Power Doppler sonography and pulse-inversion harmonic imaging in evaluation of rheumatoid arthritis synovitis

OBJECTIVE

This study evaluates the value of contrast-enhanced pulse-inversion harmonic imaging (PIHI) to detect synovial vascularization and thus the therapeutic effects of prednisolone treatment on the inflammation in finger joints in rheumatoid arthritis (RA).

MATERIALS AND METHODS

Before and after 7 days of mid- to high-dose steroid therapy, blood tests and clinical and sonographic examinations were assessed in 14 patients. Two hundred eighty finger joints (metacarpophalangeal [MCP] I-V, interphalangeal [IP], and proximal interphalangeal [PIP] II-V) were investigated on power Doppler sonography to determine, in each patient, the finger joint with the strongest hypervascularization and to score the synovial vascularization. Further dynamic examination of the selected joint was performed on PIHI after i.v. administration of a second-generation sonographic contrast medium. Vascularization was quantified by calculating the area under the time-intensity curves. The changes in signal intensities before and after therapy were correlated with clinical examinations (disease activity score [DAS]).

RESULTS

The score of the joint with the strongest hypervascularization assessed by power Doppler sonography decreased significantly from 1.7 to 1.3 (p < 0.01); however, in six patients, no change was assessed after steroid therapy. In all patients, a significant reduction in PIHI signals was observed after therapy (p < 0.05). The baseline and follow-up median values of the area under the time-intensity curves were 8.56 +/- 1.28 and 7.65 +/- 0.66, respectively. The median values of the DAS decreased significantly from 4.90 +/- 0.86 to 3.6 +/- 1.0 (p < 0.01) 7 days after the steroid therapy.

CONCLUSION

PIHI and power Doppler sonography enable the detection of synovial perfusion alterations after steroid therapy and, therefore, may be useful tools for the evaluation of active inflammation in RA and for the assessment of therapeutic response. However, minor changes of synovial vascularization can be better detected on PIHI than on power Doppler sonography.

Bone erosions and bone marrow edema as defined by magnetic resonance imaging reflect true bone marrow inflammation in rheumatoid arthritis

OBJECTIVE

To investigate the pathologic nature of features termed "bone erosion" and "bone marrow edema" (also called "osteitis) on magnetic resonance imaging (MRI) scans of joints affected by rheumatoid arthritis (RA).

METHODS

RA patients scheduled for joint replacement surgery (metacarpophalangeal or proximal interphalangeal joints) underwent MRI on the day before surgery. The presence and localization of bone erosions and bone marrow edema as evidenced by MRI (MRI bone erosions and MRI bone marrow edema) were documented in each joint (n=12 joints). After surgery, sequential sections from throughout the whole joint were analyzed histologically for bone marrow changes, and these results were correlated with the MRI findings.

RESULTS

MRI bone erosion was recorded based on bone marrow inflammation adjacent to a site of cortical bone penetration. Inflammation was recorded based on either invading synovial tissue (pannus), formation of lymphocytic aggregates, or increased vascularity. Fat-rich bone marrow was replaced by inflammatory tissue, increasing water content, which appears as bright signal enhancement on STIR MRI sequences. MRI bone marrow edema was recorded based on the finding of inflammatory infiltrates, which were less dense than those of MRI bone erosions and localized more centrally in the joint. These lesions were either isolated or found in contact with MRI bone erosions.

CONCLUSION

MRI bone erosions and MRI bone marrow edema are due to the formation of inflammatory infiltrates in the bone marrow of patients with RA. This emphasizes the value of MRI in sensitively detecting inflammatory tissue in the bone marrow and demonstrates that the inflammatory process extends to the bone marrow cavity, which is an additional target structure for antiinflammatory therapy.

[Computer assisted radiological diagnostics of arthritic joint alterations]

Computer assisted diagnosis (CAD) schemes are currently used in the field of musculoskeletal diseases to quantitatively assess vertebral fractures, joint space narrowing, andr erosion. Most systems work semi-automatically, i.e. they are operator dependent in the selection of anatomical landmarks. Fully automatic programs are currently under development. Some CAD products have already been successfully used in clinical trials.

Accuracy of treatment planning based on stereolithography in computer assisted surgerya)

Three-dimensional stereolithographic models (SL models), made of solid acrylic resin derived from computed-tomography (CT) data, are an established tool for preoperative treatment planning in numerous fields of medicine. An innovative approach, combining stereolithography with computer-assisted point-to-point navigation, can support the precise surgical realization of a plan that has been defined on an SL model preoperatively. The essential prerequisites for the application of such an approach are: (1) The accuracy of the SL models (including accuracy of the CT scan and correspondence of the model with the patient's anatomy) and (2) the registration method used for the transfer of the plan from the SL model to the patient (i.e., whether the applied registration markers can be added to the SL model corresponding to the markers at the patient with an accuracy that keeps the "cumulative error" at the end of the chain of errors, in the order of the accuracy of contemporary navigation systems). In this study, we focus on these two topics: By applying image-matching techniques, we fuse the original CT data of the patient with the corresponding CT data of the scanned SL model, and measure the deviations of defined parameter (e.g., distances between anatomical points). To evaluate the registration method used for the planning transfer, we apply a point-merge algorithm, using four marker points that should be located at exactly corresponding positions at the patient and at connective bars that are added to the surface of the SL model. Again, deviations at defined anatomical structures are measured and analyzed statistically. Our results prove sufficient correspondence of the two data sets and accuracy of the registration method for routine clinical application. The evaluation of the SL model accuracy revealed an arithmetic mean of the relative deviations from 0.8% to 5.4%, with an overall mean deviation of 2.2%. Mean deviations of the investigated anatomical structures ranged from 0.8 mm to 3.2 mm. An overall mean (comprising all structures) of 2.5 mm was found. The fiducial registration error of the point-merge algorithm ranged from 1.0 mm to 1.4 mm. The evaluated chain of errors showed a mean deviation of 2.5 mm. This study verifies that preoperative planning on SL models and intraoperative transfer of this plan with computer assisted navigation is a suitable and sufficiently reliable method for clinical applications.

[Quantitative imaging in rheumatoid arthritis: from scoring to measurement]

The need of clinical sciences to measure therapy effects on chronic illness led to development, evaluation, and publication of several radiological methods to monitor disease progression of rheumatic diseases. This review article explains the basics and background of scoring and measurement. The radiologist thus learns to report more compactly and to communicate the results more specifically.

Sportschaden und Sporttrauma der Wirbelsäule: bildgebende Diagnostik

Sports injuries, especially those due to trend sports, and overuse resulting from monotonous repetitive movement patterns may cause various spinal abnormalities. Indications for diagnostic imaging should be established more readily in this group of young patients than in adults, as there is a higher probability to find morphologic abnormalities. This diagnostic strategy should also be applied for MRI and CT investigations. Image findings should be interpreted with view on kinetic chains related to distinct sporting activities.

Dose classification scheme for computed tomography of the paranasal sinuses

PURPOSE

The purpose of this study was to define objective and reproducible standards for the quality of CT images as a function of radiation doses and therapeutic validity.

MATERIALS AND METHODS

CT images of the paranasal sinuses of 145 patients (77 female, 68 male; 5-83 years old; mean age, 39.9 years) were classified both subjectively (with a view toward their validity for the planning of functional endoscopic sinus surgery, FESS) and objectively by defining the pixel noise (the standard deviation, STD, of the CT number) in a homogeneous region of interest (ROI), centered on the M. masseter and on the frontal lobe. These measurements were then compared to measurements obtained from scan images of a water-filled Perspex phantom.

RESULTS

The pixel noise measured in the phantom images was nearly identical to the respective values on the M. masseter on the patient images. The use of an edge-enhancing reconstruction algorithm and low-dose protocols, with a pixel noise amounting to 70-90 Hounsfield Units (HU), are indicated for children, chronic sinusitis, and septum deviation, while standard protocols, with a pixel noise of 50-70 HU, are recommended for the preoperative planning and postoperative control of FESS. The pixel noise for high-dose protocols is less than 50 HU; nonetheless, such protocols should generally be avoided.

CONCLUSION

The pixel noise measured in a water-filled Perspex phantom is indicative of the clinical potential and image quality of paranasal sinus CT scans. Alternatively, the M. masseter can be chosen as an ROI to measure the pixel noise in order to obtain a rough estimate of the image quality or radiation dose class.

Musculoskeletal ultrasound including definitions for ultrasonographic pathology

Ultrasound (US) has great potential as an outcome in rheumatoid arthritis trials for detecting bone erosions, synovitis, tendon disease, and enthesopathy. It has a number of distinct advantages over magnetic resonance imaging, including good patient tolerability and ability to scan multiple joints in a short period of time. However, there are scarce data regarding its validity, reproducibility, and responsiveness to change, making interpretation and comparison of studies difficult. In particular, there are limited data describing standardized scanning methodology and standardized definitions of US pathologies. This article presents the first report from the OMERACT ultrasound special interest group, which has compared US against the criteria of the OMERACT filter. Also proposed for the first time are consensus US definitions for common pathological lesions seen in patients with inflammatory arthritis.

Diffusion weighted imaging of bone marrow pathologies

Diffusion weighted imaging of non-CNS tissue has attracted much attention during the last years. Its capability of probing the microstructure of a biologic tissue at a sub-millimeter range is used to evaluate its diffusion capacity, which is tissue specific and can be used for tissue characterization. Processes involving bone marrow where the primary target for DWI during the last years. Most experience has been gained for differentiating benign from pathologic vertebral compression fractures, which can be reliably done when quantitative diffusion measurements are available. However, preliminary results exist indicating that this non-invasive technique may be a potential tool for therapy monitoring, which will revise the management of cancer patients. Moreover, this will be the first non-invasive and quantifiable tool for evaluating the effectiveness of modern tumor treatment. In this article, we will give an overview on the current status of DWI in the evaluation of bone marrow alterations; on currently available DWI techniques and a short out-look on future aspects of DWI in bone marrow pathologies.

Detektion von primär malignen und intermediären Knochentumoren: Wertigkeit der Projektionsradiographie

PURPOSE

To evaluate the role of projectional radiography in the detection of primary and potentially malignant bone neoplasms.

MATERIALS AND METHODS

We retrospectively reviewed the images and medical records of 80 patients (42 male, 38 female; range: 6 to 73 years; mean: 33 years) with pathologically proven primary or indeterminate bone tumors.

RESULTS

The most common symptom was local pain (84 %). In 69 of 80 patients (86 %), projectional radiography was the first imaging modality, which correctly identified the malignant character of the bone lesion in 60 of these 69 patients (87 %). In 2 patients, bone neoplasms were overlooked due to diagnostically inadequte image quality. The false-diagnosis rate was not significantly different between board-certified radiologists working in hospitals and radiologists in outpatient facilities (p > 0.05). Bone tumors predominantly affecting adults, such as chondrosarcomas, needed a longer time for the diagnosis than bone tumors mainly found in childhood, such as osteosarcomas. The median age of patients with delayed imaging work-up because of attempted conservative therapy (45 years +/- 20 years) was significant higher than the median age of patients with immediate radiographic work-up (27 years +/- 16 years).

CONCLUSION

Projectional radiography is the most common initial imaging method for bone pain and continues to play an important role to reduce the time gap between first onset of symptoms and definitive treatment. In unremitting focal bone pain, bone neoplasms should be taken into consideration not only in children but also in patients beyond adolescence.

Teleradiotherapy of joints in rheumatoid arthritis: lack of efficacy

BACKGROUND

Low dose radiotherapy is commonly used for painful rheumatic conditions in clinical practice. Teleradiotherapy may be a cheap, painless procedure which is applicable to many joints at a time.

OBJECTIVE

To determine if the local application of x rays to inflamed joints in rheumatoid arthritis (RA) affects the signs and symptoms of inflammation.

METHODS

In a randomised, controlled, double blind study, roentgen irradiation was administered in a total dose of 20 Gy during 2 weeks to single joints in six patients with RA who were receiving constant and stable pharmacological treatment with DMARDs and NSAIDs. Single inflamed joints on the contralateral side of the body were used as controls and received sham irradiation. Swelling and tenderness was assessed by blinded investigators before and until 3 months after the irradiation; general disease activity and pain scales were included in the assessment.

RESULTS

No change in the scores for tenderness, swelling, pain, or disease activity was seen. The trial was stopped for ethical reasons.

CONCLUSION

Local roentgen treatment of RA at a substantial dose of 20 Gy was ineffective in this pilot trial.

Extracorporeal shockwave treatment is effective in calcific tendonitis of the shoulder. A randomized controlled trial

BACKGROUND

Calcific tendonitis of the shoulder is often associated with chronic pain and impairment of function. Extracorporeal shockwave therapy (ESWT) is considered to be a treatment option. We compared the effects of two different ESWT regimens.

METHODS

43 patients (57 shoulders) with symptomatic calcific tendonitis of the shoulder for more than six months were included in a double-blinded study. Thirty-one shoulders were treated at the area of maximum pain with application of 2 x 2000 impulses of 0.28 mJ/mm2 at an interval of two weeks (treatment group) and 26 shoulders with 2 x 2000 impulses of < 0.07 mJ/mm2 at an interval of two weeks (control group), without pretreatment analgesia. Shoulder function (Constant score) and pain (visual analogue scale, VAS) were assessed before treatment and at one week, three months and seven months after treatment. Shoulder X-rays were performed at the 3- and 7-month follow-up visits.

RESULTS

Improvement in Constant score was significantly higher in the treatment group at all follow-up visits (p < 0.05). Seven months post-treatment, calcifications dissolved completely in 19% of the treatment group and 8% of the control group, and a > 50% reduction was observed in 19% and 8% respectively. With regard to reduction of pain, there was significant improvement in the treatment group compared with the control group at the 1-week follow-up (p < 0.05). However, at the 3-month and 7-month visits, no significant between-group difference in pain could be detected.

CONCLUSION

As applied, ESWT with an energy flux density of 0.28 mJ/mm2 led to a significantly greater improvement in shoulder function and a slightly higher, nonsignificant, rate of > 50% disintegration of calcific deposits compared with the control group. However, this did not result in reduction of pain.

Differential diagnosis of rheumatic diseases using conventional radiography

The approach to the differential diagnosis of rheumatic diseases using conventional radiography is systematic and module-oriented, which, with respect to future developments, forms the basis for computer-assisted diagnosis (CAD). The indications follow consensus-based referral criteria and attempts should be made to raise the evidence level of the recommendations. Investigation techniques have been improved in the last few years with the use of digital radiography. New imaging technologies may be available in the future that will achieve at least the same quality of images, while exposing patients to a significantly lower radiation dose. The interpretation of radiographical signs could be enhanced through a correlation with other imaging modalities. Computer-assisted techniques with image processing tools for automated measurements, lesion detection and in the form of expert systems are under development. With conventional radiography embedded in CAD systems, promising options will be available to enhance the differential diagnosis of rheumatic diseases.

Value of combined XCT/SPECT technology for avoiding false positive planar (123)I-MIBG scintigraphy

AIM

The clinical value of combined XCT/SPECT technology in a single device in patients undergoing (123)I-MIBG scintigraphy was analyzed.

METHODS

31 patients (19 men, 12 women; mean age 55 years, range: 31-79 years) demonstrating focal accumulation in planar (123)I-MIBG scan were further investigated with a double headed gamma camera with an X-ray tomograph mounted on the same gantry (GE Medical Systems, Millennium VG with Hawkeye, Milwaukee, USA) for anatomical definition of the focal (123)I-MIBG uptake. The patients were referred to (123)I-MIBG scintigraphy because of biochemically (81%) and/or clinically (19%) suspected pheochromocytoma.

RESULTS

In 23 out of 31 patients (74%) the fused images demonstrated physiological accumulation (i. e. intestinal, renal) of (123)I-MIBG. In two patients (6%) suspected adrenal MIBG-accumulation was caused by inhomogeneous liver uptake. In two patients (6%) focal abdominal accumulation was correctly localised in the adrenal glands. Furthermore, the differentiation of bone metastasis from a local recurrence for phaeochromocytoma was accurately possible for two patients (6%). Adrenal lesions mimicking liver foci were correctly localised in the remaining two patients (6%).

CONCLUSION

Our study demonstrates the clinical value of XCT/SPECT in a single device in patients demonstrating focal (123)I-MIBG uptake in planar scintigraphy. The combined XCT/SPECT technology provides a higher diagnostic accuracy.

Rotator cuff tears in asymptomatic individuals: a clinical and ultrasonographic screening study

OBJECTIVE

To determine the prevalence and clinical impact of rotator cuff tears in asymptomatic volunteers.

MATERIALS AND METHODS

Sonographic examinations of the shoulder of 212 asymptomatic individuals between 18 and 85 years old were performed by a single experienced operator. The prevalence and location of complete rotator cuff tears were evaluated. The clinical assessment was based on the Constant Score. Magnetic resonance imaging (MRI) of the shoulder was obtained in those patients where US showed rotator cuff pathology.

RESULTS

Ultrasound showed a complete rupture of the supraspinatus tendon in 6% of 212 patients from 56 to 83 years of age (mean: 67 years). MRI confirmed a complete rupture of the supraspinatus tendon in 90%. All patients reported no functional deficits, although strength was significantly lower in the patient group with complete supraspinatus tendon tear (P < 0.01).

CONCLUSION

There is a higher prevalence in older individuals of rotator cuff tendon tears that cause no pain or decrease in activities of daily living.

Neoadjuvant radiochemotherapy of oral cavity and oropharyngeal cancer: evaluation of tumor response by CT differs from histopathologic response assessment in a significant fraction of patients

BACKGROUND

Our aim was to compare and assess the predictive value of CT and histopathologic grading of tumor regression at primary tumor sites in patients with squamous cell carcinoma of the oral cavity and oropharynx after neoadjuvant (preoperative) radiochemotherapy (RCT).

METHODS

We investigated 55 patients with carcinomas of the oral cavity and oropharynx who underwent RCT before curative surgery. Two blinded observers measured RCT-induced reduction of tumor volume in pretherapeutic and posttherapeutic CT scans. Volume changes were compared with histopathologic findings obtained at surgery.

RESULTS

Histopathologic response evaluation revealed 31 complete remissions, 12 cases of partial response, and 12 nonresponders. We performed a logistic regression analysis to evaluate whether measured volume reduction could predict the likelihood of belonging to a certain response group. Taken together, we found 35 correct, 12 false-negative, and seven false-positive predictions.

CONCLUSIONS

The extent of remission as assessed by CT scans 4 to 5 weeks after completion of neoadjuvant RCT leads to false predictions in a significant percentage of patients.