Role of radiosynovectomy in the treatment of rheumatoid arthritis and hemophilic arthropathies

Monoarticular juvenile idiopathic arthritis as a distinct clinical entity A proof-of-concept study

BACKGROUND

Currently, monoarticular Juvenile Idiopathic Arthritis (monoJIA) is included in the ILAR classification as oligoarticular subtype although various aspects, from clinical practice, suggest it as a separate entity.

OBJECTIVES

To describe the clinical characteristics of persistent monoJIA.

METHODS

Patients with oligoJIA and with at least two years follow-up entered the study. Those with monoarticular onset and persistent monoarticular course were compared with those with oligoJIA. Variables considered were: sex, age at onset, presence of benign joint hypermobility (BJH), ANA, uveitis, therapy and outcome. Patients who had not undergone clinical follow-up for more than 12 months were contacted by structured telephone interview.

RESULTS

Of 347 patients with oligoJIA, 196 with monoarticular onset entered the study and 118 (60.2%), identified as persistent monoJIA, were compared with 229 oligoJIA. The mean follow-up was 11.4 years. The switch from monoarticular onset to oligoarticular course of 78 patients (38.8%) occurred by the first three years from onset. In comparison with oligoJIA, the most significant features of monoJIA were later age at onset (6.1 vs. 4.7 years), lower female prevalence (70.3 vs. 83.4%), higher frequency of BJH (61.9 vs. 46.3%), lower frequency of uveitis (14.4 vs. 34.1%) and ANA+ (68.6 vs. 89.5%) and better long-term outcome.

CONCLUSIONS

MonoJIA, defined as persistent arthritis of unknown origin of a single joint for at least three years, seems to be a separate clinical entity from oligoJIA. This evidence may be taken into consideration for its possible inclusion into the new classification criteria for JIA and open new therapeutic perspectives.

Therapy Response of the Yttrium-90 (Y-90) Colloid and Rhenium-186 (Re-186) Sulphur Colloid Radiosynovectomy in Hemophilic Arthropathy

Introduction

Radiosynovectomy (also known as radiosynoviorthesis) is a local form of radiotherapy that is used in chronic hemophilic synovitis in the absence of radiological evidence of extensive joint damage and in patients that have failed conservative therapy with clotting factor replacement and physiotherapy.

Objectives

To evaluate the effectiveness of the Yttrium-90 (Y-90) colloid and Rhenium-186 (Re-186) sulphur colloid radiosynovectomy in hemophilic arthropathy in terms of bleeding frequency, pain score, range of motion and performance score.

Methodology

This was a prospective cohort trial. A total of 68 hemophilic arthropathy patients who had been treated with radiosynovectomy for knee, ankle, elbow and hip joint were included in this study. Patients were followed up to assess their bleeding frequency, pain score, range of motion of the affected joint and Karnofsky or Lansky performance scale at pre and 6 months post therapy.

Result

A marked decrease (80–100%) in bleeding frequency was seen in 66.2% of patients, 14.7% of patients had moderate decrease (51–79%) and mild decrease (30–50%) was seen in 14.7% of patients. The frequency of intraarticular bleeding and pain score were significantly reduced at 6 months follow up ( p<0.005). The Karnofsky and Lansky performance scales were also improved at 6 months follow up ( p<0.005). There was no significant difference between percentage of range of motion measured before and after the therapy ( p>0.005).

Conclusion

Radiosynovectomy is a safe and effective procedure in limiting bleeding frequency, reducing pain and increasing performance scale.

The use of radiosynovectomy in patients with juvenile idiopathic arthritis. Assessment of treatment efficacy and safety

Objectives

The aim of the study was to evaluate the usefulness of knee joint radiosynovectomy (RS) in patients suffering from juvenile idiopathic arthritis (JIA).

Material and methods

One hundred RS procedures performed in 58 patients with JIA in average age 10.4 years were evaluated.

Results

After 6 weeks, a decrease in the number of cases with joint pain from 90.3% to 29%, with joint oedema from 100% to 74.5%, with joint exudate from 100% to 60.6%, with gait disorders from 19.4% to 3.2%, with joint mobility disorders from 51.1% to 26.6% in the RS cases was observed. A reduction of the score in the Colorado scale from 10.9 to 4.66, in the pain visual analogue scale (VAS) from 50 to 10, in the illness VAS assessed by the patient/parent from 69.9 to 32.4, in the illness VAS assessed by the physician from 68.8 to 36.9 was observed. Six months after the RS procedure, a reduction in the number of cases with joint pain from 89.5% prior to the procedure to 29.5%, with oedema from 100% to 58.3%, with exudate from 100% to 46.9%, with gait disorders from 20% to 2.1%, with joint motility disorders from 51.1% to 26.1% was achieved. The score in the Colorado scale was reduced from 10.9 to 4.04, in the pain VAS from 40 to 0, in the illness VAS assessed by the patient/parent from 69.7 to 27.9, in the illness VAS assessed by the physician from 68.8 to 32.4. In ultrasound examinations, the greatest improvement compared to the initial condition was recorded in the 6^th month after the RS. Radiosynovectomy was positively evaluated by parents and patients in 34 anonymous surveys. Early and late observations (average 1473 days) did not show lesions at the isotope injection site, and no neoplastic lesions were observed.

Conclusions

Radiosynovectomy is a valuable therapeutic option for local treatment in patients with JIA.

Medicinal inorganic chemistry: an updated review on the status of metallodrugs and prominent metallodrug candidates

Metallodrugs correspond to a small portion of all available drugs in the market and, yet, some of them are among the most used and important drugs in modern medicine. However, medicinal inorganic chemistry remains an underestimated area within medicinal chemistry and the main reason is the mislead association of metals to toxic agents. Thus, in this review, the potential of medicinal inorganic chemistry in drug designing is highlighted through a description of the current status of metallodrugs and metallodrug candidates in advanced clinical trials. The broad spectrum of application of metal-based drugs in medicine for both therapy and diagnosis is addressed by the extensive list of examples presented herein.

ICRP Publication 140: Radiological Protection in Therapy with Radiopharmaceuticals

Radiopharmaceuticals are increasingly used for the treatment of various cancers with novel radionuclides, compounds, tracer molecules, and administration techniques. The goal of radiation therapy, including therapy with radiopharmaceuticals, is to optimise the relationship between tumour control probability and potential complications in normal organs and tissues. Essential to this optimisation is the ability to quantify the radiation doses delivered to both tumours and normal tissues. This publication provides an overview of therapeutic procedures and a framework for calculating radiation doses for various treatment approaches. In radiopharmaceutical therapy, the absorbed dose to an organ or tissue is governed by radiopharmaceutical uptake, retention in and clearance from the various organs and tissues of the body, together with radionuclide physical half-life. Biokinetic parameters are determined by direct measurements made using techniques that vary in complexity. For treatment planning, absorbed dose calculations are usually performed prior to therapy using a trace-labelled diagnostic administration, or retrospective dosimetry may be performed on the basis of the activity already administered following each therapeutic administration. Uncertainty analyses provide additional information about sources of bias and random variation and their magnitudes; these analyses show the reliability and quality of absorbed dose calculations. Effective dose can provide an approximate measure of lifetime risk of detriment attributable to the stochastic effects of radiation exposure, principally cancer, but effective dose does not predict future cancer incidence for an individual and does not apply to short-term deterministic effects associated with radiopharmaceutical therapy. Accident prevention in radiation therapy should be an integral part of the design of facilities, equipment, and administration procedures. Minimisation of staff exposures includes consideration of equipment design, proper shielding and handling of sources, and personal protective equipment and tools, as well as education and training to promote awareness and engagement in radiological protection. The decision to hold or release a patient after radiopharmaceutical therapy should account for potential radiation dose to members of the public and carers that may result from residual radioactivity in the patient. In these situations, specific radiological protection guidance should be provided to patients and carers.

Design, synthesis and characterization of hydroxyapatite-chitosan nanocomposite radiolabelled with 153Sm as radiopharmaceutical for use in radiosynovectomy

The aim of the present study was to introduction of hydroxyapatite/chitosan nanocomposite as a new radiosynovectomy agent with excellent properties. In this work, the nanocomposite was prepared through a reliable method and characterized using different techniques to elucidate its chemical structure and physiochemical properties. The prepared nanocomposite was successfully radiolabeled with 153Sm under optimal conditions and with high radiolabelling yield (99 %). The radiochemical purity of the prepared radiopharmaceutical was found to be >99 % as determined by ITLC technique. In vitro stability studies in saline solution and in human serum showed that the radiolabeled nanocomposite retained its stability for at least 6 days. The biodistribution and imaging studies in wild-type rats revealed high retention of the agent into the synovial joints of the knee even at 96 h post-injection, thereby indicating excellent in vivo stability of 153Sm labeled hydroxyapatite-chitosan nanocomposite. Therefore, the prepared radiopharmaceutical would be a potential therapeutic agent for use in radiosynovectomy procedure.

Glucose-holmium for radiotherapy: Characterization and in vitro assays

BACKGROUND

The existence of saccharide-holmium complexes, containing mono or polysaccharide molecules, is an attractive hypothesis toward a radiation therapy (RT) with beta-emitters targeting high glucose metabolic human sites. To exam such hypothesis, the aim of this study was to investigate the possible chemical interactions of Ho and glucose molecules and if glucose may be a facilitator to holmium cell internalization based on in vitro uptake assays and mass spectrometry analyses.

METHODS

The ionic-solution preparations were based on glucose-anhydrous and holmium-nitrate hydrated in aqueous solution, in non-radioactive condition. The uptakes in MDAMB231 cell lineage were evaluated, at 0 and 50 µg mL^-1 holmium solution, in incubation times of 10, 30 and 50 min. The measurements of the holmium mass into the dried cell were evaluated by Neutron Activation Analysis - NAA method. Also, the ionic solution was tested in Electrospray Ionization Mass Spectrometry (ESI-MS) in order to identify Ho and glucose interactions.

RESULTS

There were intracellular holmium-uptake in MDAMB-231 of 3.6 ± 0.1, 6.8 ± 0.2 and 9.7 ± 0.3 μg increasing linearly with incubation time. The m/z ions at 523, 586, 649, 991 and 1054 were attributed to the positively loaded species containing Ho⁺³, glucose (GLU) and NO₃^-, making up the possible molecular compound formulae, involving Ho, GLU, and anions.

CONCLUSIONS

The findings of the in vitro assay and the ESI-MS suggested a suitable holmium cell uptake, increased in function of incubation time, due to the presence of glucose and holmium chemical interactions in solution.

An overview of nanoscale radionuclides and radiolabeled nanomaterials commonly used for nuclear molecular imaging and therapeutic functions

Recent advances in the field of nanotechnology applications in nuclear medicine offer the promise of better diagnostic and therapeutic options. In recent years, increasing efforts have been focused on developing nanoconstructs that can be used as core platforms for attaching medical radionuclides with different strategies for the purposes of molecular imaging and targeted drug delivery. This review article presents an introduction to some commonly used nanomaterials with zero-dimensional, one-dimensional, two-dimensional, and three-dimensional structures, describes the various methods applied to radiolabeling of nanomaterials, and provides illustrative examples of application of the nanoscale radionuclides or radiolabeled nanocarriers in nuclear nanomedicine. Especially, the passive and active nanotargeting delivery of radionuclides with illustrating examples for tumor imaging and therapy was reviewed and summarized. The accurate and early diagnosis of cancer can lead to increased survival rates for different types of this disease. Although, the conventional single-modality diagnostic methods such as positron emission tomography/single photon emission computed tomography or MRI used for such purposes are powerful means; most of these are limited by sensitivity or resolution. By integrating complementary signal reporters into a single nanoparticulate contrast agent, multimodal molecular imaging can be performed as scalable images with high sensitivity, resolution, and specificity. The advent of radiolabeled nanocarriers or radioisotope-loaded nanomaterials with magnetic, plasmonic, or fluorescent properties has stimulated growing interest in the developing multimodality imaging probes. These new developments in nuclear nanomedicine are expected to introduce a paradigm shift in multimodal molecular imaging and thereby opening up an era of new diagnostic medical imaging agents. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part A: 107A: 251-285, 2019.

Dosimetry perspectives in radiation synovectomy

Rheumatoid arthritis (RA) is a chronic inflammatory disease that can potentially damage the synovial joints. One of the effective treatment modality for RA is radiation synovectomy (RSV) where properly selected radionuclide is injected into the joint space, enabling controlled destruction of diseased synovial membrane via radiation exposure. Radiation dosimetry in RSV appears challenging due to the heterogeneous nature of synovial membrane, nonuniform distribution and leakage of radionuclide from the synovial cavity. This article reviews the dosimetric perspective pertaining to RSV. Specifically, characteristics of radionuclide for RSV and radiation dose to target and non-target (i.e., articular cartilage, bone, bloodstream, gonads, etc.) tissues of patient have been discussed. The personal dose H_p(0.07) to the hands of medical staff (i.e., radiochemist, therapist physician, nurse) may be considerably high due to handling of high specific activities (∼500 MBq/ml for Y-90); such doses are typically measured using thermoluminescence dosimeters (TLD) ring dosimeters and ranges from 1 to 21.5, 0.1 to 40 and 0.1 to 5 µSv/MBq for the radiochemist, therapist physician and the nurse, respectively. Methods to minimize radiation doses to the patient, medical staff and public are elaborated. Contamination risks and precautionary measures are also reported.

Short-term clinico-radiological outcome of chronic knee synovitis among haemophilia A patients post phosphorus-32 radiosynoviorthesis

PURPOSE

Various modes of therapy have been directed at breaking the vicious cycle at early stage of synovitis in haemophilia patients. This study was planned to assess the short-term clinico-radiological outcome of chronic knee synovitis among haemophilia A patients post phosphorus-32 (P-32) radiosynoviorthesis.

METHODS

P-32 samarium radiocolloid was injected into the knee and patients were followed up at 1 and 3 months, respectively. Clinical outcomes was assessed using Tegner Lysholm scores (TLSs), Modified Knee Society Clinical Rating System (MKSS) score and circumference of the knee joint. The radiological outcomes were assessed using X-ray, ultrasonography and bone scan.

RESULTS

Among the fifteen haemophilia A patients studied, there was statistically significant difference in TLS ( χ²(2) = 27.887 and p value < 0.001), MKSS scores ( χ²(2) = 27.745 and p < 0.001) and circumference of the knee joint ( χ²(2) = 21.333 and p < 0.001) at preoperatively, 1- and 3-month follow-up. There were no changes noted in follow-up X-rays compared with the preoperative X-ray. Ultrasonography showed that clinical improvement was more in suprapatellar and medial parapatellar regions in the last 2 months compared to the first month of follow-up. Post P-32 bone scan showed marked decrease in uptake in the affected knee joint suggestive of radio ablation of synovial tissue.

CONCLUSION

P-32 radiosynoviorthesis done for chronic synovitis among haemophilia A patients showed significant improvement in both clinical and radiological parameters. Ultrasonography can be utilized as non-invasive radiological modality for follow-up of P32 response for knee joint.

IL-17A and TNF-α Increase the Expression of the Antiapoptotic Adhesion Molecule Amigo-2 in Arthritis Synoviocytes

Rheumatoid arthritis (RA) is a chronic inflammatory disorder, characterized by a persistent immune cell infiltrate in the synovium accompanied by high levels of inflammatory mediators and synovial hyperplasia. Despite significant therapeutic advances, RA remains an important unmet medical need. To discover potential new genes controlling inflammation and apoptosis in synoviocytes, genes induced by the two pro-inflammatory cytokines, tumor necrosis factor α (TNF-α) and interleukin 17A (IL-17A), were systematically searched. We identified Amphoterin-induced gene and ORF 2 (Amigo-2), a novel antiapoptotic adhesion molecule, as synergistically upregulated by the IL-17A/TNF combination specifically in RA synoviocytes. In addition, when RA synoviocytes were cocultured with immune cells, Amigo2 expression was significantly increased in both fibroblasts and immune cells. This induction persisted in RA synoviocytes even after the removal of the immune cells. Amigo2 induction was ERK-dependent and on the contrary, inhibited by JNK. Furthermore, Amigo2 expression levels correlated with apoptosis of the cells when exposed to the proapoptotic agent cadmium (Cd). Interestingly, exposure of the cells to HMGB1 in inflammatory conditions increased synergistically Amigo2 expression and significantly reduced Cd-mediated cellular toxicity. Our findings support a model whereby cell–cell contact with immune cells and exposure to the combination of both inflammatory cytokines and HMGB1 in the joints of RA patients increases Amigo2 expression in synoviocytes in an ERK-dependent manner which, in turn, enhances cellular adhesion and promotes cell survival and cellular proliferation.

Therapeutic radionuclides in nuclear medicine: current and future prospects

The potential use of radionuclides in therapy has been recognized for many decades. A number of radionuclides, such as iodine-131 ((131)I), phosphorous-32 ((32)P), strontium-90 ((90)Sr), and yttrium-90 ((90)Y), have been used successfully for the treatment of many benign and malignant disorders. Recently, the rapid growth of this branch of nuclear medicine has been stimulated by the introduction of a number of new radionuclides and radiopharmaceuticals for the treatment of metastatic bone pain and neuroendocrine and other malignant or non-malignant tumours. Today, the field of radionuclide therapy is enjoying an exciting phase and is poised for greater growth and development in the coming years. For example, in Asia, the high prevalence of thyroid and liver diseases has prompted many novel developments and clinical trials using targeted radionuclide therapy. This paper reviews the characteristics and clinical applications of the commonly available therapeutic radionuclides, as well as the problems and issues involved in translating novel radionuclides into clinical therapies.

Hemophilic arthropathy of the elbow: prophylaxis, imaging, and the role of invasive management

Hemophilia is an X-linked recessive deficiency of clotting factor VIII (hemophilia A) or IX (hemophilia B) that can result in hemarthrosis of various joints, including the elbow. Left unchecked, this can lead to progressive joint destruction and significant morbidity. Appropriate management of the elbow joint through prophylactic measures, accurate imaging, and timely intervention is essential. Replacing or supplementing deficient factor with a plasma-derived or recombinant factor concentrate can minimize bleeding episodes. Joints should be routinely monitored for damage. Plain films offer an inexpensive window into bone disease and joint space changes but lack soft tissue detail and may not detect early changes. Magnetic resonance imaging provides a high level of detail but may be limited by its cost and need for sedation in younger patients. Ultrasound may not achieve the same level of resolution as magnetic resonance imaging, but it is increasingly used as a convenient, effective, and relatively inexpensive alternative. Patients who experience hemarthrosis of the elbow with joint damage often require more invasive treatment. Radiosynovectomy and arthroscopic synovectomy are effective at minimizing pain and preventing future bleeding episodes, whereas extensive joint damage may necessitate total elbow replacement.

Radiation Synovectomy: an effective alternative treatment for inflamed small joints

An inflamed painful joint is one of the most common indications for the patient to be referred to a rheumatologist or an orthopedician. In relation to the aetiology, the therapeutic approach might be systemic, local or a combination of them in some cases, always with the thought of balancing risk with benefit for the patient. In all cases, independently of the cause, the goal of therapy is to improve the quality of life through the reduction of pain, improvement of mobility and preservation of function. Nuclear Medicine has to offer Radiosynoviorthesis, an effective alternative procedure for treating inflamed small joints. Various radionuclides are available for radiosynoviorthesis. Their selection depends on the size of the joint to be treated. Small joints are mainly treated with [169Er] erbium under a fluoroscopic or sonographic guidance, usually with a simultaneous instillation of a corticoid. Candidates for radiosynoviorthesis should have been under a six-month systemic treatment without encouraging results or should have undergone at least one unsuccessful intra-articular injection of a long acting glucocorticoid. Since 1973, when [169Er] erbium was firstly suggested as a therapeutic agent for radiosynoviorthesis of the finger joints, there has been quite enough experience in its' application. It has been found to be cost effective in providing long term relief of pain and deformity of the inflamed joints in comparison to other therapeutic approaches. Additionally, there is no radiation risk and can be performed on an out patient basis. Therefore it can stand as an effective alternative procedure for treating early stages of chronic synovitis in RA (rheumatoid arthritis) patients, with minor damage of the cartilage and the adjacent bones, and for synovitis secondary to inflammatory arthropathies.