Efficacy, Safety, and Sample Quality of Ultrasound-Guided Synovial Needle Biopsy in Clinical Practice and Research: A Prospective Observational Study

Intensive training programme for ultrasound-guided minimally invasive synovial tissue biopsy on knees and wrists in different phases of inflammation

OBJECTIVES

To develop an intensive training programme for ultrasound (US)-guided synovial tissue (ST) biopsy on knees and wrists in inflammatory arthritis and to assess the learning curve, patient tolerability, sample quality and trainees' expectations.

METHODS

Active or remission rheumatoid arthritis patients were enrolled. Nine trainees joined the 4-month programme in a centre experienced in performing US-guided ST biopsies consisting of four sequential phases: (1) observation, (2) performance of guided step-by-step phases, (3) execution of the whole procedure on paired joints (knees or wrists) of the same patient in parallel with the trainer and (4) performance of the procedure autonomously. Sample representativity was assessed by histology, and procedure-related adverse events were recorded. Before and after the programme, trainees' expectations and perceptions were collected.

RESULTS

328 ST biopsy procedures were included. The rate of trainees' informative samples was: (1) comparable to the trainers in active and remission knees, but lower in active wrists (70% for trainees vs 100% for trainers, p=0.06) in phase 3; (2) excellent on active knees and wrists (91.9% and 90.9% respectively) but lower (77.6%, p=0.0089) on remission knees in phase 4. Procedures performed by trainees did not affect patient tolerability. Trainees' expectations about procedure-related invasiveness and pain infliction decreased while the difficulty of procedure execution on active wrists and remission knees remained perceived as moderately difficult.

CONCLUSIONS

This intensive training programme develops advanced skills in the performance of US-guided ST biopsy on knees and wrists, yielding high-quality specimens available for basic and translational studies on inflammatory joint diseases.

What Bedside Skills Could the Modern Rheumatologist Possess? Part II. "Certain Technical Procedures"

ABSTRACT

Rheumatologists have never been reluctant to adopt procedures that might enhance their diagnostic or therapeutic powers. Their propensity to penetrate the joints of the patients they were treating set them apart from the general internist. Since the 1980s, when a chance to look inside the joints they were treating attracted a few rheumatologists, other things that could be done at the bedside emerged with now an array of bedside procedures that could be part of a rheumatologist's skill set. Besides gains in diagnosis and/or therapy, each constitutes a chance to restore the physical contact between physician and patient, riven by factors of the last decade, such as electronic medical records and COVID. With such contact so important to satisfaction of the patient and physician alike, acquisition of proficiency in certain technical procedures described herein offers one path to begin restoring rheumatology to the richly fulfilling practice it once was.

Best practices for ultrasound-guided synovial biopsy in the United States

The target organ in many forms of inflammatory arthritis is the synovium. However, synovial tissue has historically been perceived as either difficult to obtain or of little practical value. Ultrasound-guided synovial biopsy [UGSB] is a safe and well-tolerated bedside procedure that is established in Europe and rapidly growing in popularity in the United States. The technique can be mastered by rheumatologists who are already experienced in ultrasound-guided procedures such as joint aspirations. The USGB procedure allows the proceduralist to access small, medium, and large joints and is inexpensive and less invasive compared to surgical alternatives. The relative ease of obtaining this tissue, along with recent research suggesting that synovium may have more clinical and investigational utility than previously thought, has led clinicians and researchers to a new appreciation of the role of synovial biopsy in both the clinical and research setting. In this manuscript, the authors present recommendations on best practices for ultrasound-guided synovial biopsy in the United States, based on our initial training with well-established experts overseas and our own subsequent collective experience in performing numerous synovial biopsies in the United States over the past 7 years for both clinical and research indications. We envision a future where UGSB is more frequently incorporated in the standard diagnostic workup of arthritis and drives novel research initiatives.

[Sterile puncture of large joints]

OBJECTIVE

Puncture of large joints is performed for diagnostic purposes on the one hand and for the treatment of joint pathologies on the other. Puncture can be used for rapid pain relief by relieving effusions or intra-articular hematomas. The obtained puncture specimen allows immediate visual assessment and subsequent microscopic-cytological and microbiological evaluation in the laboratory.

INDICATIONS

The indication for puncture of a large joint is for diagnosis and/or therapy of inflammatory, traumatic or postoperative joint problems. Diagnostic punctures are used to obtain punctate, to differentiate the location of pain or (rarely) to apply contrast medium for magnetic resonance arthrography. Therapeutic punctures allow the injection of drugs or platelet-rich plasma (PRP) as well as the relief or drainage of effusions.

CONTRAINDICATIONS

If there are inflammatory skin alterations-especially purulent inflammation-joint punctures through these lesions are absolutely contraindicated. Special attention is necessary if the patients are on anticoagulants.

SURGICAL TECHNIQUE

Absolute sterile handling is mandatory. Unnecessary pain can be avoided by a sterile skin wheal of local anesthesia, safe puncture points, and careful handling of the cannulas.

POSTOPERATIVE MANAGEMENT

Joint aspiration material has to be handled according to the local, intrahospital rules in a timely manner. Puncture sites are covered with sterile dressings, and if intra-articular medication is administered, the joints have to be passively moved through the range of motion to distribute the medication. Thereafter, compression therapy from distally to proximally while also covering the puncture site avoids recurrence of swelling or hematoma.

FACTS

If sterile conditions are guaranteed, infections rarely occur (0.04-0.08%, 4-8/10,000 cases). The risk of false-positive detection of microorganisms is extremely low.

The EFSUMB Guidelines and Recommendations for Musculoskeletal Ultrasound - Part II: Joint Pathologies, Pediatric Applications, and Guided Procedures

The second part of the Guidelines and Recommendations for Musculoskeletal Ultrasound (MSUS), produced under the auspices of EFSUMB, following the same methodology as for Part 1, provides information and recommendations on the use of this imaging modality for joint pathology, pediatric applications, and musculoskeletal ultrasound-guided procedures. Clinical application, practical points, limitations, and artifacts are described and discussed for every joint or procedure. The document is intended to guide clinical users in their daily practice.

Impact of the biopsy forceps size on histological analysis and performances of the histological scoring systems

To improve the reliability of the quantitative scorings of the synovial biopsies, we evaluate whether diameter of arthroscopic forceps influences histological quality of synovial tissue and/or histological scores and we compare the intra- and inter-observer performances of the main histological scoring systems. Synovial biopsies were retrieved in the same part of the joint using 1, 2 and 4 mm diameters grasping forceps. After standard staining and immunohistochemistry with anti-CD68 antibody, slides were scored blindly by 2 independent experienced operators for tissue quality and with Krenn score, de Bois-Tak score and CD68 semi-quantitative score. Four samples did not pass quality control. No difference other than a higher number of vessels in the 4 mm versus 2 mm forceps (p = 0.01) was found among the 3 groups. CD68 score was significantly higher in the 2 versus 4 mm forceps (p = 0.009). So we concluded that only vessels quantification and CD68 semi-quantitative score seemed affected by the forceps size. The intra-reader agreement was variable across observers and features: 0.78 (0.66–0.87) for the Krenn scoring system, 0.89 (0.78–0.97) for the de Bois-Tak score and 0.93 (0.81–1.00) for the CD68 score. Interobserver reliabilities of Krenn score, de Bois-Tak score and CD68 scores were satisfactory: 0.95 (0.92–0.99) for Krenn, 0.98 (0.96–0.99) for de Bois-Tak and 0.80 (0.71–0.89) for CD68.

Regarding Arthroscopy: Can Orthopedists and Rheumatologists Be Friends?

BACKGROUND/OBJECTIVE

Rheumatologists' interest in arthroscopy began before the 1980s, when many era practitioners began to take up the procedure in earnest. Some of the important players in pre-World War II explorations of arthroscopy were rheumatologists, and the father of modern arthroscopy Makei Watanabe counted many rheumatologists among his postwar students, who were publishing about arthroscopic insights into rheumatic conditions in the 1960s and 1970s. We chose to review this evolution to demonstrate the diverging interests of rheumatologists and orthopedists in arthroscopy and emphasize the chances for reconciliation and cooperation. Methods involve our personal recollection and review of the literature.

RESULTS

Guidelines for the practice of arthroscopy were published by the American Rheumatism Association (now the American College of Rheumatology) 7 years before similar guidelines appeared from the Arthroscopy Association of North America. American rheumatologists ceased arthroscopy when controlled trials showed no effect in osteoarthritis beyond placebo and biologics for synovitis virtually eliminated situations in which synovectomy might be considered. The research potential of arthroscopy has been realized mainly by European rheumatologists, although the ultrasound-guided biopsy is supplanting arthroscopy as means to secure synovium for investigation, despite the advantages of the latter, such as the ability to obtain larger amounts of tissue, select tissue based on macroscopic appearance, sample multiple area in the same joint, and deliver the potentially therapeutic effect of washout. New miniscopes suitable for office use could restore some of the lagging interest in arthroscopy for investigation. Orthopedists have generally been resistant to rheumatologists doing arthroscopy but would not be sharing any turf with rheumatologists using the miniscope.

CONCLUSIONS

We hope that we orthopedists and rheumatologists could be friends as we enter this new phase of arthroscopy as we use the technique for different purposes.

EULAR points to consider for minimal reporting requirements in synovial tissue research in rheumatology

BACKGROUND

Synovial tissue research has become widely developed in several rheumatology centres, however, large discrepancies exist in the way synovial tissue is handled and, more specifically, how data pertaining to biopsy procedure, quality check and experimental results are reported in the literature. This heterogeneity hampers the progress of research in this rapidly expanding field. In that context, under the umbrella of European Alliance of Associations for Rheumatology, we aimed at proposing points to consider (PtC) for minimal reporting requirements in synovial tissue research.

METHODS

Twenty-five members from 10 countries across Europe and USA met virtually to define the key areas needing evaluation and formulating the research questions to inform a systematic literature review (SLR). The results were presented during a second virtual meeting where PtC were formulated and agreed.

RESULTS

Study design, biopsy procedures, tissue handling, tissue quality control and tissue outcomes (imaging, DNA/RNA analysis and disaggregation) were identified as important aspects for the quality of synovial tissue research. The SLR interrogated four databases, retrieved 7654 abstracts and included 26 manuscripts. Three OPs and nine PtC were formulated covering the following areas: description of biopsy procedure, overarching clinical design, patient characteristics, tissue handling and processing, quality control, histopathology, transcriptomic analyses and single-cell technologies.

CONCLUSIONS

These PtC provide guidance on how research involving synovial tissue should be reported to ensure a better evaluation of results by readers, reviewers and the broader scientific community. We anticipate that these PtC will enable the field to progress in a robust and transparent manner over the coming years.

Title Current Status of the Search for Biomarkers for Optimal Therapeutic Drug Selection for Patients with Rheumatoid Arthritis

Rheumatoid arthritis (RA) is an autoimmune disease characterized by destructive synovitis. It is significantly associated with disability, impaired quality of life, and premature mortality. Recently, the development of biological agents (including tumor necrosis factor-α and interleukin-6 receptor inhibitors) and Janus kinase inhibitors have advanced the treatment of RA; however, it is still difficult to predict which drug will be effective for each patient. To break away from the current therapeutic approaches that could be described as a “lottery,” there is an urgent need to establish biomarkers that stratify patients in terms of expected therapeutic responsiveness. This review deals with recent progress from multi-faceted analyses of the synovial tissue in RA, which is now bringing new insights into diverse features at both the cellular and molecular levels and their potential links with particular clinical phenotypes.

Will rheumatologists ever pick up the arthroscope again?

Conditions prompting physicians and surgeons first adapting endoscopes to peer into joints were mainly the sort of synovial conditions that would concern today's rheumatologists. Rheumatologists were among the pre-World War II pioneers developing and documenting arthroscopy. The post-War father of modern arthroscopy, Watanabe, found rheumatologists among his early students, who took back the technique to their home countries, teaching orthopedists and rheumatologists alike. Rheumatologists described and analyzed the intra-articular features of their common diseases in the '60s and '70s. A groundswell of interest from academic rheumatologists in adapting arthroscopy grew considerably in the '90s with development of "needle scopes" that could be used in an office setting. Rheumatologists helped conduct the very trials the findings of which reduced demand for their arthroscopic services by questioning the efficacy of arthroscopic debridement in osteoarthritis (OA) and also developing biological compounds that greatly reduced the call for any resective intervention in inflammatory arthropathies. The arthroscope has proven an excellent tool for viewing and sampling synovium and continues to serve this purpose at several international research centers. While cartilage is now imaged mainly by magnetic resonance imaging, some OA features - such as a high prevalence of visible calcinosis - beg further arthroscopy-directed investigation. A new generation of "needle scopes" with far superior optics awaits future investigators, should they develop interest.

Ultrasound-Guided Synovial Biopsy: A Review

Ultrasound-guided synovial biopsy is a safe, well-tolerated, and effective method to collect good-quality synovial tissue from all types of joints for clinical and research purposes. Although synovial biopsy cannot be used to distinguish between types of inflammatory rheumatic disease, analysis of synovial tissue has led to remarkable advances in the understanding of the pathobiology of rheumatoid arthritis and other inflammatory rheumatic diseases. Synovitis is the hallmark of these diseases; hence, accessing the core of the pathological process, synovial tissue, provides an opportunity to gather information with potential diagnostic and prognostic utility.

Synovial biopsies in clinical practice and research: current developments and perspectives

Synovial biopsy techniques have developed and widely expanded over the past few years, in particular due to the development of ultrasound-guided procedures. This article reviews the different techniques, clinical applications, and the latest advances in translational research as well as current challenges and perspectives. The first part focuses on different techniques available for biopsy, along with their feasibility, success rate, tolerance, and training requirements. In the second part, clinical applications are described. Data on diagnostic performances are reported, especially regarding septic arthritis. Translational research applications are described and explained in the final part, from the early histological studies and the first description of pathotype to more recent technologies involving -omics. Latest developments involving single-cell RNA sequence analysis have allowed the discovery of new cell subpopulations with remarkable roles in RA pathophysiology. These studies pave the ground for the discovery of new therapeutic targets and the implementation of personalized therapy in RA.

Key Point •This review provides an overview of synovial biopsy techinques and applications especially in clinical and translational research.