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De Stefano L, Bugatti S, Piccin V, D'Ambrosio G, Luvaro T, Xoxi B, Montecucco C, Manzo A. The access route through the anatomical snuffbox in ultrasound-guided synovial biopsy of the wrist allows for a safe and effective collection of tissue samples in inflammatory arthritis. Arthritis Res Ther 2023; 25:119. [PMID: 37422683 PMCID: PMC10329327 DOI: 10.1186/s13075-023-03101-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 06/27/2023] [Indexed: 07/10/2023] Open
Abstract
BACKGROUND A proof-of-concept study to evaluate the feasibility and safety of minimally invasive ultrasound (US)-guided synovial biopsy of the radiocarpal (RC) joint using the anatomical snuffbox as an access route. METHODS Twenty consecutive patients with active chronic arthritis of the wrist underwent minimally invasive US-guided synovial biopsy of the RC joint using the anatomical snuffbox as the access route. Samples were retrieved from 3 predetermined biopsy target sites of the RC synovia (proximal, vault, and distal site), aiming for a minimum of 12 samples. The procedure's feasibility was evaluated based on the number and histological quality of retrieved tissue fragments tested on pre-defined histometric parameters. The safety and tolerability of the procedure were assessed through 1-week and 1-month follow-up clinical evaluations. RESULTS A median number of 17 fragments (≥ 1 mm diameter size at macroscopic evaluation) per procedure was processed for histopathology (range 9-24) and dedicated to the study. At the histopathologic evaluation, a gradable tissue (visible lining layer and ≥ 4 fragments with IST) was recognized in 19/20 biopsies (95%), and all pre-defined histometric parameters were judged applicable and successfully measured in 19/19 gradable biopsies. All three biopsy target sites showed sampling accessibility. The entire procedure was generally well tolerated. At the 1-month follow-up, no patients showed infectious complications. CONCLUSIONS The access route through the anatomical snuff box in US-guided synovial biopsies of the RC joint allows for a safe and targeted collection of adequate tissue samples. This modification of the traditional access route may allow easier, repeatable, and safer sampling of anatomically distinct areas of the wrist in the course of arthritis.
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Affiliation(s)
- Ludovico De Stefano
- Department of Internal Medicine and Therapeutics, Università Di Pavia, Pavia, Italy.
- Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100, Pavia, Italy.
| | - Serena Bugatti
- Department of Internal Medicine and Therapeutics, Università Di Pavia, Pavia, Italy
- Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100, Pavia, Italy
| | - Veronica Piccin
- Department of Internal Medicine and Therapeutics, Università Di Pavia, Pavia, Italy
- Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100, Pavia, Italy
| | | | - Terenzj Luvaro
- Department of Internal Medicine and Therapeutics, Università Di Pavia, Pavia, Italy
| | - Blerina Xoxi
- Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100, Pavia, Italy
| | - Carlomaurizio Montecucco
- Department of Internal Medicine and Therapeutics, Università Di Pavia, Pavia, Italy
- Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100, Pavia, Italy
| | - Antonio Manzo
- Department of Internal Medicine and Therapeutics, Università Di Pavia, Pavia, Italy
- Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100, Pavia, Italy
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2
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Ben-Artzi A, Horowitz DL, Mandelin AM, Tabechian D. Best practices for ultrasound-guided synovial biopsy in the United States. Best Pract Res Clin Rheumatol 2023; 37:101834. [PMID: 37263809 DOI: 10.1016/j.berh.2023.101834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 04/24/2023] [Indexed: 06/03/2023]
Abstract
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.
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Affiliation(s)
- Ami Ben-Artzi
- Cedars Sinai Medical Center Staff Member, Los Angeles, CA, USA; Scripps Memorial Hospital Staff Member, San Diego, CA, USA.
| | - Diane L Horowitz
- Zucker School of Medicine at Hofstra/Northwell, Department of Medicine, Division of Rheumatology, Great Neck, NY, USA
| | - Arthur M Mandelin
- Northwestern University Feinberg School of Medicine, Department of Medicine, Division of Rheumatology, Chicago, IL, USA
| | - Darren Tabechian
- Department of Medicine, Division of Allergy Immunology and Rheumatology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
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3
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Reitsema RD, Jiemy WF, Wekema L, Boots AMH, Heeringa P, Huitema MG, Abdulahad WH, van Sleen Y, Sandovici M, Roozendaal C, Diepstra A, Kwee T, Dasgupta B, Brouwer E, van der Geest KSM. Contribution of pathogenic T helper 1 and 17 cells to bursitis and tenosynovitis in polymyalgia rheumatica. Front Immunol 2022; 13:943574. [PMID: 36032100 PMCID: PMC9402989 DOI: 10.3389/fimmu.2022.943574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 07/22/2022] [Indexed: 11/13/2022] Open
Abstract
Background Although polymyalgia rheumatica (PMR) is a very common rheumatic inflammatory disease, current insight into the pathobiology of PMR is limited and largely based on studies in blood. We investigated T helper 1 (TH1) and T helper 17 (TH17) cell responses in blood, synovial fluid and bursa tissue of patients with PMR. Materials and methods Blood samples were collected from 18 patients with new-onset PMR and 32 healthy controls. Synovial fluid was aspirated from the inflamed shoulder bursae or biceps tendon sheath of 13 patients. Ultrasound-guided biopsies of the subacromial-subdeltoid (SASD) bursa were obtained from 11 patients. T cells were examined by flow cytometry, immunohistochemistry and immunofluorescence staining. Results Besides an increase of TH17 (CD4+IL-17+IFN-γ-) cells and T cytotoxic 17 (TC17; CD8+IL-17+IFN-γ-) cells, no other major changes were noted in the circulating T cell compartment of patients with PMR. Absolute numbers of CD4+ and CD8+ T cells were similar in blood and synovial fluid of patients with PMR. Synovial fluid T cells showed an effector-memory (CD45RO+CCR7-) phenotype. Percentages of TH1 (CD4+IFN-γ+IL-17-) cells and TH1/TH17 (CD4+IFN-γ+IL-17+) cells, but not TH17 or TC17 cells, were increased in the synovial fluid. Bursa tissue biopsies contained a small number of T cells, which were mostly CD8 negative. The majority of bursa tissue T cells produced IFN-γ but not IL-17. For comparison, B cells were scarcely detected in the bursa tissue. Conclusion Although the circulating TH17 cell pool is expanded in patients with PMR, our findings indicate that TH1 cells are involved in the inflammation of bursae and tendon sheaths in this condition. Our study points towards the TH1 cell pathway as a potential target for therapy in PMR.
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Affiliation(s)
- Rosanne D. Reitsema
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - William F. Jiemy
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Lieske Wekema
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Annemieke M. H. Boots
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Peter Heeringa
- Department of Pathology and Medical Biology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Minke G. Huitema
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Wayel H. Abdulahad
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
- Department of Pathology and Medical Biology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Yannick van Sleen
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Maria Sandovici
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Caroline Roozendaal
- Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Arjan Diepstra
- Department of Pathology and Medical Biology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Thomas Kwee
- Medical Imaging Center, Department of Radiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Bhaskar Dasgupta
- Department of Rheumatology, Southend University Hospital, Westcliff-on-Sea, United Kingdom
| | - Elisabeth Brouwer
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Kornelis S. M. van der Geest
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
- *Correspondence: Kornelis S. M. van der Geest,
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4
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Promising role of polymeric nanoparticles in the treatment of rheumatoid arthritis. Inflammopharmacology 2022; 30:1207-1218. [PMID: 35524837 DOI: 10.1007/s10787-022-00997-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 04/11/2022] [Indexed: 11/05/2022]
Abstract
Rheumatoid arthritis (RA) is a chronic inflammatory illness caused by an autoimmune disorder of synovial membrane resulting in synovial membrane dysfunction. The available treatment particularly focuses on inhibiting macrophage proliferation and reducing the generation of pro-inflammatory cytokines. However, therapeutic success of current treatment options at targeted site is limited; therefore, development of promising therapeutic strategy is the need of time that may provide better targeted delivery of drug with added safety. In development of precision medicine to manage RA, nanotechnology is a viable option to be considered. Recent research using nanoparticles for the treatment of RA, particularly polymeric nanoparticles, has been discussed in this article. Using polymeric nanoparticles as a therapeutic method has shown considerable promise of enhancing treatment success over standard medications used in routine. It is exclusively evident that the viability of using nanoparticles is mainly owed due to their biocompatibility, chemical stability, controlled drug release, and selective drug delivery to inflamed tissues in RA model animals. The current analysis focuses on the critical design characteristics of RA-targeted nanotechnology-based strategies in quest of better therapeutic strategies for RA, and to identify leading polymer as the most effective medications in RA therapy.
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Najm A, Costantino F, Alivernini S, Alunno A, Bianchi E, Bignall J, Boyce B, Canete JD, Carubbi F, Durez P, Fonseca JE, Just SA, Largo R, Manzo A, Maybury M, Naredo E, Orr C, Pitzalis C, Rivellese F, Romão VC, van Rompay J, Tas SW, Veale DJ, D'Agostino MA, Filer A. EULAR points to consider for minimal reporting requirements in synovial tissue research in rheumatology. Ann Rheum Dis 2022; 81:1640-1646. [PMID: 35210263 DOI: 10.1136/annrheumdis-2021-221875] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 01/20/2022] [Indexed: 11/04/2022]
Abstract
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.
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Affiliation(s)
- Aurélie Najm
- Institute of Infection, Immunity and Inflammation, University of Glasgow College of Medical Veterinary and Life Sciences, Glasgow, UK
| | - Félicie Costantino
- Université Paris-Saclay, UVSQ, Inserm U1173, Infection et Inflammation, Laboratory of Excellence Inflamex, Montigny-Le-Bretonneux, France.,Rheumatology Department, AP-HP, Boulogne-billancourt, Paris, France
| | - Stefano Alivernini
- UOC di Reumatologia, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alessia Alunno
- Internal Medicine and Nephrology Unit, Department of Clinical Medicine Life Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Elettra Bianchi
- Department of Pathology, Department of Anatomical Pathology, Central University Hospital of Liege, Liege, Belgium
| | - Jacqueline Bignall
- Rheumatology Patient Group, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Brendan Boyce
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Juan D Canete
- Arthritis Unit, Rheumatology Dpt, IDIBAPS, Barcelona, Spain.,Joint and Bone Research Unit. Rheumatology Dept, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Francesco Carubbi
- Internal Medicine and Nephrology Unit, Department of Clinical Medicine Life Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy.,Department of Medicine, San Salvatore Hospital, L'Aquila, Italy
| | - Patrick Durez
- Pôle de Recherche en Rhumatologie, Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain Secteur des sciences de la santé, Bruxelles, Belgium.,Pôle de Recherche en Rhumatologie, Institut de Recherche Expérimentale et Clinique, Cliniques universitaires Saint-Luc, Bruxelles, Belgium
| | - João Eurico Fonseca
- Serviço de Reumatologia, Centro Hospitalar Universitário Lisboa Norte, Instituto de Medicina Molecular, Lisboa, Portugal
| | - Søren Andreas Just
- Department of Rheumatology, Bone and Joint Research Unit, Odense Universitetshospital, Odense, Denmark
| | - Raquel Largo
- Joint and Bone Research Unit. Rheumatology Dept, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain.,Universidad Autónoma de Madrid, Madrid, Spain
| | - Antonio Manzo
- Translational Immunology Research Laboratories (LaRIT), Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Mark Maybury
- Rheumatology Research Group and Research into Inflammatory Arthritis Centre Versus Arthritis, Institute of Inflammation and Ageing, NIHR Birmingham Biomedical Research Center, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Esperanza Naredo
- Universitario Fundación Jiménez Díaz, IIS Fundación Jiménez Díaz, Rheumatology, Universidad Autónoma de Madrid, Madrid, Spain
| | - Carl Orr
- Centre for Arthritis and Rheumatic Disease, University College Dublin, Dublin, Ireland.,The Conway Institute, St Vincent's University Hospital, Dublin, Ireland
| | - Costantino Pitzalis
- Centre for Experimental Medicine and Rheumatology, Barts and The London School of Medicine and Dentistry William Harvey Research Institute, London, UK
| | - Felice Rivellese
- Centre for Experimental Medicine and Rheumatology, Barts and The London School of Medicine and Dentistry William Harvey Research Institute, London, UK
| | - Vasco C Romão
- Serviço de Reumatologia, Centro Hospitalar Universitário Lisboa Norte, Instituto de Medicina Molecular, Lisboa, Portugal
| | - Jef van Rompay
- Patient Research Partners, Antwerp Province, Antwerpen, Belgium
| | - Sander W Tas
- Amsterdam Rheumatology and Immunology Center, Department of Clinical Immunology and Rheumatology, Amsterdam University Medical Centres, Amsterdam, Noord-Holland, The Netherlands
| | - Douglas J Veale
- Centre for Arthritis and Rheumatic Disease, University College Dublin, Dublin, Ireland.,The Conway Institute, St Vincent's University Hospital, Dublin, Ireland
| | - Maria-Antonietta D'Agostino
- Université Paris-Saclay, UVSQ, Inserm U1173, Infection et Inflammation, Laboratory of Excellence Inflamex, Montigny-Le-Bretonneux, France.,UOC di Reumatologia, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Andrew Filer
- Rheumatology Research Group and Research into Inflammatory Arthritis Centre Versus Arthritis, Institute of Inflammation and Ageing, NIHR Birmingham Biomedical Research Center, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Najm A, Costantino F, Weill C, Filer A, D'Agostino MA. Impact of synovial biopsy procedures and disease-specific aspects on synovial tissue outcome: a systematic literature review informing the EULAR points to consider for the minimal reporting requirements in synovial tissue research in rheumatology. RMD Open 2022; 8:rmdopen-2021-002116. [PMID: 35177556 PMCID: PMC8860072 DOI: 10.1136/rmdopen-2021-002116] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 01/15/2022] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND The aim of this work was to summarise the literature evaluating the impact of biopsy procedures, tissue handling, tissue quality and disease-specific aspects including joint biopsied and disease stage, on synovial tissue outcome. METHODS Two reviewers independently identified eligible studies according to the Patients, Intervention, Comparator and Outcome framework obtained for five research questions formulated during the first EULAR task force meeting to produce points to consider (PtC) for minimal reporting requirements in synovial tissue studies. The databases explored were Medline, Embase, CENTRAL and Cinhal. The risk of bias of each study was evaluated using an adapted version of the Joanna Briggs Institute checklist for analytical cross-sectional studies. RESULTS Of the 7654 records yielded, 75 full texts were assessed, leading to the inclusion of 26 manuscripts in the systematic literature review (SLR). Two papers assessed the impact of biopsy procedures on the quality and quantity of tissue retrieved alongside patient tolerability; six papers focused on synovial tissue variability. Four papers studied the impact of sample handling or randomisation and 14 assessed the impact of disease stage and state, namely early or established active rheumatoid arthritis and remission on histopathological and transcriptomic results. CONCLUSIONS This SLR informs the EULAR PtC for minimal reporting requirements in synovial tissue research in rheumatology. Characteristics related to the study design, population, sample handling, randomisation and analysis can affect the final synovial tissue outcome in the studies reviewed. Thus, accurate reporting of these factors is required in order to ensure the scientific validity of manuscripts describing synovial tissue outcomes.
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Affiliation(s)
- Aurélie Najm
- Musculoskeletal Research Group, Institute of Infection, Immunity and Inflammation, University of Glasgow College of Medical Veterinary and Life Sciences, Glasgow, UK
| | - Félicie Costantino
- Université Paris-Saclay, UVSQ, Inserm U1173, Infection et inflammation, Laboratory of excellence Inflamex, Paris, Île-de-France, France.,Rheumatology Department, Ambroise Paré Hospital, Boulogne-Billancourt, France
| | - Catherine Weill
- Medicine, University of Paris Health Interuniversity Library, Paris, Île-de-France, France
| | - Andrew Filer
- Rheumatology Research Group and Research into Inflammatory Arthritis Centre Versus Arthritis, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Maria Antonieta D'Agostino
- Université Paris-Saclay, UVSQ, Inserm U1173, Infection et inflammation, Laboratory of excellence Inflamex, Paris, Île-de-France, France.,Rheumatology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Lazio, Italy
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Abstract
Rheumatoid Arthritis (RA) is a chronic systemic autoimmune disease. RA mainly affects synovial joints, with inflammation of the synovial membrane (synovitis), characterised by neo-angiogenesis, hyperplasia of lining layer, and immune cell infiltration that drive local inflammation and, if untreated, can lead to joint destruction and disability. In parallel to the well-known clinical heterogeneity, the underlying synovitis can also be significantly heterogeneous, both at cellular and molecular level, which can at least in part explain why despite the availability of highly effective treatment options, a large proportion of patients are resistant to some individual treatments. The assimilation of recent high-throughput data from analysis at the single-cell level with rigorous and high-quality clinical outcomes obtained from large randomised clinical trials support the definition of disease and treatment response endotypes. Looking ahead, the integration of histological and molecular signatures from the diseased tissue into clinical algorithms may help decision making in the management of patients with Rheumatoid Arthritis in clinical practice.
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8
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Saraiva F. Ultrasound-Guided Synovial Biopsy: A Review. Front Med (Lausanne) 2021; 8:632224. [PMID: 33968950 PMCID: PMC8100029 DOI: 10.3389/fmed.2021.632224] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 02/22/2021] [Indexed: 11/29/2022] Open
Abstract
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.
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Affiliation(s)
- Fernando Saraiva
- Serviço de Reumatologia, Hospital de Santa Maria, Centro Hospitalar e Universitário de Lisboa Norte, Lisbon, Portugal.,Unidade de Investigação em Reumatologia, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
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9
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Romão VC, Polido-Pereira J, Barros R, Luís R, Vidal B, Vieira-Sousa E, Vitorino E, Humby F, Kelly S, Pitzalis C, Saraiva F, Fonseca JE. Efficacy, Safety, and Sample Quality of Ultrasound-Guided Synovial Needle Biopsy in Clinical Practice and Research: A Prospective Observational Study. Arthritis Care Res (Hoboken) 2020; 72:1497-1505. [PMID: 31421034 DOI: 10.1002/acr.24050] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Accepted: 08/13/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To study the efficacy, tolerability, safety, and sampling variation of ultrasound (US)-guided synovial biopsies performed in clinical practice and research. METHODS We included all patients who had a US-guided synovial needle biopsy from November 2013 to January 2018. Patients were evaluated for procedure safety and tolerability. Usefulness of synovial biopsy was considered based on contribution for achieving the proposed aims. We analyzed samples for presence and quality of synovial tissue, synovitis score/grade, and pathotype. Variation across patients, samples, section levels, and sampling order was assessed. RESULTS A total of 64 US-guided synovial biopsies were performed (n = 52 in clinical practice, n = 12 in research). Patient tolerability (70% no/mild discomfort) was remarkably high. There was no significant aggravation of symptoms or US synovitis in the biopsied joint. Procedures were overall safe, with few minor, 2 moderate, and no major adverse events. Usefulness of US-guided synovial biopsies was high, both in clinical practice (37% direct diagnostic impact, 100% positive/95% negative predictive values for infection) and in research (92% success). Synovial tissue was retrieved in 88% of biopsies, with a median of 75% gradable samples. There was significant variation in sample quality and synovitis features across patients and samples, but not between different section levels. Samples collected later in the procedure had a lower frequency of synovial tissue and were poorly concordant in pathotype with those collected earlier. CONCLUSION US-guided synovial needle biopsy is an effective, safe, and well-tolerated means to collect good quality synovial tissue for clinical and research purposes. Samples collected for different aims should be retrieved in parallel, rather than sequentially.
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Affiliation(s)
- Vasco C Romão
- Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, and Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon Academic Medical Centre, Lisbon, Portugal
| | - Joaquim Polido-Pereira
- Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, and Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon Academic Medical Centre, Lisbon, Portugal
| | - Rita Barros
- Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, and Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon Academic Medical Centre, Lisbon, Portugal
| | - Rita Luís
- Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, and Faculdade de Medicina, Universidade de Lisboa, Lisbon Academic Medical Centre, Lisbon, Portugal
| | - Bruno Vidal
- Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon Academic Medical Centre, Lisbon, Portugal
| | - Elsa Vieira-Sousa
- Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, and Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon Academic Medical Centre, Lisbon, Portugal
| | - Emília Vitorino
- Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Centre, London, United Kingdom
| | - Frances Humby
- William Harvey Research Institute, Barts and the London School of Medicine , London, United Kingdom
| | - Stephen Kelly
- Mile End Hospital, Barts Health NHS Trust, London, UK
| | - Costantino Pitzalis
- William Harvey Research Institute, Barts and the London School of Medicine , London, United Kingdom
| | - Fernando Saraiva
- Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Centre, London, United Kingdom
| | - João Eurico Fonseca
- Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, and Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon Academic Medical Centre, Lisbon, Portugal
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10
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Transforming clinical trials in rheumatology: towards patient-centric precision medicine. Nat Rev Rheumatol 2020; 16:590-599. [PMID: 32887976 DOI: 10.1038/s41584-020-0491-4] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2020] [Indexed: 01/20/2023]
Abstract
Despite the success of targeted therapies in the treatment of inflammatory arthritides, the lack of predictive biomarkers drives a 'trial and error' approach to treatment allocation, leading to variable and/or unsatisfactory responses. In-depth characterization of the synovial tissue in rheumatoid arthritis, as well as psoriatic arthritis and spondyloarthritis, is bringing new insights into the diverse cellular and molecular features of these diseases and their potential links with different clinical and treatment-response phenotypes. Such progress raises the tantalizing prospect of improving response rates by matching the use of specific agents to the cognate target pathways that might drive particular disease subtypes in specific patient groups. Innovative patient-centric, molecular pathology-driven clinical trial approaches are needed to achieve this goal. Whilst progress is clearly being made, it is important to emphasize that this field is still in its infancy and there are a number of potential barriers to realizing the premise of patient-centric clinical trials.
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Nerviani A, Di Cicco M, Mahto A, Lliso-Ribera G, Rivellese F, Thorborn G, Hands R, Bellan M, Mauro D, Boutet MA, Giorli G, Lewis M, Kelly S, Bombardieri M, Humby F, Pitzalis C. A Pauci-Immune Synovial Pathotype Predicts Inadequate Response to TNFα-Blockade in Rheumatoid Arthritis Patients. Front Immunol 2020; 11:845. [PMID: 32431716 PMCID: PMC7214807 DOI: 10.3389/fimmu.2020.00845] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 04/14/2020] [Indexed: 01/17/2023] Open
Abstract
Objectives: To assess whether the histopathological features of the synovium before starting treatment with the TNFi certolizumab-pegol could predict clinical outcome and examine the modulation of histopathology by treatment. Methods: Thirty-seven RA patients fulfilling UK NICE guidelines for biologic therapy were enrolled at Barts Health NHS trust and underwent synovial sampling of an actively inflamed joint using ultrasound-guided needle biopsy before commencing certolizumab-pegol and after 12-weeks. At 12-weeks, patients were categorized as responders if they had a DAS28 fall >1.2. A minimum of 6 samples was collected for histological analysis. Based on H&E and immunohistochemistry (IHC) staining for CD3 (T cells), CD20 (B cells), CD138 (plasma cells), and CD68 (macrophages) patients were categorized into three distinct synovial pathotypes (lympho-myeloid, diffuse-myeloid, and pauci-immune). Results: At baseline, as per inclusion criteria, DAS28 mean was 6.4 ± 0.9. 94.6% of the synovial tissue was retrieved from the wrist or a metacarpophalangeal joint. Histological pathotypes were distributed as follows: 58% lympho-myeloid, 19.4% diffuse-myeloid, and 22.6% pauci-immune. Patients with a pauci-immune pathotype had lower levels of CRP but higher VAS fatigue compared to lympho- and diffuse-myeloid. Based on DAS28 fall >1.2, 67.6% of patients were deemed as responders and 32.4% as non-responders. However, by categorizing patients according to the baseline synovial pathotype, we demonstrated that a significantly higher number of patients with a lympho-myeloid and diffuse-myeloid pathotype in comparison with pauci-immune pathotype [83.3% (15/18), 83.3 % (5/6) vs. 28.6% (2/7), p = 0.022) achieved clinical response to certolizumab-pegol. Furthermore, we observed a significantly higher level of post-treatment tender joint count and VAS scores for pain, fatigue and global health in pauci-immune in comparison with lympho- and diffuse-myeloid patients but no differences in the number of swollen joints, ESR and CRP. Finally, we confirmed a significant fall in the number of CD68+ sublining macrophages post-treatment in responders and a correlation between the reduction in the CD20+ B-cells score and the improvement in the DAS28 at 12-weeks. Conclusions: The analysis of the synovial histopathology may be a helpful tool to identify among clinically indistinguishable patients those with lower probability of response to TNFα-blockade.
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Affiliation(s)
- Alessandra Nerviani
- Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Maria Di Cicco
- Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Arti Mahto
- Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Gloria Lliso-Ribera
- Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Felice Rivellese
- Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Georgina Thorborn
- Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Rebecca Hands
- Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Mattia Bellan
- Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Daniele Mauro
- Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Marie-Astrid Boutet
- Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Giovanni Giorli
- Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Myles Lewis
- Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Stephen Kelly
- Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Michele Bombardieri
- Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Frances Humby
- Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Costantino Pitzalis
- Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
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12
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Rivellese F, Humby F, Bugatti S, Fossati‐Jimack L, Rizvi H, Lucchesi D, Lliso‐Ribera G, Nerviani A, Hands RE, Giorli G, Frias B, Thorborn G, Jaworska E, John C, Goldmann K, Lewis MJ, Manzo A, Bombardieri M, Pitzalis C. B Cell Synovitis and Clinical Phenotypes in Rheumatoid Arthritis: Relationship to Disease Stages and Drug Exposure. Arthritis Rheumatol 2020; 72:714-725. [PMID: 31785084 PMCID: PMC7217046 DOI: 10.1002/art.41184] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 11/26/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To define the relationship of synovial B cells to clinical phenotypes at different stages of disease evolution and drug exposure in rheumatoid arthritis (RA). METHODS Synovial biopsy specimens and demographic and clinical data were collected from 2 RA cohorts (n = 329), one of patients with untreated early RA (n = 165) and one of patients with established RA with an inadequate response to tumor necrosis factor inhibitors (TNFi-IR; n = 164). Synovial tissue was subjected to hematoxylin and eosin and immunohistochemical staining and semiquantitative assessment for the degree of synovitis (on a scale of 0-9) and of CD20+ B cell infiltrate (on a scale of 0-4). B cell scores were validated by digital image analysis and B cell lineage-specific transcript analysis (RNA-Seq) in the early RA (n = 91) and TNFi-IR (n = 127) cohorts. Semiquantitative CD20 scores were used to classify patients as B cell rich (≥2) or B cell poor (<2). RESULTS Semiquantitative B cell scores correlated with digital image analysis quantitative measurements and B cell lineage-specific transcripts. B cell-rich synovitis was present in 35% of patients in the early RA cohort and 47.7% of patients in the TNFi-IR cohort (P = 0.025). B cell-rich patients showed higher levels of disease activity and seropositivity for rheumatoid factor and anti-citrullinated protein antibody in early RA but not in established RA, while significantly higher histologic synovitis scores in B cell-rich patients were demonstrated in both cohorts. CONCLUSION We describe a robust semiquantitative histologic B cell score that closely replicates the quantification of B cells by digital or molecular analyses. Our findings indicate an ongoing B cell-rich synovitis, which does not seem to be captured by standard clinimetric assessment, in a larger proportion of patients with established RA than early RA.
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Affiliation(s)
- F. Rivellese
- Barts and The London School of Medicine and DentistryQueen Mary University of LondonLondonUK
| | - F. Humby
- Barts and The London School of Medicine and DentistryQueen Mary University of LondonLondonUK
| | - S. Bugatti
- IRCCSPoliclinico San Matteo Foundation and University of PaviaPaviaItaly
| | - L. Fossati‐Jimack
- Barts and The London School of Medicine and DentistryQueen Mary University of LondonLondonUK
| | | | - D. Lucchesi
- Barts and The London School of Medicine and DentistryQueen Mary University of LondonLondonUK
| | - G. Lliso‐Ribera
- Barts and The London School of Medicine and DentistryQueen Mary University of LondonLondonUK
| | - A. Nerviani
- Barts and The London School of Medicine and DentistryQueen Mary University of LondonLondonUK
| | - R. E. Hands
- Barts and The London School of Medicine and DentistryQueen Mary University of LondonLondonUK
| | - G. Giorli
- Barts and The London School of Medicine and DentistryQueen Mary University of LondonLondonUK
| | - B. Frias
- Barts and The London School of Medicine and DentistryQueen Mary University of LondonLondonUK
| | - G. Thorborn
- Barts and The London School of Medicine and DentistryQueen Mary University of LondonLondonUK
| | - E. Jaworska
- Barts and The London School of Medicine and DentistryQueen Mary University of LondonLondonUK
| | - C. John
- Barts and The London School of Medicine and DentistryQueen Mary University of LondonLondonUK
| | - K. Goldmann
- Barts and The London School of Medicine and DentistryQueen Mary University of LondonLondonUK
| | - M. J. Lewis
- Barts and The London School of Medicine and DentistryQueen Mary University of LondonLondonUK
| | - A. Manzo
- IRCCSPoliclinico San Matteo Foundation and University of PaviaPaviaItaly
| | - M. Bombardieri
- Barts and The London School of Medicine and DentistryQueen Mary University of LondonLondonUK
| | - C. Pitzalis
- Barts and The London School of Medicine and DentistryQueen Mary University of LondonLondonUK
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Labinsky H, Panipinto PM, Ly KA, Khuat DK, Madarampalli B, Mahajan V, Clabeaux J, MacDonald K, Verdin PJ, Buckner JH, Noss EH. Multiparameter Analysis Identifies Heterogeneity in Knee Osteoarthritis Synovial Responses. Arthritis Rheumatol 2020; 72:598-608. [PMID: 31702112 DOI: 10.1002/art.41161] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 11/05/2019] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Synovial membrane inflammation is common in osteoarthritis (OA) and increases cartilage injury. However, synovial fluid and histology studies suggest that OA inflammatory responses are not homogeneous. Greater understanding of these responses may provide new insights into OA disease mechanisms. We undertook this study to develop a novel multiparameter approach to phenotype synovial responses in knee OA. METHODS Cell composition and soluble protein production were measured by flow cytometry and multiplex enzyme-linked immunosorbent assay in synovium collected from OA patients undergoing knee replacement surgery (n = 35). RESULTS Testing disaggregation conditions showed that aggressive digestion improved synovial cell yield and mesenchymal staining by flow cytometry, but it negatively impacted CD4+ T cell and CD56+ natural killer cell staining. Less aggressive digestion preserved these markers and showed highly variable T cell infiltration (range 0-43%; n = 32). Correlation analysis identified mesenchymal subpopulations associated with different nonmesenchymal populations, including macrophages and T cells (CD45+CD11b+HLA-DR+ myeloid cells with PDPN+CD73+CD90-CD34- mesenchymal cells [r = 0.65, P < 0.0001]; and CD45+CD3+ T cells with PDPN+CD73+CD90+CD34+ mesenchymal cells [r = 0.50, P = 0.003]). Interleukin-6 (IL-6) measured by flow cytometry strongly correlated with IL-6 released by ex vivo culture of synovial tissue (r = 0.59, P = 0.0012) and was highest in mesenchymal cells coexpressing CD90 and CD34. IL-6, IL-8, complement factor D, and IL-10 release correlated positively with tissue cellularity (P = 0.0042, P = 0.018, P = 0.0012, and P = 0.038, respectively). Additionally, increased CD8+ T cell numbers correlated with retinol binding protein 4 (P = 0.033). Finally, combining flow cytometry and multiplex data identified patient clusters with different types of inflammatory responses. CONCLUSION We used a novel approach to analyze OA synovium, identifying patient-specific inflammatory clusters. Our findings indicate that phenotyping synovial inflammation may provide new insights into OA patient heterogeneity and biomarker development.
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Affiliation(s)
- Hannah Labinsky
- University of Washington, Seattle, and University Medical Center of Johannes Gutenberg University, Germany
| | | | - Kaytlyn A Ly
- Virginia Mason Medical Center, Seattle, Washington
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Tuckwell K, Gabay C, Sornasse T, Laubender RP, Wang J, Townsend MJ. Levels of CXCL13 and sICAM-1 correlate with disease activity score in patients with rheumatoid arthritis treated with tocilizumab. Adv Rheumatol 2019; 59:54. [DOI: 10.1186/s42358-019-0097-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 11/15/2019] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Tocilizumab (TCZ), a humanized monoclonal antibody against the interleukin-6 receptor, has been proven to be a safe and effective treatment for rheumatoid arthritis (RA). Because RA is a heterogenous disease and patient response to treatments can vary, identifying characteristics that predict which patients are more likely to respond to TCZ is important for optimal patient care. Serum levels of C-X-C motif chemokine ligand 13 (CXCL13) and soluble intercellular adhesion molecule-1 (sICAM-1) have been associated with response to TCZ in patients with RA.
Objectives
To evaluate the association of CXCL13 and sICAM-1 with disease activity and response to TCZ in patients with early RA and those with inadequate response to disease-modifying antirheumatic drugs (DMARD-IR).
Methods
Baseline and week 24 serum CXCL13 and sICAM-1 levels were measured using available patient samples from the FUNCTION (early RA) and LITHE (DMARD-IR) trials. Correlations between CXCL13 and sICAM-1 levels and Disease Activity Score in 28 joints calculated with erythrocyte sedimentation rate (DAS28-ESR) at baseline and between change in CXCL13 and sICAM-1 and change in DAS28-ESR at week 24 were estimated. CXCL13 and sICAM-1 changes from baseline to week 24 were compared between treatment arms. The effects of TCZ treatment and baseline DAS28-ESR, CXCL13 and sICAM-1 levels on DAS28-ESR remission and 50% improvement per the American College of Rheumatology (ACR50) response at week 24 were determined.
Results
Overall, 458 patients from FUNCTION and 287 patients from LITHE were included. Correlation of baseline serum CXCL13 and sICAM-1 levels with DAS28-ESR was weak to moderate. CXCL13 and sICAM-1 levels decreased significantly at week 24 in TCZ-treated patients in both the early-RA and DMARD-IR populations. CXCL13 and sICAM-1 changes correlated moderately to weakly with DAS28-ESR changes at week 24 in both populations. The treatment regimen, but not baseline CXCL13 and sICAM-1 levels, had a significant effect on the likelihood of DAS28-ESR remission and ACR50 response.
Conclusions
Although CXCL13 and sICAM-1 are modestly associated with RA disease activity, they do not predict response to TCZ in all RA populations.
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15
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Just SA, Nielsen C, Werlinrud JC, Larsen PV, Klinkby CS, Schrøder HD, Humby F, Torfing T, Lindegaard H. Six-month prospective trial in early and long-standing rheumatoid arthritis: evaluating disease activity in the wrist through sequential synovial histopathological analysis, RAMRIS magnetic resonance score and EULAR-OMERACT ultrasound score. RMD Open 2019; 5:e000951. [PMID: 31413866 PMCID: PMC6667976 DOI: 10.1136/rmdopen-2019-000951] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Revised: 06/10/2019] [Accepted: 06/14/2019] [Indexed: 11/04/2022] Open
Abstract
Introduction Standardised scoring systems for rheumatoid arthritis (RA) joint disease activity include Larsen score for radiographs, rheumatoid arthritis magnetic resonance imaging score (RAMRIS) for MRI and using the European League Against Rheumatisms-Outcome Measures in Rheumatology (EULAR-OMERACT) score for ultrasound (US) images. The aim of this prospective study was to investigate the relationship between histological synovitis and radiological synovitis, assessed by conventional X-ray, US and MRI of the wrist radiocarpal joint. Methods 20 patients with treatment naive early RA (ERA) and 20 with long-standing RA (LRA) were enrolled in a 6-month prospective study. Patients with RA underwent US-guided synovial biopsy, X-ray and US of the wrist at enrolment and 6 months. MRI at baseline and also at 6 months for the ERA group, and scored with the RAMRIS system. X-ray was scored by Larsen score and US by the EULAR-OMERACT system. Synovial biopsy inflammation was determined by the Krenn score. Results In the ERA group at baseline, Krenn score was correlated strongly with both US combined score (r = 0.77 p < 0.001) and MRI synovitis score (r = 0.85 p < 0.001), while uncorrelated at 6 months. In the LRA group at baseline, these scores correlated strongly (r = 0.83, p < 0.001) to moderately (r = 0.61, p = 0.002), and persisted at 6 months for US score (r = 0.81 p < 0.001). For all patients with RA, change in Krenn score between baseline and 6 months was correlated with both change in US combined score (r = 0.65, p < 0.001) and change in MRI synovitis score (r = 0.50, p = 0.03). Conclusion The MRI RAMRIS synovitis score and EULAR-OMERACT US scoring system are sensitive measures of histological synovitis in LRA and ERA. After 6 months, this correlation persists in the established RA group, but not in the ERA group. Overall, decreases in MRI/US synovitis are associated with reductions in histological synovitis. The study validates the use of MRI RAMRIS and EULAR-OMERACT US scores as surrogate markers of histological synovitis in established RA and early untreated RA.
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Affiliation(s)
- Søren Andreas Just
- Department of Rheumatology, Odense University Hospital, Odense, Denmark.,Section of Rheumatology, Department of Medicine, Svendborg Sygehus OUH, Svendborg, Denmark
| | - Christian Nielsen
- Department of Clinical Immunology, Odense University Hospital, Odense, Denmark.,Odense Patient data Explorative Network (OPEN), Odense University Hospital, Odense, Denmark
| | | | - Pia Veldt Larsen
- Department of Epidemiology and Biostatistics, University of Southern Denmark, Odense, Denmark
| | | | | | - Fran Humby
- Centre for Experimental Medicine and Rheumatology, Barts and the London School of Medicine and Dentistry, London, UK
| | - Trine Torfing
- Section of musculoskeletal radiology, Department of Radiology, Odense University Hospital, Odense, Denmark
| | - Hanne Lindegaard
- Department of Rheumatology, Odense University Hospital, Odense, Denmark
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16
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Manzo A, Bugatti S, Rossi S. Clinical Applications of Synovial Biopsy. Front Med (Lausanne) 2019; 6:102. [PMID: 31134204 PMCID: PMC6524205 DOI: 10.3389/fmed.2019.00102] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 04/25/2019] [Indexed: 11/13/2022] Open
Abstract
The synovial tissue is a primary target of multiple diseases characterized by different pathogenic mechanisms, including infective, deposition, neoplastic, and chronic immune-inflammatory pathologies. Synovial biopsy can have a relevant role in differential diagnosis of specific conditions in clinical practice, although its exploitation remains relatively limited. In particular, no validated synovial-tissue-derived biomarkers are currently available in the clinic to aid in the diagnosis and management in most frequent forms of chronic inflammatory arthropathies, namely rheumatoid arthritis (RA) and the spondyloarthritides (SpA). In this brief review, we will discuss the current spectrum of clinical applications of synovial biopsy in routine rheumatologic care and will provide an analysis of the perspectives for its potential exploitation in patients with chronic inflammatory arthritides.
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Affiliation(s)
- Antonio Manzo
- Rheumatology and Translational Immunology Research Laboratories, Division of Rheumatology, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Serena Bugatti
- Rheumatology and Translational Immunology Research Laboratories, Division of Rheumatology, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Silvia Rossi
- Rheumatology and Translational Immunology Research Laboratories, Division of Rheumatology, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
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17
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Alivernini S, Bruno D, Tolusso B, Bui L, Petricca L, Gigante MR, Birra D, Fedele AL, Peluso G, Federico F, Ferraccioli G, Gremese E. Differential synovial tissue biomarkers among psoriatic arthritis and rheumatoid factor/anti-citrulline antibody-negative rheumatoid arthritis. Arthritis Res Ther 2019; 21:116. [PMID: 31072400 PMCID: PMC6509792 DOI: 10.1186/s13075-019-1898-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Accepted: 04/17/2019] [Indexed: 12/17/2022] Open
Abstract
Background Differential diagnosis among psoriatic arthritis (PsA) and seronegative rheumatoid arthritis (Abneg RA) can be challenging particularly in the clinical setting of peripheral phenotype and autoantibodies seronegativity. The aim of the study was to identify synovial tissue (ST) biomarkers differentially expressed in PsA and Abneg RA and test their predictive value of therapeutic response. Methods Thirty-four PsA patients [12 DMARD naive and 22 non-responder to methotrexate (MTX-IR)] with peripheral joint involvement and 55 Abneg RA (27 DMARD naive and 28 MTX-IR) underwent US-guided ST biopsy and immunohistochemistry (IHC) for CD68+, CD3+, CD20+, CD21+, CD117+, and CD138+ cells. After study entry, each DMARD-naive patient started MTX therapy and was followed in an outpatient setting for at least 6 months to define the achievement of Minimal Disease Activity (PsA) and DAS remission (Abneg RA) status respectively. Each IR-MTX patient was treated according to EULAR recommendations. Results At study entry, IHC analysis revealed that PsA patients had comparable levels of lining and sublining CD68+ and sublining CD21+, CD20+, and CD3+ cells than Abneg RA, despite the therapeutic regimen. Moreover, regardless of the therapeutic scheme, PsA patients showed higher IHC score of CD117+ cells (p = 0.0004 and p = 0.0005 for naive and MTX-IR patients respectively) compared to Abneg RA patients. Conversely, Abneg RA patients showed higher IHC score of CD138+ cells, irrespective to the therapeutic scheme (p = 0.04 and p = 0.002 for naive and MTX-IR patients respectively). Analyzing the response rate to the therapeutic scheme, naive PsA patients reaching MDA status at 6 months follow-up, showed, at the study entry, lower IHC score of CD3+ cells compared to PsA patients not reaching this outcome (p = 0.02); conversely, naive Abneg RA patients reaching DAS remission status at 6 months follow-up, showed, at the study entry, lower IHC score of sublining CD68+ cells compared to Abneg RA patients not reaching this outcome (p < 0.001). Conclusions CD117+ and CD138+ cells are differentially distributed among PsA and Abneg RA. Histological analysis of ST may help to solve the clinical overlap between the two diseases and provides prognostic data about the therapy success. Electronic supplementary material The online version of this article (10.1186/s13075-019-1898-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Stefano Alivernini
- Division of Rheumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Institute of Rheumatology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Dario Bruno
- Institute of Rheumatology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Barbara Tolusso
- Division of Rheumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Laura Bui
- Institute of Pathology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Luca Petricca
- Division of Rheumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Maria Rita Gigante
- Division of Rheumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Domenico Birra
- Institute of Rheumatology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Anna Laura Fedele
- Division of Rheumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giusy Peluso
- Division of Rheumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesco Federico
- Institute of Pathology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Institute of Pathology, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Elisa Gremese
- Division of Rheumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy. .,Institute of Rheumatology, Università Cattolica del Sacro Cuore, Rome, Italy.
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18
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Humby FC. Synovial Tissue Sampling in Rheumatological Practice-Past Developments and Future Perspectives. Front Med (Lausanne) 2019; 6:4. [PMID: 30761301 PMCID: PMC6361834 DOI: 10.3389/fmed.2019.00004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 01/09/2019] [Indexed: 11/21/2022] Open
Abstract
Synovial biopsies are performed in routine clinical care in order to refine diagnosis as well as within a research setting. Progress in the development of minimally invasive synovial sampling methods in the last century has accelerated and facilitated novel insights into disease pathogenesis. This review discusses the development of synovial biopsy techniques as well as examining the three currently most commonly used approaches: arthroscopic, blind needle biopsy and ultrasound guided approaches. It also highlights major research advances driven through synovial research and considers future developments.
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Affiliation(s)
- Frances C Humby
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
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19
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Lazarou I, Kelly SG, Meric de Bellefon L. Ultrasound-Guided Synovial Biopsies of Wrists, Metacarpophalangeal, Metatarsophalangeal, Interphalangeal Joints, and Tendon Sheaths. Front Med (Lausanne) 2019; 6:2. [PMID: 30719434 PMCID: PMC6348247 DOI: 10.3389/fmed.2019.00002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 01/04/2019] [Indexed: 11/23/2022] Open
Abstract
Ultrasound-guided synovial biopsy (UGSB) is a minimally-invasive procedure which allows quality synovial tissue retrieval. In this article, we will discuss overarching principles of the procedure performed in wrists, metacarpophalangeal (MCP), metatarsophalangeal (MTP), interphalangeal joints (IP), and tendon sheaths, including basic sonoanatomy, entry site and biopsy technique, as well as special considerations for each structure whenever relevant.
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Affiliation(s)
- Ilias Lazarou
- Department of Rheumatology, University Hospitals of Geneva, Geneva, Switzerland
| | - Stephen Gerard Kelly
- Department of Rheumatology, Barts Health NHS Trust, Mile End Hospital, London, United Kingdom
| | - Laurent Meric de Bellefon
- Department of Rheumatology, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
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Kondo Y, Suzuki K, Inoue Y, Sakata K, Takahashi C, Takeshita M, Kassai Y, Miyazaki T, Morita R, Niki Y, Kaneko Y, Yasuoka H, Yamaoka K, Yoshimura A, Takeuchi T. Significant association between joint ultrasonographic parameters and synovial inflammatory factors in rheumatoid arthritis. Arthritis Res Ther 2019; 21:14. [PMID: 30630515 PMCID: PMC6327469 DOI: 10.1186/s13075-018-1802-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 12/20/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ultrasonography (US) can directly demonstrate joint inflammation, including grayscale (GS) signs of synovial hypertrophy and power Doppler (PD) techniques to demonstrate increased blood flow and vascularization. Recently, echogenicity, especially hypoechoic synovium, has also been associated with local inflammatory activity. However, only a few studies have demonstrated correlation between histopathologic and immunopathologic evaluation and US findings. The aim of this study was to clarify whether joint US findings including synovial hypertrophy, vascularity, and echogenicity can accurately characterize synovial pathophysiology in patients with active rheumatoid arthritis (RA). METHODS A total of 44 patients with RA were included, both treated (n = 25) and untreated (n = 19) and scheduled for US examination of the knee joint with synovial fluid (SF) aspiration and two treated patients also underwent synovial biopsy. US images were quantitatively analyzed using grayscale assessment of synovial hypertrophy and PD for vascularity and echogenicity. Levels of nine SF cytokines and growth factors were also measured. RESULTS Both US synovial hypertrophy and PD vascularity significantly correlated with SF inflammatory cytokine levels such as IL-6, IL-8, IL-1β and IL-10 in untreated patients. Angiogenic factors, including vascular endothelial growth factor (VEGF), only correlated with PD vascularity. In the treated patients, the associations between synovial hypertrophy and any cytokines were diminished, although synovial vascularity and echogenicity correlated with IL-6 and VEGF (p < 0.05). Histopathologic analysis revealed that hypoechogenicity of the synovium correlated with marked infiltration of lymphocytes and hypervascularity. CONCLUSIONS We demonstrated the pathophysiological origins of US findings in the joint. The degree of US vascularity of the synovium correlated with local inflammatory cytokine levels and angiogenetic factors in patients with active RA. Synovial echogenicity, and not hypertrophy, correlated with inflammation, especially in treated patients with RA.
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Affiliation(s)
- Yasushi Kondo
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan
| | - Katsuya Suzuki
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan
| | - Yumiko Inoue
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan
| | - Koumei Sakata
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan
| | - Chihiro Takahashi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan
| | - Masaru Takeshita
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan
| | - Yoshiaki Kassai
- Immunology Unit, Research, Takeda Pharmaceutical Company Limited, Fujisawa, Kanagawa, Japan
| | - Takahiro Miyazaki
- Immunology Unit, Research, Takeda Pharmaceutical Company Limited, Fujisawa, Kanagawa, Japan.,Nektar Therapeutics, San Francisco, CA, USA
| | - Rimpei Morita
- Department of Microbiology and Immunology, Keio University School of Medicine, Tokyo, Japan
| | - Yasuo Niki
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yuko Kaneko
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan
| | - Hidekata Yasuoka
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan
| | - Kunihiro Yamaoka
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan
| | - Akihiko Yoshimura
- Department of Microbiology and Immunology, Keio University School of Medicine, Tokyo, Japan
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan.
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21
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Ferrante A, Ciccia F, Giammalva GR, Iacopino DG, Visocchi M, Macaluso F, Maugeri R. The Craniovertebral Junction in Rheumatoid Arthritis: State of the Art. ACTA NEUROCHIRURGICA SUPPLEMENT 2019; 125:79-86. [DOI: 10.1007/978-3-319-62515-7_12] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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22
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Najm A, Le Goff B, Orr C, Thurlings R, Cañete JD, Humby F, Alivernini S, Manzo A, Just SA, Romão VC, Krenn V, Müller-Ladner U, Addimanda O, Tas SW, Stoenoiu M, Meric de Bellefon L, Durez P, Strand V, Wechalekar MD, Fonseca JE, Lauwerys B, Fearon U, Veale DJ. Standardisation of synovial biopsy analyses in rheumatic diseases: a consensus of the EULAR Synovitis and OMERACT Synovial Tissue Biopsy Groups. Arthritis Res Ther 2018; 20:265. [PMID: 30509322 PMCID: PMC6276172 DOI: 10.1186/s13075-018-1762-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 11/06/2018] [Indexed: 11/10/2022] Open
Abstract
Background The aim of this global collaboration was to develop a consensual set of items for the analysis of synovial biopsies in clinical practice and translational research through the EULAR Synovitis Study Group (ESSG) and OMERACT Synovial Tissue Biopsy Group. Methods Participants were consulted through a modified Delphi method. Three sequential rounds occurred over 12 months. Members were sent a written questionnaire containing items divided into two parts. Items were identified and formulated based on a scoping review. The first part of the questionnaire referred to synovial biopsies in clinical practice including five subsections, and the second part to translational research with six subsections. Every participant was asked to score each item on a 5-point Likert scale. Items with a median score above 3.5 and a ≥ 70% agreement were selected for the next round. The last round was conducted orally at EULAR in June 2017. Results Twenty-seven participants from 19 centers were contacted by email. Twenty participants from 17 centers answered. Response rates for next rounds were 100%. For the first part relating to clinical practice, 20/44 items (45.5%) were selected. For the second part relating to translational research, 18/43 items (41.9%) were selected for the final set. Conclusions We herein propose a consensual set of analysis items to be used for synovial biopsies conducted in clinical practice and translational research. Electronic supplementary material The online version of this article (10.1186/s13075-018-1762-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Aurélie Najm
- Rheumatology Department, Centre Hospitalier Universitaire de Nantes, Nantes, France. .,INSERM UMR 1238, Faculty of Biology of Nantes, Nantes, France.
| | - Benoît Le Goff
- Rheumatology Department, Centre Hospitalier Universitaire de Nantes, Nantes, France.,INSERM UMR 1238, Faculty of Biology of Nantes, Nantes, France
| | - Carl Orr
- The Centre for Arthritis and Rheumatic Diseases, Saint Vincent's University Hospital and Dublin Academic Medical Centre, University College Dublin, Elm Park, Dublin, Ireland
| | - Rogier Thurlings
- Institute for Molecular Life Sciences, Radboud UMC, Theodoor Craanenlaan 11, Nijmegen, 6525 GA, The Netherlands
| | - Juan D Cañete
- Hospital Clínic de Barcelona Rheumatology Department, Arthritis Unit, Barcelona, Spain and IDIBAPS, Barcelona, Spain
| | - Frances Humby
- Centre for Experimental Medicine and Rheumatology, John Vane Science Centre, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ, UK
| | - Stefano Alivernini
- Division of Rheumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS - Catholic University of the Sacred Heart, Rome, Italy
| | - Antonio Manzo
- Rheumatology and Translational Immunology Research Laboratories (LaRIT), Division of Rheumatology, IRCCS Policlinico San Matteo Foundation/University of Pavia, 27100, Pavia, Italy
| | - Søren Andreas Just
- Department of Medicine, Svendborg Hospital, Odense University Hospital, Valdemarsgade 53, 5700, Svendborg, Denmark
| | - Vasco C Romão
- Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa and Rheumatology Department, Hospital de Santa Maria, Lisbon Academic Medical Centre, Lisbon, Portugal
| | - Veit Krenn
- MVZ-Zentrum für Histologie, Zytologie und Molekulare Diagnostik, Trier, Germany
| | - Ulf Müller-Ladner
- Department of Rheumatology and Clinical Immunology, Justus-Liebig-University Giessen, Campus Kerckhoff, Giessen, Germany
| | - Olga Addimanda
- Medicine & Rheumatology Unit, Rizzoli Orthopaedic Institute, Bologna and Department Of Biomedical and Neuromotor Sciences, University of Bologna, 40136, Bologna, Italy
| | - Sander W Tas
- Amsterdam Rheumatology and immunology Center, Department of Clinical Immunology and Rheumatology, and Laboratory for Experimental Immunology, Academic Medical Center/University of Amsterdam, Bologna, The Netherlands
| | - Maria Stoenoiu
- Department of Rheumatology, Cliniques Universitaires Saint-Luc, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain Bruxelles, Bruxelles, Belgium
| | - Laurent Meric de Bellefon
- Department of Rheumatology, Cliniques Universitaires Saint-Luc, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain Bruxelles, Bruxelles, Belgium
| | - Patrick Durez
- Department of Rheumatology, Cliniques Universitaires Saint-Luc, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain Bruxelles, Bruxelles, Belgium
| | - Vibeke Strand
- Division of Immunology and Rheumatology, Stanford University, Bruxelles, CA, USA
| | - Mihir D Wechalekar
- Rheumatology Unit, Flinders Medical Centre and Flinders University, Adelaide, SA, Australia
| | - Joao E Fonseca
- Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa and Rheumatology Department, Hospital de Santa Maria, Lisbon Academic Medical Centre, Lisbon, Portugal
| | - Bernard Lauwerys
- Department of Rheumatology, Cliniques Universitaires Saint-Luc, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain Bruxelles, Bruxelles, Belgium
| | - Ursula Fearon
- Department of Molecular Rheumatology, Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin 2, Ireland
| | - Douglas J Veale
- The Centre for Arthritis and Rheumatic Diseases, Saint Vincent's University Hospital and Dublin Academic Medical Centre, University College Dublin, Elm Park, Dublin, Ireland
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23
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Just SA, Humby F, Lindegaard H, Meric de Bellefon L, Durez P, Vieira-Sousa E, Teixeira R, Stoenoiu M, Werlinrud J, Rosmark S, Larsen PV, Pratt A, Choy E, Gendi N, Buch MH, Edwards CJ, Taylor PC, McInnes IB, Fonseca JE, Pitzalis C, Filer A. Patient-reported outcomes and safety in patients undergoing synovial biopsy: comparison of ultrasound-guided needle biopsy, ultrasound-guided portal and forceps and arthroscopic-guided synovial biopsy techniques in five centres across Europe. RMD Open 2018; 4:e000799. [PMID: 30488001 PMCID: PMC6241983 DOI: 10.1136/rmdopen-2018-000799] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 09/21/2018] [Accepted: 09/22/2018] [Indexed: 12/31/2022] Open
Abstract
Background We present a European multicenter study, comparing safety data and patient-reported outcomes (PRO) from patients undergoing synovial biopsy using ultrasound-guided needle biopsy (US-NB), ultrasound-guided portal and forceps (US-P&F) or arthroscopic-guided (AG) procedures. Objectives To describe safety and PRO data on joint indices of pain, stiffness and swelling before and after biopsy, procedural discomfort, joint status compared with before biopsy and willingness to undergo a second biopsy for each technique and compare the three techniques. To evaluate the impact on PRO and safety data of corticosteroid therapy as part of the biopsy procedure and sequential biopsy procedures. Methods Data were collected on the day of biopsy and 7-14 days postprocedure. Joint pain, swelling and stiffness indices were recorded as 0-100 mm Visual Analogue Scale; qualitative outcome variables on five-point Likert scales. Groups were compared with linear regression, adjusting for disease activity, corticosteroid therapy and prebiopsy PRO value and accounting for repeated measurements. Results A total of 524 synovial biopsy procedures were documented (402 US-NB, 65 US-P&F and 57 AGSB). There were eight adverse events (1.5%) with no difference between biopsy methods (p=0.55). All PROs were improved 2 weeks postprocedure, and there were no differences in postbiopsy change in PROs between biopsy methods. Corticosteroid administration, whether intramuscular (n=62) or intra-articular (n=38), did not result in more adverse events (p=0.81) and was associated with reduction in postbiopsy swelling (p<0.01). Sequential biopsy procedures (n=103 patients) did not result in more adverse events (p=0.61) or worsening in PRO data. Conclusion Overall, our results do not suggest a significant difference in safety or patient tolerability between US-NB, US-P&F and AGSB sampling. Further, corticosteroid therapy as part of the biopsy procedure and sequential biopsies is safe and well tolerated in patients.
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Affiliation(s)
| | - Frances Humby
- Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Hanne Lindegaard
- Department of Rheumatology, Odense University Hospital, Odense, Denmark
| | - Laurent Meric de Bellefon
- Department of Rheumatology, Saint-Pierre University Hospital, Brussels, Belgium.,Rhumatologie, Cliniques Universitaires Saint-Luc, Institut de Recherche Expérimentale et Clinique (IREC), Bruxelles, Belgium
| | - Patrick Durez
- Rhumatologie, Cliniques Universitaires Saint-Luc, Institut de Recherche Expérimentale et Clinique (IREC), Bruxelles, Belgium
| | - Elsa Vieira-Sousa
- Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal.,Rheumatology Department, Hospital de Santa Maria, CHLN, Lisbon Academic Medical Centre, Lisbon, Portugal
| | - Rui Teixeira
- Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal.,Rheumatology Department, Hospital de Santa Maria, CHLN, Lisbon Academic Medical Centre, Lisbon, Portugal
| | - Maria Stoenoiu
- Rhumatologie, Cliniques Universitaires Saint-Luc, Institut de Recherche Expérimentale et Clinique (IREC), Bruxelles, Belgium
| | - Jens Werlinrud
- Department of Orthopedics, Odense University Hospital, Odense, Denmark
| | - Sofie Rosmark
- Department of Rheumatology, Odense University Hospital, Odense, Denmark
| | - Pia Veldt Larsen
- Epidemiology and Biostatistics, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Arthur Pratt
- Institute of Cellular Medicine, Newcastle University, Newcastle, UK.,Newcastle NIHR Biomedical Research Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust and Newcastle University, Newcastle, UK
| | - Ernest Choy
- CREATE Centre, Section of Rheumatology, Division of Infection and Immunity, Cardiff University School of Medicine, Cardiff, UK
| | | | - Maya H Buch
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,NIHR Leeds Musculoskeletal Biomedical Research Centre, Leeds, UK
| | - Christopher J Edwards
- Southampton MSK Research Unit, NIHR Clinical Research Facility, University Hospital Southampton, Southampton, UK
| | - Peter C Taylor
- Botnar Research Centre, NDORMS, Oxford University, Oxford, UK
| | - Iain B McInnes
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - João Eurico Fonseca
- Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal.,Rheumatology Department, Hospital de Santa Maria, CHLN, Lisbon Academic Medical Centre, Lisbon, Portugal
| | - Costantino Pitzalis
- Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Andrew Filer
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, UK
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24
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Purkayastha N, Humby F, Rocher-Ros V, Pitzalis C, Kelly S. Wrist ultrasound - the model method for grey-scale and power Doppler scoring. Ann Rheum Dis 2018; 78:441-442. [PMID: 30297327 DOI: 10.1136/annrheumdis-2018-213977] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 08/21/2018] [Accepted: 09/24/2018] [Indexed: 01/12/2023]
Affiliation(s)
- Nirupam Purkayastha
- Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University, London, UK
| | - Frances Humby
- Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University, London, UK
| | - Vidalba Rocher-Ros
- Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University, London, UK
| | - Costantino Pitzalis
- Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University, London, UK
| | - Stephen Kelly
- Barts Health NHS Trust, Mile End Hospital, London, UK
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25
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Nerviani A, Pitzalis C. Role of chemokines in ectopic lymphoid structures formation in autoimmunity and cancer. J Leukoc Biol 2018; 104:333-341. [PMID: 29947426 PMCID: PMC6099300 DOI: 10.1002/jlb.3mr0218-062r] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 05/09/2018] [Accepted: 05/21/2018] [Indexed: 12/19/2022] Open
Abstract
Ectopic (or tertiary) lymphoid structures (ELS) are organized aggregates of lymphocytes resembling secondary lymphoid organs and developing in chronically inflamed nonlymphoid tissues during persistent infections, graft rejection, autoimmune conditions, and cancer. In this review, we will first depict the mechanisms regulating ELS generation, focusing on the role played by lymphoid chemokines. We will then characterize ELS forming in target organs during autoimmune conditions, here exemplified by rheumatoid arthritis, and cancer, highlighting the relevance of the tissue-specific factors. Finally, we will discuss the clinical significance of ELS and the therapeutic potential of their inhibition and/or enhancement depending on the disease considered.
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Affiliation(s)
- Alessandra Nerviani
- Centre for Experimental Medicine & Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Costantino Pitzalis
- Centre for Experimental Medicine & Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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26
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Barton A, Pitzalis C. Stratified medicine in rheumatoid arthritis-the MATURA programme. Rheumatology (Oxford) 2018; 56:1247-1250. [PMID: 28165532 PMCID: PMC5850849 DOI: 10.1093/rheumatology/kew369] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 11/04/2016] [Indexed: 11/14/2022] Open
Affiliation(s)
- Anne Barton
- Arthritis Research UK Centre for Genetics and Genomics, Centre for Musculoskeletal Research, Manchester Academic Health Sciences Centre, The University of Manchester.,NIHR Manchester Musculoskeletal BRU, Central Manchester Foundation Trust, Manchester
| | - Costantino Pitzalis
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, John Vane Science Centre, London, UK
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27
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Mandelin AM, Homan PJ, Shaffer AM, Cuda CM, Dominguez ST, Bacalao E, Carns M, Hinchcliff M, Lee J, Aren K, Thakrar A, Montgomery AB, Bridges SL, Bathon JM, Atkinson JP, Fox DA, Matteson EL, Buckley CD, Pitzalis C, Parks D, Hughes LB, Geraldino-Pardilla L, Ike R, Phillips K, Wright K, Filer A, Kelly S, Ruderman EM, Morgan V, Abdala-Valencia H, Misharin AV, Budinger GS, Bartom ET, Pope RM, Perlman H, Winter DR. Transcriptional Profiling of Synovial Macrophages Using Minimally Invasive Ultrasound-Guided Synovial Biopsies in Rheumatoid Arthritis. Arthritis Rheumatol 2018; 70:841-854. [PMID: 29439295 DOI: 10.1002/art.40453] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 02/08/2018] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Currently, there are no reliable biomarkers for predicting therapeutic response in patients with rheumatoid arthritis (RA). The synovium may unlock critical information for determining efficacy, since a reduction in the numbers of sublining synovial macrophages remains the most reproducible biomarker. Thus, a clinically actionable method for the collection of synovial tissue, which can be analyzed using high-throughput strategies, must become a reality. This study was undertaken to assess the feasibility of utilizing synovial biopsies as a precision medicine-based approach for patients with RA. METHODS Rheumatologists at 6 US academic sites were trained in minimally invasive ultrasound-guided synovial tissue biopsy. Biopsy specimens obtained from patients with RA and synovial tissue from patients with osteoarthritis (OA) were subjected to histologic analysis, fluorescence-activated cell sorting, and RNA sequencing (RNA-seq). An optimized protocol for digesting synovial tissue was developed to generate high-quality RNA-seq libraries from isolated macrophage populations. Associations were determined between macrophage transcriptional profiles and clinical parameters in RA patients. RESULTS Patients with RA reported minimal adverse effects in response to synovial biopsy. Comparable RNA quality was observed from synovial tissue and isolated macrophages between patients with RA and patients with OA. Whole tissue samples from patients with RA demonstrated a high degree of transcriptional heterogeneity. In contrast, the transcriptional profile of isolated RA synovial macrophages highlighted different subpopulations of patients and identified 6 novel transcriptional modules that were associated with disease activity and therapy. CONCLUSION Performance of synovial tissue biopsies by rheumatologists in the US is feasible and generates high-quality samples for research. Through the use of cutting-edge technologies to analyze synovial biopsy specimens in conjunction with corresponding clinical information, a precision medicine-based approach for patients with RA is attainable.
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Affiliation(s)
- Arthur M Mandelin
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Philip J Homan
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Carla M Cuda
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Emily Bacalao
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mary Carns
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Jungwha Lee
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kathleen Aren
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Anjali Thakrar
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Anna B Montgomery
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | - John P Atkinson
- Washington University School of Medicine, St. Louis, Missouri
| | - David A Fox
- University of Michigan School of Medicine, Ann Arbor
| | - Eric L Matteson
- Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Christopher D Buckley
- University of Birmingham Research Laboratories, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Costantino Pitzalis
- William Harvey Research Institute and Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Deborah Parks
- Washington University School of Medicine, St. Louis, Missouri
| | | | | | - Robert Ike
- University of Michigan School of Medicine, Ann Arbor
| | | | - Kerry Wright
- Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Andrew Filer
- University of Birmingham Research Laboratories, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Stephen Kelly
- William Harvey Research Institute and Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Eric M Ruderman
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Vince Morgan
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | - G Scott Budinger
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Richard M Pope
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Harris Perlman
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Deborah R Winter
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
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28
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Humby F, Romão VC, Manzo A, Filer A, Bugatti S, Vieira-Sousa E, Kelly S, Wechalekar M, Ahmed M, Rocher V, Hands R, Montecucco C, Fonseca J, Pitzalis C. A Multicenter Retrospective Analysis Evaluating Performance of Synovial Biopsy Techniques in Patients With Inflammatory Arthritis: Arthroscopic Versus Ultrasound-Guided Versus Blind Needle Biopsy. Arthritis Rheumatol 2018; 70:702-710. [PMID: 29409140 DOI: 10.1002/art.40433] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 01/25/2018] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To evaluate whether the choice of synovial biopsy technique (arthroscopy, blind needle [BN] biopsy, ultrasound [US]-guided portal and forceps [P&F], or US-guided needle biopsy [NB]) translates to significant variation in synovial tissue quality and quantity, with the aim of informing recommendations for the choice of synovial sampling technique within clinical trials. METHODS In total, 159 procedures from 5 academic rheumatology centers were evaluated. Hematoxylin and eosin-stained, paraffin-embedded synovial tissue sections from patients with inflammatory arthritis were assessed in order to determine the proportion of graded synovial fragments, total area of graded synovial tissue, and synovitis score per procedure. RNA quantity (μg of RNA) and quality (RNA integrity number) per procedure were also assessed in the synovial samples. RESULTS In this study, 84 of the 159 procedures performed on large joints at baseline (25 arthroscopic, 35 US-P&F, 11 US-NB, and 13 BN biopsies), 41 of the 159 procedures performed on small joints at baseline (11 US-P&F, 20 US-NB, and 10 BN biopsies), and 34 sequential biopsy procedures were evaluated. Compared to all other techniques evaluated in the small and large joints, fewer small joint BN biopsies and a significantly lower proportion of large joint BN biopsies yielded graded synovial tissue. No significant difference in either the proportion of graded tissue samples or total graded synovial tissue area between the US-NB and arthroscopic large joint procedures was demonstrated. Among the sequential biopsy procedures evaluated (small joint US-NB, large joint arthroscopy, US-P&F biopsy, and BN biopsy), no significant difference in the proportion of graded synovial tissue or total graded synovial tissue area was demonstrated. All procedures yielded RNA of significant quality and quantity for subsequent transcriptomic analysis. CONCLUSION These data support the integration of US-guided methods along with arthroscopic biopsy for clinical trial protocols in which sequential sampling of synovium from the large and small joints is needed for both histologic and molecular analysis. BN biopsy may be considered if graded synovial tissue is not required for subsequent analyses.
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Affiliation(s)
- Frances Humby
- William Harvey Research Institute, Barts and the London School of Medicine, London, UK
| | - Vasco C Romão
- Universidade de Lisboa, Lisbon Academic Medical Centre and Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - Antonio Manzo
- IRCCS Policlinico San Matteo Foundation/University of Pavia, Pavia, Italy
| | | | - Serena Bugatti
- IRCCS Policlinico San Matteo Foundation/University of Pavia, Pavia, Italy
| | - Elsa Vieira-Sousa
- Universidade de Lisboa, Lisbon Academic Medical Centre and Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | | | - Mihir Wechalekar
- Repatriation General Hospital and Flinders University, Adelaide, South Australia, Australia
| | - Manzoor Ahmed
- William Harvey Research Institute, Barts and the London School of Medicine, London, UK
| | - Vidalba Rocher
- William Harvey Research Institute, Barts and the London School of Medicine, London, UK
| | - Rebecca Hands
- William Harvey Research Institute, Barts and the London School of Medicine, London, UK
| | | | - Joao Fonseca
- Universidade de Lisboa, Lisbon Academic Medical Centre and Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - Costantino Pitzalis
- William Harvey Research Institute, Barts and the London School of Medicine, London, UK
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Ruderman EM, Mandelin AM, Perlman HR. Willie Sutton Was Right: It's Time to Turn to the Synovium to Drive Rheumatoid Arthritis Therapy. J Rheumatol 2018; 43:2089-2091. [PMID: 27909137 DOI: 10.3899/jrheum.161285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Eric M Ruderman
- Division of Rheumatology, Northwestern University Feinberg School of Medicine;
| | - Arthur M Mandelin
- Division of Rheumatology, Northwestern University Feinberg School of Medicine
| | - Harris R Perlman
- Division of Rheumatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Humby F, Mahto A, Ahmed M, Barr A, Kelly S, Buch M, Pitzalis C, Conaghan PG. The Relationship Between Synovial Pathobiology and Magnetic Resonance Imaging Abnormalities in Rheumatoid Arthritis: A Systematic Review. J Rheumatol 2017; 44:1311-1324. [DOI: 10.3899/jrheum.161314] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2017] [Indexed: 01/16/2023]
Abstract
Objective.Magnetic resonance imaging (MRI) has been increasingly recognized as a critical tool for the assessment of patients with rheumatoid arthritis (RA) and is able to reliably identify synovitis, bone marrow edema, bone erosion, and joint space narrowing (JSN)/cartilage loss. Understanding the exact relationship between each MRI feature and local synovial pathobiology is critical to dissect disease pathogenesis as well as develop future predictive models.Methods.A systematic review was performed of the current published literature examining the relationship between MRI abnormalities and synovial pathobiology in patients with RA.Results.Eighteen studies were identified; most focused on validation of MRI as a tool to detect and quantify synovitis, with a significant relationship demonstrated. Additionally, from the limited data available, a critical role seems likely for synovial pathways, at least in driving joint damage. However, there was a lack of data examining the relationship between synovial pathobiology and bone marrow abnormalities and JSN.Conclusion.Although understanding the interrelationship of these disease biomarkers offers the potential to enhance the predictive validity of modern imaging with concomitant synovial pathobiological analysis, further studies integrating MRI with synovial tissue analysis in well-controlled cohorts at distinct disease stages before and after therapeutic intervention are required to achieve this.
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31
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Rocha B, Ruiz-Romero C, Blanco FJ. Mass spectrometry imaging: a novel technology in rheumatology. Nat Rev Rheumatol 2016; 13:52-63. [DOI: 10.1038/nrrheum.2016.184] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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32
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Chaturvedi V, Thabah MM, Ravindran V, Kiely PDW. Medical arthroscopy: A tool for diagnosis and research in rheumatology. Int J Rheum Dis 2016; 20:145-153. [DOI: 10.1111/1756-185x.12951] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
| | - Molly Mary Thabah
- Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER); Puducherry India
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Abstract
Rheumatoid arthritis is a chronic inflammatory joint disease, which can cause cartilage and bone damage as well as disability. Early diagnosis is key to optimal therapeutic success, particularly in patients with well-characterised risk factors for poor outcomes such as high disease activity, presence of autoantibodies, and early joint damage. Treatment algorithms involve measuring disease activity with composite indices, applying a treatment-to-target strategy, and use of conventional, biological, and newz non-biological disease-modifying antirheumatic drugs. After the treatment target of stringent remission (or at least low disease activity) is maintained, dose reduction should be attempted. Although the prospects for most patients are now favourable, many still do not respond to current therapies. Accordingly, new therapies are urgently required. In this Seminar, we describe current insights into genetics and aetiology, pathophysiology, epidemiology, assessment, therapeutic agents, and treatment strategies together with unmet needs of patients with rheumatoid arthritis.
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Affiliation(s)
- Josef S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria; 2nd Department of Medicine, Hietzing Hospital Vienna, Vienna, Austria.
| | - Daniel Aletaha
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Iain B McInnes
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
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