of precaution are heeded. Chemical synoviorthesis, mainly by osmium tetroxide, is applied above all in exudative inflammatory diseases, whereas radiosynoviorthesis with the nuclides used at present is mainly applied in proliferative diseases; as a rule, synovectomy should be preferred in young patients. Likewise, synovectomy is the method of choice, respectively, in tenosynovitis and if reconstructive measures at the joint are necessary.

[Hemophilic arthropathy. The therapeutic approaches in the clinical picture of hemophilia]

The ambulatory treatment of hemophilic arthropathy decreased the amount of replacement therapy with factor VIII from 3,220,000 U in 1984 to 2,217,700 U (32%) in 1988. Radioactive synovectomy diminished the number of hemarthroses in 97 per cent. Intraarticular dexamethasone reduced bleeding episodes and improved joint function in 48 per cent. These procedures for hemophilic arthropathy allowed to integrate the patient into society and diminished transfusion risks.

The rheumatoid elbow: patterns of joint involvement and the outcome of synoviorthesis

Rheumatoid arthritis of the elbow is a common condition. A group of 86 patients has been reviewed. Patterns of joint involvement are described. These patients have been subjected to 137 radioisotopic synoviortheses. 72% achieved a result classed as "good" and this review underlines the efficacy of the procedure of synoviorthesis. Radiological staging has been shown to have prognostic significance; 89% of good results were obtained in management of Steinbrocker grade I. No complications were recorded.

[Radiosynoviorthese in the treatment of patients with rheumatoid arthritis]

Radiosynoviorthese, a new method for the treatment of patients with rheumatoid arthritis, was developed. Altogether 260 patients with rheumatoid arthritis were treated. The therapeutic activity of radioactive colloid Au was administered intra-articularly to all the patients. Indications and contraindications for radiation therapy of rheumatoid arthritis were developed. Good short- and long-term results were noted in most of the patients after radiation therapy. Radiosynoviorthese as a method of local active therapy of affected joints with colloid Au in the multiple modality treatment of rheumatoid arthritis is effective; its prolonged stable therapeutic effect in patients is observed.

Dysprosium (165Dy) hydroxide macroaggregates for radiation synovectomy--animal studies

This paper reports the development of a new chemical formulation, Dy-HMA, to utilise the advantages of dysprosium 165 in radiation synovectomy of certain forms of arthritis. Dy-HMA is a sterile suspension of dysprosium hydroxide macroaggregates (approximately 6 mg Dy/ml) in saline with the majority of particles in the 3-5 microns range. The absence of ferric hydroxide and a higher concentration of dysprosium in the formulation offer advantages over dysprosium ferric hydroxide macroaggregates, Dy-165-FHMA. Biodistribution studies in rats and rabbits with Dy-HMA show less leakage than with Dy-FHMA and considerably less leakage than with yttrium silicate colloid. Rabbits treated with intra-articular injections of Dy-HMA equivalent to 10-30 times the typical clinical dose showed no signs of any toxic effects.