Are bone erosions detected by magnetic resonance imaging and ultrasonography true erosions? A comparison with computed tomography in rheumatoid arthritis metacarpophalangeal joints

The Clinical Utility of Musculoskeletal Ultrasound for Disease Activity Evaluation and Therapeutic Response Prediction in Rheumatoid Arthritis Patients: A Narrative Review

Rheumatoid arthritis (RA) is characterized by persistent synovitis and joint/bone destruction. There is an unmet need to predict the therapeutic response to disease-modifying anti-rheumatic drugs (DMARDs) and achieve a treat-to-target goal. Musculoskeletal ultrasound (MSUS) is widely used to identify structural change and assess therapeutic response in RA. This review aims to summarize the available evidence regarding the clinical application of MSUS in evaluating disease activity and predicting therapeutic responses to DMARDs. We searched the MEDLINE database using the PubMed interface and reviewed English-language literature from 2000 to 2022. This review focuses on the updated role of MSUS in assessing disease activity and predicting therapeutic responses to DMARDs in RA patients. MSUS is now widely applied to identify articular structural change and assess the disease activity of RA. Combined use of gray scale and power Doppler MSUS is also superior to clinical assessment and laboratory examination in evaluating disease activity of RA. With portable use, good viability, and high sensitivity to articular inflammation, MSUS would be useful in assessing therapeutic response to biologic/targeted synthetic DMARDs (b/tsDMARDs) in RA patients. Given MSUS could also detect subclinical inflammation in a substantial proportion of RA patients with clinical remission, it is recommended to assess b/tsDMARDs-treated RA patients who have achieved low disease activity or remission. Although substantial literature data have revealed clinical utility of MSUS for monitoring disease activity and evaluating therapeutic response in RA patients, the evidence regarding its predictive value for the effectiveness of b/tsDMARDs is limited.

ACR Appropriateness Criteria® Chronic Extremity Joint Pain-Suspected Inflammatory Arthritis, Crystalline Arthritis, or Erosive Osteoarthritis: 2022 Update

Evaluation for suspected inflammatory arthritis as a cause for chronic extremity joint pain often relies on imaging. It is essential that imaging results are interpreted in the context of clinical and serologic results to add specificity because there is significant overlap of imaging findings among the various types of arthritis. This document provides recommendations for imaging evaluation of specific types of inflammatory arthritis, including rheumatoid arthritis, seronegative spondyloarthropathy, gout, calcium pyrophosphate dihydrate disease (or pseudogout), and erosive osteoarthritis. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Imaging of Rheumatic Diseases Affecting the Lower Limb

Imaging methods capable of detecting inflammation, such as MR imaging and ultrasound, are of paramount importance in rheumatic disease management, not only for diagnostic purposes but also for monitoring disease activity and treatment response. However, more advanced stages of arthritis, characterized by findings of cumulative structural damage, have traditionally been accomplished by radiographs and computed tomography. The purpose of this review is to provide an overview of imaging of some of the most prevalent inflammatory rheumatic diseases affecting the lower limb (osteoarthritis, rheumatoid arthritis, and gout) and up-to-date recommendations regarding imaging diagnostic workup.

The Reliability of Ultrasound in the Assessment of Hyaline Cartilage in Rheumatoid Arthritis and Healthy Metacarpal Heads

PURPOSE

 i) To assess the inter- and intra-observer reliability of ultrasound (US) in the evaluation of the hyaline cartilage (HC) of the metacarpal head (MH) in patients with rheumatoid arthritis (RA) and in healthy subjects (HS) both qualitatively and quantitatively. ii) To calculate the smallest detectable difference (SDD) of the MH cartilage thickness measurement. iii) To correlate the qualitative scoring system and the quantitative assessment.

MATERIALS AND METHODS

 US examination was performed on 280 MHs of 20 patients with RA and 15 HS using a very high frequency probe (up to 22 MHz). HC status was evaluated both qualitatively (using a five-grade scoring system) and quantitatively (using the average value of the longitudinal and transverse measures). The HC of MHs from II to V metacarpophalangeal joint of both hands were scanned independently on the same day by two rheumatologists to assess inter-observer reliability. All subjects were re-examined using the same scanning protocol and the same US setting by one sonographer after a week to assess intra-observer reliability.

RESULTS

 The inter-observer agreement and intra-observer agreement were moderate to substantial (k = 0.66 and k = 0.73) for the qualitative scoring system and high (ICC = 0.93 and ICC = 0.94) for the quantitative assessment. The SDD of the MH cartilage thickness measurement was 0.09 mm. A significant correlation between the two scoring systems was found (r = -0.35; p < 0.001).

CONCLUSION

 The present study describes the main methodological issues of HC assessment. Using a standardized protocol, both the qualitative and the quantitative scoring systems can be reliable.

Comparison of High-Resolution Ultrasonography With Magnetic Resonance Imaging in Rheumatoid Arthritis

Objective:

The aim of this study was to examine whether high-resolution ultrasonography (HRUS) can provide information, on signs of inflammation and destruction, due to rheumatoid arthritis (RA). The focus was on the wrist joint, during early and late disease and compared the findings to those with magnetic resonance imaging (MRI).

Materials and Methods:

The study was based on 31 RA patients, with joint involvements, who were selected from those attending the outpatient rheumatology clinic. The patients completed both HRUS and MRI examinations, and their results were compared.

Results:

The HRUS and MRI images had near-perfect agreement, for detecting joint anomalies, in those RA patients. While comparing the overall performance of the HRUS and MRI studies, it was observed that HRUS was equal or nearly equal, demonstrating 90.83%, 100.0% and 94.93%, diagnostic sensitivity, specificity, and accuracy, respectively, for diagnosing RA pathologies.

Conclusion:

The early diagnosis of RA with HRUS and MRI examinations is very important, in the early treatment of RA. The HRUS examinations demonstrated a sensitive and reliable diagnostic method for assessing inflammatory activity and destructive changes in the joints of these RA patients, with HRUS findings comparable to those of MRI.

A deep-learning framework for metacarpal-head cartilage-thickness estimation in ultrasound rheumatological images

OBJECTIVE

Rheumatoid arthritis (RA) is a chronic disease characterized by erosive symmetrical polyarthritis. Bone and cartilage are the main joint targets of this disease. Cartilage damage is one of the most relevant determinants of physical disability in RA patients. Cartilage damage is nowadays assessed by clinicians, which manually measure cartilage thickness in ultrasound (US) imaging. This poses issues relevant to intra-and inter-observer variability. Relying on the acquisition of metacarpal-head US images from 38 subjects, this work addresses the problem of automatic cartilage-thickness measurement by designing a new deep-learning (DL) framework.

METHODS

The framework consists of a Convolutional Neural Network (CNN), responsible for regressing cartilage-interface distance fields, followed by a post-processing step to delineate the two cartilage interfaces from the predicted distance fields and compute the cartilage thickness.

RESULTS

Our framework achieved encouraging results with a mean absolute difference (ADF) of 0.032 (±0.026) mm against manual thickness annotation by an expert clinician. When evaluating the intra-observer variability, we obtained an ADF = 0.036 (±0.028) mm.

CONCLUSION

The proposed framework achieved an ADF against manual annotation that was comparable to the intra-observer variability, proving the potential of DL in the field.

SIGNIFICANCE

This work is the first to address the problem of automatic cartilage-thickness estimation in US rheumatological images with DL, paving the way for future research in the field. From a clinical perspective, the proposed framework proved to be a valuable tool to support the clinical routine increasing the reproducibility of cartilage thickness measurements.

Management of Rheumatoid Arthritis: An Overview

Rheumatoid arthritis (RA) is a multifactorial autoimmune disease of unknown etiology, primarily affecting the joints, then extra-articular manifestations can occur. Due to its complexity, which is based on an incompletely elucidated pathophysiological mechanism, good RA management requires a multidisciplinary approach. The clinical status of RA patients has improved in recent years due to medical advances in diagnosis and treatment, that have made it possible to reduce disease activity and prevent systemic complications. The most promising results were obtained by developing disease-modifying anti-rheumatic drugs (DMARDs), the class to which conventional synthetic, biologic, and targeted synthetic drugs belong. Furthermore, ongoing drug development has led to obtaining molecules with improved efficacy and safety profiles, but further research is needed until RA turns into a curable pathology. In the present work, we offer a comprehensive perspective on the management of RA, by centralizing the existing data provided by significant literature, emphasizing the importance of an early and accurate diagnosis associated with optimal personalized treatment in order to achieve better outcomes for RA patients. In addition, this study suggests future research perspectives in the treatment of RA that could lead to higher efficacy and safety profiles and lower financial costs.

Erosive arthritis in systemic lupus erythematosus: not only Rhupus

Systemic lupus erythematosus (SLE)-related arthritis has been traditionally defined as non-erosive and is therefore considered a minor manifestation requiring a mild treatment. However, the concept of non-erosive arthritis in SLE has been challenged with the advent of sensitive imaging techniques, such as high-resolution ultrasound with power Doppler or magnetic resonance. The application of these new imaging tools has demonstrated that up to 40% of SLE patients with joint involvement can develop erosive damage. Thus, this more aggressive phenotype can be identified not only in patients overlapping with rheumatoid arthritis (RA). This issue has been considered for the first time in the classification criteria proposed by Systemic Lupus International Collaborating Clinics in 2012, in which the old definition of "non-erosive arthritis" was replaced with either synovitis or tenderness in two or more joints with morning stiffness, suggesting the possible presence of an erosive phenotype. Accordingly, the 2019 EULAR/ACR's SLE recommendations advise treatment with immunosuppressant or biological drugs for patients with RA-like moderate arthritis. As a result, several studies have investigated the presence of biomarkers associated with SLE erosive damage. A relevant role seems to be played by the autoantibodies directed against post-translational modified proteins: above all, a significant association has been observed with antibodies directed against citrullinated and carbamylated proteins. Conversely, the rheumatoid factor was not associated with this more aggressive SLE-related arthritis. Nonetheless, some pro-inflammatory factors have been associated with erosive damage in SLE patients. These results suggest new pathogenic mechanisms underlining erosive arthritis, only partially shared with RA. Hence, in the present narrative review, we summarized available data about erosive arthritis in SLE patients, in the light of its impact on therapeutic decisions.

Comparison Between Ultrasonographic and Standing Magnetic Resonance Imaging Findings in the Podotrochlear Apparatus of Horses With Foot Pain

This prospective study aimed to blindly compare the ultrasonographic and standing magnetic resonance imaging (sMRI) findings in deep digital flexor tendon (DDFT), navicular bone, and navicular bursa in horses with foot pain, positive digital analgesia, and without definitive radiographic diagnosis. Ultrasonography detected more DDFT abnormalities (32/34 feet vs. 27/34 with sMRI) but identified less palmar navicular abnormalities (23/34 feet vs. 30/34 with sMRI). In suprasesamoidean DDFT lesions, which were mainly dorsally located, changes in echogenicity did not correspond to a particular pattern of sMRI signal change. Transcuneal ultrasonography did not allow assessment of morphology and extent of distal DDFT lesions, and sporadically discriminated the affected lobe compared to sMRI. Defects of the palmar compact bone were identified with both modalities except a parasagittal defect, which was only seen at sMRI.

Sonographic assessment of cartilage damage at metacarpal head in rheumatoid arthritis: qualitative versus quantitative methods

OBJECTIVE

To test the validity of the Outcome Measure in Rheumatology (OMERACT) semiquantitative score by comparing with a quantitative method in the sonographic (US) assessment of hyaline cartilage at the metacarpal head (MH) in patients with rheumatoid arthritis (RA) and healthy subjects (HS).

METHODS

The hyaline cartilage from second to fifth MHs of both hands was scanned. Hyaline cartilage was scored semiquantitatively and quantitatively (by measuring cartilage thickness and comparing with reference values). In RA patients, radiographic joint space narrowing (JSN) was scored on the same joints using the Simple Erosion Narrowing Score (SENS).

RESULTS

Four-hundred and eight MHs in 51 RA patients and 320 MHs in 40 HS were evaluated. The OMERACT semiquantitative score was quicker to perform than the quantitative method (6.0 ± 0.5 vs 8.0 ± 1.5 min, p< 0.01). A significant correlation between the US scores (R = 0.68), and between the US scores and the JSN-SENS (R = 0.61 and R = 0.63, for semiquantitative and quantitative method, respectively) was found. The frequency of cartilage abnormalities was similar between the two US methods in RA patients (58.8% and 51.0% RA patients for semiquantitative and quantitative method, p= 0.46), while the former revealed more abnormalities in HS (27.5% and 7.5% of HS, p= 0.02).

CONCLUSION

The higher feasibility of the OMERACT semiquantitative score suggests its use as first-choice method in the evaluation of cartilage damage. However, despite its limits, the quantitative assessment of HC, providing patient-tailored information due to age- and sex-corrected cut-off values, may represent a valid supplement for optimizing the evaluation of cartilage damage in selected cases.

Bisphosphonates in inflammatory rheumatic diseases

The main well recognized action of bisphosphonates (BPs) is their antiresorptive capacity, making them first-line drugs in the treatment of osteoporosis and other metabolic bone diseases. In this review we have compiled other possible actions of BPs, particularly in the areas of immunomodulation, anti-inflammatory capacity and in the prevention of structural joint damage in inflammatory rheumatic diseases. The immunomodulatory capacity of BPs has been focused on the mechanisms involved in the acute-phase response associated with the administration of nitrogen containing BPs (N-BPs), with the stimulus of pro-inflammatory cytokines, through the mevalonate pathway, activation of T-cells and the decrease in the cytotoxic T-lymphocyte antigen-4 (CTLA-4). In relation to their anti-inflammatory capacity, special attention has been given to their effect on preventing structural damage in inflammatory joint diseases and on the differential immune response in bone lesions of the most common and representative inflammatory rheumatic diseases, i.e. rheumatoid arthritis and spondyloarthropathies. The present data indicate that more studies are needed to improve the knowledge on the effect of BPs on inflammatory-mediated diseases and particularly on the prevention and/or treatment of the structural damage in these disorders, since these agents could be a potential useful concomitant therapy.

The sonographic identification of cortical bone interruptions in rheumatoid arthritis: a morphological approach

Bone erosions are the hallmark of structural damage in rheumatoid arthritis (RA). Among imaging techniques, ultrasonography (US) has emerged as an accurate, reliable, repeatable, low-cost and non-invasive imaging modality to detect erosive changes in RA. However, small interruptions of the cortical bone detectable by last generation US equipment do not necessarily represent bone erosions. According to the available data, in addition to cortical bone interruption itself, only a few morphological US findings have been proposed to define RA bone erosions. However, other additional features may be considered to facilitate the interpretation of US cortical bone interruptions in RA. These could be summarised using the following four domains: size, site, shape and scenery. This hypothesis article provides a critical literature review of US features characteristic of RA bone erosions and pictorial evidence supporting the potential role of a morphological analysis in the US identification of bone erosions in RA patients.

Plain language summary

The ultrasonographic morphology of cortical interruptions is helpful for the identification of bone erosions in rheumatoid arthritis: the "four Ss" approach Bone erosions are characteristic features of rheumatoid arthritis. They are associated with a more aggressive disease and with irreversible physical disability. In recent years, ultrasonography has emerged as an accurate and reliable technique for the detection of bone erosions, that appear as interruptions of the cortical bone with variable size. However, cortical bone interruptions do not necessarily represent bone erosions. Since bone erosions represent the earliest evidence of the destructive behaviour of RA, their identification is crucial.Besides the cortical interruption itself, only a few morphological ultrasonographic features were proposed to characterise bone erosions in rheumatoid arthritis.We believe that a morphological approach, including size, site, shape and scenery, may be considered to facilitate the interpretation of ultrasonographic cortical bone interruptions in rheumatoid arthritis.In this hypothesis article we carried out a critical review of the scientific literature and provided extensive pictorial evidence of the ultrasonographic spectrum of cortical interruptions supporting the potential role of considering the "four Ss" for the ultrasonographic identification of bone erosions in rheumatoid arthritis.

Structural damage in rheumatoid arthritis assessed by musculoskeletal ultrasound: A systematic literature review by the Structural Joint Damage Task Force of the OMERACT Ultrasound Working Group

OBJECTIVES

To identify and synthesize the evidence for the use and measurement properties of musculoskeletal ultrasound in assessing structural joint damage in patients with rheumatoid arthritis (RA).

METHODS

A systematic literature search (SLR) of the PubMed, Embase and Cochrane Library was performed. Original articles were included published in English reporting on ultrasound of bone erosion, cartilage damage and the measurement properties of ultrasound according to the OMERACT filter 2.1.

RESULTS

Of the 1.495 identified articles 149 were included in the final review, most of which reported on cross-sectional studies and used the OMERACT definitions for ultrasonographic pathology. Among these, bone erosions were assessed in 139 (93.3%), cartilage damage in 24 (16.1%), enthesophytes in 8 (5.4%), osteophytes in 15 (10.1%) and malalignment and ankylosis in a single (0.9%) study, respectively. Most studies (126/149, 84.6%) assessed the joints of the hands. The overwhelming majority of studies (127/149, 85.2%) assessed structural joint damage bilaterally. Validity, reliability and responsiveness were assessed in 21 (14.1%), 34 (22.8%) and 17 (11.4%) studies, respectively.

CONCLUSION

While the results of this SLR suggest that ultrasound is a sensitive, reliable and feasible tool to detect damage in RA, they also highlight the need for further research and validation. Findings of this SLR will inform the next steps of the OMERACT Ultrasound Working Group in developing an ultrasound score for assessing structural joint damage in patients with RA.

Artificial Intelligence for Ultrasound Informative Image Selection of Metacarpal Head Cartilage. A Pilot Study

Objectives: This study aims to develop an automatic deep-learning algorithm, which is based on Convolutional Neural Networks (CNNs), for ultrasound informative-image selection of hyaline cartilage at metacarpal head level. The algorithm performance and that of three beginner sonographers were compared with an expert assessment, which was considered the gold standard.

Methods: The study was divided into two steps. In the first one, an automatic deep-learning algorithm for image selection was developed using 1,600 ultrasound (US) images of the metacarpal head cartilage (MHC) acquired in 40 healthy subjects using a very high-frequency probe (up to 22 MHz). The algorithm task was to identify US images defined informative as they show enough information to fulfill the Outcome Measure in Rheumatology US definition of healthy hyaline cartilage. The algorithm relied on VGG16 CNN, which was fine-tuned to classify US images in informative and non-informative ones. A repeated leave-four-subject out cross-validation was performed using the expert sonographer assessment as gold-standard. In the second step, the expert assessed the algorithm and the beginner sonographers' ability to obtain US informative images of the MHC.

Results: The VGG16 CNN showed excellent performance in the first step, with a mean area (AUC) under the receiver operating characteristic curve, computed among the 10 models obtained from cross-validation, of 0.99 ± 0.01. The model that reached the best AUC on the testing set, which we named “MHC identifier 1,” was then evaluated by the expert sonographer. The agreement between the algorithm, and the expert sonographer was almost perfect [Cohen's kappa: 0.84 (95% confidence interval: 0.71–0.98)], whereas the agreement between the expert and the beginner sonographers using conventional assessment was moderate [Cohen's kappa: 0.63 (95% confidence interval: 0.49–0.76)]. The conventional obtainment of US images by beginner sonographers required 6.0 ± 1.0 min, whereas US videoclip acquisition by a beginner sonographer lasted only 2.0 ± 0.8 min.

Conclusion: This study paves the way for the automatic identification of informative US images for assessing MHC. This may redefine the US reliability in the evaluation of MHC integrity, especially in terms of intrareader reliability and may support beginner sonographers during US training.

Identification, localization and differentiation of erosions and physiological bone channels by ultrasound in rheumatoid arthritis patients

OBJECTIVES

Ultrasound (US) can detect cortical bone lesions in RA. However, not all cortical bone lesions are erosions. Herein, we aimed to define whether US can differentiate between physiological bone channels and pathological erosions in RA and to provide topographic description of their differential localization.

METHODS

RA patients and healthy controls (HC) received US examination of the metacarpophalangeal (MCPJ) and proximal inter-phalangeal (PIPJ) joints adjudicating cortical bone lesions as physiological bone channels or pathological erosions. In a subset of RA patients and HC, high-resolution peripheral quantitative computed tomography (HR-pQCT) of the hand was performed to validate the classification of lesions.

RESULTS

A total of 40 RA patients and 43 HC were enrolled and totally 771 MCPJ and 638 PIPJ were examined by US, and 94 and 51, respectively, by HR-pQCT. US-defined cortical bone lesions clustered in the lateral part of the MCP (50%) and the dorsal part of the PIPJ (66.7%) in RA. US-defined physiological bone channels clustered in the palmar parts of the MCPJ and PIPJ in both RA (78.8% and 100%, respectively) and HC (51.8% and 80%, respectively). HR-pQCT data confirmed US data with respect to adjudication of physiological bone channels and pathological erosions. Erosions were significantly (all P <0.000001) larger than physiological channels and preferentially localized at radial and ulnar sites, while physiological channels were clustered at palmar sites. Specificity of US was excellent for erosions in RA and for physiological bone channels in HC and RA.

CONCLUSION

US allows differentiation between physiological channels and bone erosions in RA.

Quantification of Joint Space Width Difference on Radiography Via Phase-Only Correlation (POC) Analysis: a Phantom Study Comparing with Various Tomographical Modalities Using Conventional Margin-Contouring

Several visual scoring methods are currently used to assess progression of rheumatoid arthritis (RA) on radiography. However, they are limited by its subjectivity and insufficient sensitivity. We have developed an original measurement system which uses a technique called phase-only correlation (POC). The purpose of this study is to validate the system by using a phantom simulating the joint of RA patients.A micrometer measurement apparatus that can adjust arbitrary joint space width (JSW) in a phantom joint was developed to define true JSW. The phantom was scanned with radiography, 320 multi detector CT (MDCT), high-resolution peripheral quantitative CT (HR-pQCT), cone beam CT (CBCT), and tomosynthesis. The width was adjusted to the average size of a women's metacarpophalangeal joint, from 1.2 to 2.2 mm with increments of 0.1 mm and 0.01 mm. Radiographical images were analyzed by the POC-based system and manual method, and images from various tomographical modalities were measured via the automatic margin detection method. Correlation coefficients between true JSW difference and measured JSW difference were all strong at 0.1 mm intervals with radiography (POC-based system and manual method), CBCT, 320MDCT, HR-pQCT, and tomosynthesis. At 0.01 mm intervals, radiography (POC-based system), 320MDCT, and HR-pQCT had strong correlations, while radiography (manual method) and CBCT had low correlations, and tomosynthesis had no statistically significant correlation. The smallest detectable changes for radiography (POC-based system), radiography (manual method), 320MDCT, HR-pQCT, CBCT, and tomosynthesis were 0.020 mm, 0.041 mm, 0.076 mm, 0.077 mm, 0.057 mm, and 0.087 mm, respectively. We conclude that radiography analyzed with the POC-based system might sensitively detect minute joint space changes of the finger joint.

HR-pQCT in vivo imaging of periarticular bone changes in chronic inflammatory diseases: Data from acquisition to impact on treatment indications

Imaging is essential for the assessment of bone and inflammatory joint diseases. There are several imaging techniques available that differ regarding resolution, radiation exposure, time expending, precision, cost, availability or ability to predict disease progression. High-resolution peripheral quantitative computed tomography (HR-pQCT) that was introduced in 2004 allows the in vivo evaluation of peripheral bone microarchitecture and demonstrated high precision in assessing bone changes in inflammatory musculoskeletal diseases. This review summarizes the use of HR-pQCT for the evaluation of the hand skeleton in inflammatory joint diseases. We conducted a review of the literature regarding the protocols that involve hand joints assessment and evaluation of bone changes as erosions and osteophytes in chronic inflammatory diseases. Apart from measuring bone density and structure of the radius and the tibia, HR-pQCT has contributed to assessment of bone erosions and osteophytes, considered the hallmark of diseases as rheumatoid arthritis and psoriatic arthritis, respectively. In this way, there are some conventions recently established by rheumatic study groups that we just summarized here in order to standardize HR-pQCT measurements.

Immune checkpoint inhibitor-induced inflammatory arthritis: identification and management

INTRODUCTION

Immune checkpoint inhibitors (ICIs) have proved to be groundbreaking in the field of oncology. However, immune system overactivation from ICIs has introduced a novel medical entity known as immune-related adverse events (irAEs), that can affect any organ or tissue. ICI-induced inflammatory arthritis (ICI-IIA) is the most common musculoskeletal irAE and can lead to significant morbidity and limitation in anti-cancer therapy.

AREAS COVERED

In this review, the authors focus on ICI-IIA. Relevant articles were identified through PubMed searches, spanning 2010 to the present. The authors detail the current understanding of its pathogenesis, diagnostic evaluation, and management strategies.

EXPERT OPINION

ICI-IIA is a complex irAE that we are just beginning to understand mechanistically and pathologically. It often presents later in the disease course than other irAEs and, due to various reasons, is under-recognized. In some patients, ICI-IIA may become a chronic disease, which distinguishes it from most irAEs that resolve after ICI discontinuation. Multiple important questions still demand further research including which patients may develop ICI-IIA? What are possible diagnostic and prognostic markers? Do anti-arthritis therapies interfere with the anti-tumor response? and when should steroid-sparing agents be initiated? Close collaboration and shared decision-making between oncologists, rheumatologists, and the patient are essential when managing this particular irAE.

The Role of Musculoskeletal Ultrasound Imaging in Rheumatoid Arthritis

Musculoskeletal ultrasound (MSUS) is gaining popularity among rheumatologists, especially in the context of rheumatoid arthritis (RA) joint assessment, as it is a non-invasive, radiation-free imaging modality that is relatively easy to set up in a clinic setting. Although ultrasonography (US) is often regarded as being operator dependent with associated reproducibility issues, the use of consensus-based scoring system along with standardized definition of joint inflammation in RA has been shown to improve its performance/reliability as an outcome measurement tool. Through this review article, we have (i) gone through the principle US findings in RA joint assessment, (ii) discussed various scoring systems for evaluation of US joint pathologies, (iii) described the literature in the use of US in areas of RA diagnosis and disease prognostication and (iv) examined the findings of recent major randomized controlled trials incorporating US as monitoring tools to help target treatment in RA. By doing so, we hope to provide clinicians with an insight into the role of musculoskeletal US imaging in areas of RA diagnosis, prognosis and disease monitoring.

Musculoskeletal ultrasound in the Differential Diagnosis of Gouty Arthritis and Rheumatoid Arthritis

Objective:

To explore the role of musculoskeletal ultrasound (MSUS) in the differential diagnosis of gouty arthritis (GA) and rheumatoid arthritis (RA) and to analyze the ultrasound imaging features of the two diseases.

Methods:

A retrospective study was carried out. A total of 66 patients who had been admitted to The First Medical Center of Chinese PLA General Hospital from May 2018 to March 2019 were enrolled. Among them, 34 patients were diagnosed with RA and were included in the RA group; 32 patients were diagnosed with gouty arthritis and were included in the GA group. The imaging features of musculoskeletal ultrasound were compared between the two groups of patients.

Results:

A total of 34 patients were included in the RA group, including 17 males and 17 females. A total of 32 patients were included in the GA group, including 14 males and 18 females. There were no significant differences in gender composition, age, and duration of disease between the two groups (P>0.05). In the RA group, there were joint bone erosions with a clear boundary in seven cases and with a blurred boundary in 27 cases; synovial hyperplasia was observed in 27 cases, and point-like hyperechoic masses were observed in four cases. In the GA group, there were joint bone erosions with a clear boundary in 27 cases and with a blurred boundary in five cases; synovial hyperplasia was observed in four cases, tophus was observed in 23 cases, point-like hyperechoic masses were observed in 27 cases, and the tram-track sign was observed in 23 cases. The differences in bone erosion boundaries (c2=26.854, P<0.01), synovial hyperplasia (c2=29.631, P<0.01), tophus (P<0.01), point-like hyperechoic mass (c2=33.095, P<0.01), and tram-track sign (P<0.01) were statistically significant between the two groups of patients. In the RA group, blood flow signaling was Grade 0 in one case, Grade-I in five cases, Grade-II in 14 cases, and Grade-III in 14 cases. In the GA group, blood flow signaling was Grade 0 in 26 cases, Grade-I in three cases, Grade-II in three cases, and Grade-III in zero cases. The difference in the synovial blood flow signaling between the two groups of patients was statistically significant (c2=34.323, P<0.01).

Conclusions:

MSUS has certain diagnostic value in the differentiation of GA and RA. Moreover, the two conditions have their own ultrasound imaging features.

A case with Behçet's disease involving erosive Metacarpophalangeal joint arthritis: the value of ultrasonography in the diagnosis of an Erosion

Background

Behçet’s disease (BD) is a chronic multisystemic vasculitis that may emerge with musculoskeletal system involvements, oral-genital recurrent aphthae, mucocutaneous lesions, and ocular symptoms. Arthritis in BD is usually non-erosive and not related to crippling disease. Erosive arthropathy is a very rare manifestation of BD.

Case presentation

Herein, we present a 60-year-old male patient suffering from BD for 33 years with erosive arthritis in his second metacarpophalangeal joint. After we assessed his finger by X-ray, we diagnosed erosive arthropathy quickly by musculoskeletal ultrasonography. In addition, a systematic literature search was performed via the PubMed and Scopus databases using the keywords, ‘Behçet’s disease [AND] erosive/destructive arthritis’.

Conclusions

Erosive arthritis due to BD can be evaluated by ultrasonography in an easy, fast and cost-effective manner. The literature search between 1985 and December 2019 revealed a total of 19 patients with peripheral erosive arthropathy related to BD and the characteristics of the results are summarized in the paper.

Assessment of structural damage progression in established rheumatoid arthritis by conventional radiography, computed tomography, and magnetic resonance imaging

Structural damage progression in patients with established rheumatoid arthritis (RA) has traditionally been assessed by conventional radiography (CR), which has proven its value in clinical practice and clinical trials over the past decades. The most prominent abnormalities visualized by CR in RA patients are erosions as a consequence of bone destruction and joint space narrowing (JSN) as a consequence of cartilage damage. Several validated scoring systems to quantify the structural joint damage and progression herein are available. Computed tomography and magnetic resonance imaging are newer, more sensitive methods for detection and monitoring of structural joint damage. A validated scoring system for magnetic resonance imaging of the hands and wrists exists, while no consensus has been reached on a scoring system for computed tomography. Structural damage identified by either CR or magnetic resonance imaging predicts a poorer disease course in patients with both early and established rheumatoid arthritis.

Pseudoerosions of Hands and Feet in Rheumatoid Arthritis: Anatomic Concepts and Redefinition

Rheumatoid arthritis is a chronic inflammatory disease characterized by the development of osseous and cartilaginous damage. The correct differentiation between a true erosion and other entities—then often called “pseudoerosions”—is essential to avoid misdiagnosing rheumatoid arthritis and to correctly interpret the progress of the disease. The aims of this systematic review were as follows: to create a definition and delineation of the term “pseudoerosion”, to point out morphological pitfalls in the interpretation of images, and to report on difficulties arising from choosing different imaging modalities. A systematic review on bone erosions in rheumatoid arthritis was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The following search terms were applied in PubMed and Scopus: “rheumatoid arthritis”, “bone erosion”, “ultrasonography”, “radiography”, “computed tomography” and “magnetic resonance imaging”. Appropriate exclusion criteria were defined. The systematic review registration number is 138826. The search resulted ultimately in a final number of 25 papers. All indications for morphological pitfalls and difficulties utilizing imaging modalities were recorded and summarized. A pseudoerosion is more than just a negative definition of an erosion; it can be anatomic (e.g., a normal osseous concavity) or artefact-related (i.e., an artificial interruption of the calcified zones). It can be classified according to their configuration, shape, content, and can be described specifically with an anatomical term. “Calcified zone” is a term to describe the deep components of the subchondral, subligamentous and subtendinous bone, and may be applied for all non-cancellous borders of a bone, thus representing a third type of the bone matrix beside the cortical and the trabecular bone.

Diagnostic test accuracy of magnetic resonance imaging and ultrasound for detecting bone erosion in patients with rheumatoid arthritis

OBJECTIVE

To evaluate and compare the diagnostic test accuracy of magnetic resonance imaging (MRI) and ultrasound (US) for bone erosion in rheumatoid arthritis (RA) patients for a specific and efficient diagnostic recommendation.

METHOD

To evaluate the diagnostic accuracy, the sensitivity, specificity, area under the summary receiver operating characteristic curve, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio of MRI and US for detecting bone erosion were calculated. Subgroup analyses were conducted to evaluate the performance of these values with different standard references when compared with types of machines and scanning positions.

RESULTS

Data from 26 articles were extracted for calculation. The comprehensive values of sensitivity and specificity were 0.77 (95% CI 0.63, 0.87)/0.89 (95% CI 0.80, 0.95) and 0.61 (95% CI 0.43, 0.77)/0.95 (95% CI 0.88, 0.98) for MRI and US, respectively. The 1.5-T Signa MRI system, General Electric© (sensitivity 0.66; specificity 0.90), and different models of LOGIQ US units and General Electric© (sensitivity 0.66; specificity 0.91) had better diagnostic capability to detect bone erosion, while the 2nd metacarpophalangeal joint (sensitivity 0.70; specificity 0.98) showed the best diagnostic performance among the hand joints with US.

CONCLUSIONS

Neither MRI nor US showed satisfactory diagnostic test accuracy in detecting bone erosion. However, the 1.5-T Signa MRI system, General Electric©, and different models of LOGIQ US units and General Electric© showed similarly good performance in detecting bone erosion in RA patients, while the 2nd metacarpophalangeal joint is the best recommended scanning position during US.

KEY POINTS

• In this study, we evaluated the diagnostic accuracy of US and MRI for bone erosion in RA patients, neither MRI nor US showed perfect diagnostic test accuracy.• 1.5-T Signa system and the LOGIQ units both from General Electric© are the machine types of MRI and US with the greatest performance, respectively.• The 2nd MCP joint is the scanning position recommended during US test.• Different reference standards will greatly influence the judgment of the results.

Should ultrasound be used routinely in the diagnosis of rheumatoid arthritis?

INTRODUCTION

A growing body of evidence indicates the benefits of early diagnosis of rheumatoid arthritis (RA) and prompt treatment with disease-modifying anti-rheumatic drugs (DMARDS) in terms of relieving symptoms, improving prognosis, and reducing long-term complications. There is however some controversy over the most beneficial method of imaging in providing accurate early diagnosis. Though current practice favours clinical and radiological assessment, this is increasingly supplemented by ultrasound techniques (and, to a lesser extent, CT and MRI scanning). While EULAR and ESSR favour the use of ultrasonography (US) as the first-line investigation in cases of suspected RA, a recent NICE review upholds the traditional place of plain film radiographs of hands and feet to detect erosions as early signs of synovitis. This review considers the evidence for US in the early diagnosis of RA and the case for it becoming the primary assessment modality in rheumatology clinics.

AIMS

This paper aims to assess the current literature on the efficacy of ultrasonography in diagnosing early RA, by comparing US with alternative imaging modalities. The goal is to propose the most appropriate method of diagnosis to improve early initiation of DMARD treatment for optimum disease outcomes.

METHODS

Searches for related studies and review articles were carried out using electronic databases and hand searches. Additional references were gleaned from the bibliographies of included papers. Related articles and pop-outs from PubMed were also used. The search was refined in PubMed, by only using reviews which were written in English and published in past 10 years and had full free text available.

RESULTS

This review confirms that US has a high level of sensitivity in diagnosing RA (and hence a low risk of missing cases of RA which might benefit from early treatment with DMARDs). It also has a high level of specificity (and hence a low risk of falsely diagnosing somebody with RA who may suffer adverse effects of DMARD therapy). US is already widely available and well accepted by clinicians and patients. It does not involve exposure to radiation and can be readily delivered by appropriately trained staff.

CONCLUSION

This review of relevant studies indicates that US should become accepted as the investigation with the most favourable balance of benefits to risks in the early diagnosis of RA. Given the continuing controversy surrounding studies of different imaging techniques in RA, further research into the diagnostic role of US in RA is indicated.

Infrared Thermography Sensor for Disease Activity Detection in Rheumatoid Arthritis Patients

A recent review of thermography studies in rheumatoid arthritis shows limited data about disease activity and mostly focuses on differences between the thermography of rheumatoid arthritis patients and typical subjects. A retrospective study compared patients with high disease activity (n = 50), moderate disease activity (n = 16), and healthy participants (n = 42), taking into account demographic, clinical, laboratory, and thermography parameters. We applied an infrared thermography sensor and a fingers examination protocol. Outcomes included the mean temperature of five fingers of a hand: In static, post-cooling, post-rewarming, the total change in mean temperature of fingers due to cold provocation, the total change in mean temperature of fingers due to rewarming, the area under the cooling curve, the area under the heating curve, the difference between the area under the rewarming and the cooling curve, and temperature intensity distribution maps. For patients with high disease activity, a lower area under the heating curve and a lower difference between the area under the rewarming curve and the cooling curve were observed, as well as a smaller total change in mean temperature due to rewarming, compared to patients with moderate disease activity (p < 0.05). Our study findings could be helpful in patients with an equivocal clinical examination.

Susceptibility-weighted MR imaging to improve the specificity of erosion detection: a prospective feasibility study in hand arthritis

OBJECTIVE

To evaluate the diagnostic potential of susceptibility-weighted imaging (SWI) for the detection of erosions of the hand, compared to T1-weighted (T1w) magnetic resonance imaging (MRI). Computed tomography (CT) was used as a reference standard.

MATERIALS AND METHODS

We prospectively investigated 37 patients with suspected arthritic activity of the hand. All patients underwent T1w, SWI, and CT on the same day. Patients were randomized to MRI or CT first. CT, T1w, SWI, and T1w/SWI were scored for erosions according to OMERACT RAMRIS guidelines. Specificity, sensitivity, and diagnostic accuracy were separately calculated for T1w, SWI, and T1w/SWI on a per-patient and per-bone basis using CT as reference. The one-tailed McNemar test was performed to test the number of erosion-positive patients in T1w, SWI, and T1w/SWI for non-inferiority. Measured erosion sizes were compared using Pearson's test.

RESULTS

CT was positive for erosions in 16 patients and 55 bones. SWI and T1w/SWI had superior diagnostic accuracy (91.2 and 93.8%) compared to T1w (87.8%) driven by a higher specificity (93.8 and 96.5%) compared to T1w (88.8%). On the patient level, SWI and T1w/SWI showed non-inferiority (p = 0.11 and p = 0.38) but not T1w alone (p < 0.0001). The lesion size on CT correlated better with SWI (Pearson's r = 0.92) compared to T1w (r = 0.69).

CONCLUSIONS

Adding SWI to a standard MRI protocol has the potential to improve erosion detection in hands by increasing specificity. SWI depicts bony erosions more accurately compared to standard MRI techniques.

Reliability of Ultrasound for the Detection of Rheumatoid Arthritis

The aim of this review article was to investigate the pooled sensitivity and specificity of musculoskeletal ultrasound (MSUS) for the detection of synovitis and early bone erosion in the small joint in rheumatoid arthritis (RA). In addition, investigate the pooled sensitivity and specificity of Power Doppler ultrasonography (PDUS) for the detection of synovial hypervascularity in small joints in RA. A systematic literature search of PubMed, Wiley online library, Google Scholar, Research gate, E-book, BioMed Central, the Journal of Rheumatology and Springer Link were investigated from 2001 to 2017. Original researches related to the article written in English including RA, synovitis, bone erosion, grayscale, and PDUS were included in this study. The sample size, study design, sensitivity, and specificity were analyzed. The review summarizes the value of MSUS for the detection of RA as it is the first choice of modality. Results show the acceptable reliability of US for the diagnosis of early bone erosions, synovitis, and synovial hypervascularity.

[Usefulness and reliabitlity of musculoskeletal point of care ultrasound in family practice (2): Muscle injuries, osteoarthritis, rheumatological diseases and eco-guided procedures]

This article is a continuation of the review initiated in the previous issue about the usefulness of musculoskeletal point of care ultrasound in Primary Care, completing the scenarios of muscle injuries, osteoarthritis, rheumatological diseases and eco-guided procedures.

Ultrasonographic criteria for the diagnosis of erosive rheumatoid arthritis using osteoarthritic patients as controls compared to validated radiographic criteria

OBJECTIVES

The aims of this study were to compare characteristics of radiography (RX) and ultrasound (US) erosive lesions in rheumatoid arthritis (RA) and osteoarthritis (OA) patients (prevalence, topography and severity), to determine thresholds for the diagnosis of erosive RA based on US and to evaluate the performance of US and RX to establish a diagnosis of erosive RA differentiated from hand OA.

METHODS

Patients fulfilling ACR 1987 and/or ACR/EULAR 2010 criteria for RA or ACR hand OA criteria were prospectively included. A modified Sharp erosion score was assessed by two blinded readers and one adjudicator for discordant cases (number of eroded joints ≤ three). Erosions in US were scored on six bilateral joints (MCP2-3, 5; MTP2-3, 5) with a four-grade scale to calculate total US score for erosions (USSe).

RESULTS

A total of 168 patients were included: 122 RA (32 early RA < 2 years; 90 late RA ≥ 2 years); 46 OA patients. On RX: 42 RA patients (6 early; 36 late) and 5 OA patients were eroded according to EULAR 2013 definition criteria with sensitivity at 34.4% and specificity at 89.1%. On US, 95 RA patients (21 early; 74 late) and 12 OA patients were eroded. Considering at least two joint facets eroded or at least one joint facet eroded at grade 2 on US, sensitivities were good (68-72.1%) and specificities excellent (89.1-100%). Agreement between RX and US was excellent (90-92%). The positive and negative likehood ratios were respectively 3.16 and 0.73 for radiography and 6.64 and 0.31 for US (for two facets eroded).

CONCLUSION

USSe can differentiate RA from OA in erosive disease and detect two times more patients with erosive RA than RX with excellent specificity and agreement.

A cross sectional study of bone and cartilage biomarkers: correlation with structural damage in rheumatoid arthritis

The aim of our study was to assess the relationship between bone and cartilage remodeling biomarkers and joint damage in Rheumatoid Arthritis (RA), and to detect whether they have the capacity to predict the progression of joint disease assessment by computed tomography (CT) erosion score. We analyzed 65 female patients with established RA in our Rheumatology Department. Serum levels of bone and cartilage markers were measured: osteocalcin (OC), N-propeptide of type I collagen (PINP), collagen type I and II, C-telopeptide (CTX I, CTX-II) and cartilage oligomeric matrix protein (COMP). Radiography of both wrist and MCP joints were available. Two expert-readers independently scored articular damage and progression using the High-resolution low dose CT scan in a blinded fashion. 65 female patients with established RA with a median age of 44 years were included. The median disease-duration was two years and the median (Disease activity score) DAS 28 score at 4.46 [2.65-7.36]. The percentage of patient with low disease activity was 13.8%, while 55.4 and 30.8% for those with moderate and high disease activity respectively. The resorption bone markers were high in active versus non-active RA. Wrist and MCP erosion scores were also associated with RA activity. Our study shows that biomarkers of bone and cartilage collagen breakdown were related to specific joint erosion in RA and could predict subsequent radiographic damage in RA. Further larger scale longitudinal studies maybe needed to confirm our data.

The Role of Dual-Energy Computed Tomography in Musculoskeletal Imaging

Dual-energy computed tomography (DECT) enables material decomposition and virtual monochromatic images by acquiring 2 different energy X-ray data sets. DECT can detect musculoskeletal pathologic conditions that CT alone cannot, and that would otherwise require MR imaging. In this review, the authors discuss several useful techniques and applications of DECT in musculoskeletal research: virtual monochromatic images, virtual noncalcium images, gout, iodine map, and tendons.

Clinical, Ultrasound, and Predictability Outcomes Following Certolizumab Pegol Treatment (with Methotrexate) in Patients with Moderate-to-Severe Rheumatoid Arthritis: 52-Week Results from the CZP-SPEED Study

Introduction

To assess the impact of certolizumab pegol (CZP) treatment on clinical, patient-reported, and musculoskeletal ultrasound outcomes and to determine the treatment response time point most predictive of long-term outcomes in Italian patients with rheumatoid arthritis (RA).

Methods

CZP-SPEED (NCT01443364) was a 52-week, open-label, prospective, interventional, multicenter study. Biologic-naïve patients with moderate-to-severe active RA, who had failed at least one DMARD treatment, received CZP (400 mg at weeks 0, 2, and 4, then 200 mg every 2 weeks) concomitantly with methotrexate. The primary objective was to identify the time point of clinical response {decrease in 28-joint Disease Activity Score [DAS28(ESR)] ≥ 1.2} most predictive of a clinical response at week 52. Additional clinical and patient-reported outcomes were measured. Power Doppler (PD) ultrasound was used to assess synovial effusion, synovial proliferation, PD signal, cartilage damage, and bone erosion according to international guidelines.

Results

A total of 132 patients were enrolled and received CZP; 91/132 (69%) completed to week 52. Predicted 52-week responses for early responders (week 2 onwards) were between 65% and 70%. Rapid improvements in joint cavity widening and PD signal were observed to week 8 and maintained to week 52. Cartilage damage and bone erosion were stable over 52 weeks. No new safety signals were identified.

Conclusion

In Italian CZP-treated patients with moderate-to-severe RA, week 12 clinical responses may be predictive of long-term response at week 52. Rapid improvements in clinical, patient-reported, and musculoskeletal ultrasound outcomes were maintained to week 52. These data may aid rheumatologists to make earlier treatment decisions.

Trial Registration

ClinicalTrials.gov identifier, NCT01443364.

Funding

UCB Pharma.

Electronic supplementary material

The online version of this article (10.1007/s12325-018-0751-8) contains supplementary material, which is available to authorized users.

ACR Appropriateness Criteria® Chronic Extremity Joint Pain-Suspected Inflammatory Arthritis

Evaluation for suspected inflammatory arthritis as a cause for chronic extremity joint pain often relies on imaging. This review first discusses the characteristic osseous and soft tissue abnormalities seen with inflammatory arthritis and how they may be imaged. It is essential that imaging results are interpreted in the context of clinical and serologic results to add specificity as there is significant overlap of imaging findings among the various types of arthritis. This review provides recommendations for imaging evaluation of specific types of inflammatory arthritis, including rheumatoid arthritis, seronegative spondyloarthropathy, gout, calcium pyrophosphate dihydrate disease (or pseudogout), and erosive osteoarthritis. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Adult Inflammatory Arthritides: What the Radiologist Should Know

Developments and improvements in knowledge are rapid and ongoing in both the radiologic and rheumatologic fields. During the past decade, the roles of imaging and the radiologist in the assessment and management of many inflammatory rheumatologic diseases have undergone several changes. To remain effective in patient care, the radiologist needs to be aware of these changes when recommending and interpreting imaging examinations for the referring physician. The goal of contemporary rheumatoid arthritis (RA) management is to redefine RA as a disease that is no longer characterized by erosions, which reflect established or long-standing untreated disease. Most cases of RA are now diagnosed clinically, but imaging increases diagnostic confidence, is superior to clinical examination for the detection of joint inflammation, and plays an important role in patient management. The concept of the seronegative spondyloarthritides has recently been redefined by the Assessment of SpondyloArthritis International Society (ASAS). This new set of ASAS classification criteria divides the spectrum of spondyloarthritis on the basis of predominantly axial skeletal clinical manifestations or predominantly peripheral skeletal clinical manifestations. For axial spondyloarthritis, magnetic resonance imaging and radiography play crucial roles for classification and diagnosis. For both peripheral spondyloarthritis and psoriatic arthritis, the radiologist can provide important information that influences classification and diagnosis, including documenting radiologic evidence of juxta-articular new bone formation, diagnosing sacroiliitis, or delineating the presence and extent of enthesitis and dactylitis. The radiologist's familiarity with recent classification criteria, in addition to the traditional diagnostic characteristics of the individual inflammatory arthritides, maximizes the productive interface between the radiologist and the rheumatologist. ^©RSNA, 2016.

The OMERACT Rheumatoid Arthritis Magnetic Resonance Imaging (MRI) Scoring System: Updated Recommendations by the OMERACT MRI in Arthritis Working Group

Objective.

The Outcome Measures in Rheumatology (OMERACT) Rheumatoid Arthritis (RA) Magnetic Resonance Imaging (MRI) scoring system (RAMRIS), evaluating bone erosion, bone marrow edema/osteitis, and synovitis, was introduced in 2002, and is now the standard method of objectively quantifying inflammation and damage by MRI in RA trials. The objective of this paper was to identify subsequent advances and based on them, to provide updated recommendations for the RAMRIS.

Methods.

MRI studies relevant for RAMRIS and technical and scientific advances were analyzed by the OMERACT MRI in Arthritis Working Group, which used these data to provide updated considerations on image acquisition, RAMRIS definitions, and scoring systems for the original and new RA pathologies. Further, a research agenda was outlined.

Results.

Since 2002, longitudinal studies and clinical trials have documented RAMRIS variables to have face, construct, and criterion validity; high reliability and sensitivity to change; and the ability to discriminate between therapies. This has enabled RAMRIS to demonstrate inhibition of structural damage progression with fewer patients and shorter followup times than has been possible with conventional radiography. Technical improvements, including higher field strengths and improved pulse sequences, allow higher image resolution and contrast-to-noise ratio. These have facilitated development and validation of scoring methods of new pathologies: joint space narrowing and tenosynovitis. These have high reproducibility and moderate sensitivity to change, and can be added to RAMRIS. Combined scores of inflammation or joint damage may increase sensitivity to change and discriminative power. However, this requires further research.

Conclusion.

Updated 2016 RAMRIS recommendations and a research agenda were developed.

Conventional Radiology in Rheumatoid Arthritis

In clinical practice, the conventional radiography is still the radiologic method for the diagnosis of rheumatoid arthritis (RA). Moreover, it provides a quick overview of the symptomatic joints to narrow the differential diagnosis and to evaluate progression. RA is a polyarticular disease with bilateral and symmetric involvement of the peripheral joints, especially small joints, and less frequently, the cervical spine. The radiologic features are soft tissue swelling, periarticular osteoporosis, erosions, loss of joint space, and in advanced disease, osteolysis and typical subluxations or deformities, such as ulnar deviation.

What the Rheumatologist Is Looking for and What the Radiologist Should Know in Imaging for Rheumatoid Arthritis

This article outlines what the rheumatologist is looking for and wants to know in the clinical diagnosis and imaging of rheumatoid arthritis, and what the radiologist should know to facilitate this.

Recommendations for the use of ultrasound and magnetic resonance in patients with rheumatoid arthritis

OBJECTIVE

To develop evidence-based recommendations on the use of ultrasound (US) and magnetic resonance imaging (MRI) in patients with rheumatoid arthritis (RA).

METHODS

Recommendations were generated following a nominal group technique. A panel of experts, consisting of 15 rheumatologists and 3 radiologists, was established in the first panel meeting to define the scope and purpose of the consensus document, as well as chapters, potential recommendations and systematic literature reviews (we used and updated those from previous EULAR documents). A first draft of recommendations and text was generated. Then, an electronic Delphi process (2 rounds) was carried out. Recommendations were voted from 1 (total disagreement) to 10 (total agreement). We defined agreement if at least 70% of experts voted ≥7. The level of evidence and grade or recommendation was assessed using the Oxford Centre for Evidence-based Medicine Levels of Evidence. The full text was circulated and reviewed by the panel. The consensus was coordinated by an expert methodologist.

RESULTS

A total of 20 recommendations were proposed. They include the validity of US and MRI regarding inflammation and damage detection, diagnosis, prediction (structural damage progression, flare, treatment response, etc.), monitoring and the use of US guided injections/biopsies.

CONCLUSIONS

These recommendations will help clinicians use US and MRI in RA patients.