The response of 99Tcm-methylene diphosphonate and 99Tcm-hexametazime-labelled neutrophils to intra-articular steroid injection in rheumatoid arthritis

Is 99mTc-HMPAO-leukocyte imaging an accurate method in evaluating therapy result in prosthetic joint infection and diagnosing suspected chronic prosthetic joint infection?

BACKGROUND

To investigate the sensitivity and specificity of 99mTc-HMPAO-leukocyte imaging in evaluating therapy result in patients with prosthetic joint infection (PJI) and in diagnosing suspected chronic PJI.

METHODS

Sixty-two patients (63 joints) with microbiologically verified PJI were examined by leukocyte imaging to evaluate therapy result during or at the end of antibiotic treatment or if the patient had a chronic PJI after treatment. Group 1 consisted of 49 patients with on-going or within less than 14 days of ending antibiotic treatment examined to evaluate response. Group 2 consisted of 13 patients examined after completed treatment on suspicion of chronic PJI with no or recently initiated renewed antibiotic treatment. This study applied a combination of different imaging approaches of 99mTc-HMPAO-leukocyte scintigraphy: delayed and late planar images, bone marrow imaging and SPECT/CT imaging. All joints were examined with at least two of the approaches and 53 joints with all three approaches. The report was based on the combined results of the approaches used. A chronic PJI was confirmed with a positive microbiological culture. A cured infection was confirmed with either a negative culture or at least 24 months antibiotic-free follow-up with no relapse.

RESULTS

In the therapy evaluation group sensitivity was 0.57 and specificity was 0.81. In the suspected chronic infection group sensitivity was 1.00 and specificity 0.91.

CONCLUSIONS

99mTc-HMPAO-leukocyte imaging appears to be an accurate method to diagnose or exclude chronic PJI, but cannot be recommended for therapy evaluation of PJI in patients with on-going antibiotic treatment.

Systematic Review of MRI, Ultrasound, and Scintigraphy as Outcome Measures for Structural Pathology in Interventional Therapeutic Studies of Knee Arthritis: Focus on Responsiveness

Objective.

Validated imaging outcome tools to assess response to therapies in a single joint are required. Our aim was to review the published literature to ascertain the responsiveness of novel imaging techniques as outcome measures in interventional therapeutic studies of knee arthritis.

Methods.

An Ovid Medline search was performed for original articles in English that used imaging techniques to assess response at the knee joint to therapy in osteoarthritis, rheumatoid arthritis, and psoriatic arthritis. Changes in response to therapy were assessed with regard to both internal and external responsiveness.

Results.

In the studies that presented appropriate statistical data to allow responsiveness to be assessed, MRI was generally found to be internally responsive to pathologies imaged, and externally responsive, referenced against both other imaging modalities and biochemical biomarkers of arthritis. Ultrasonography was found to demonstrate internal responsiveness with regard to synovial thickness, effusion size, and popliteal cyst size. External responsiveness was demonstrated against several referenced health status measures. Scintigraphy was found to be externally responsive in the majority of studies, with internal responsiveness demonstrated in 1 study.

Conclusion.

While the imaging techniques appear to be responsive from the data we present, further inspection reveals that interpreting the responsiveness of imaging techniques was difficult, largely because of a lack of standardization of image acquisition, definitions of pathology, and scoring systems. Refined pathological definitions and scoring systems are required to enable the development of valid and responsive tools for interventional clinical trials.

An evaluation of pulsed shortwave on knee osteoarthritis using radioleucoscintigraphy: a randomised, double blind, controlled trial

OBJECTIVE

To evaluate the effects of pulsed shortwave on osteoarthritis of the knee.

METHODS

A double blinded, randomised, controlled trial. Thirteen female and 14 male patients with radiographic evidence of knee osteoarthritis were randomly allocated to either low dose (10 W), or high dose (20 W) or placebo high frequency pulsed shortwave. Knee radioleucoscintigraphy was performed pre and post treatment as well as objective functional and subjective evaluations.

RESULTS

There were no significant differences between the groups in the pre and post treatment percentage change for radioleucoscintigraphy (P > 0.05). Functional and subjective measures also revealed no pre and post treatment differences between the groups (P > 0.05), except for improved knee range of motion in the placebo group (P < 0.05).

CONCLUSION

Joint inflammation in knee osteoarthritis, measured using radioleucoscintigraphy, was not altered significantly by pulsed shortwave, therefore this therapeutic modality has little or no anti-inflammatory effect on conditions such as osteoarthritis of the knee.

99mTc-dextran scintigraphy to detect disease activity in patients with rheumatoid arthritis

AIM

To test the applicability of Tc-dextran joint scintigraphy in the assessment of disease activity in patients with rheumatoid arthritis (RA), and to compare it with the clinical disease activity scores and laboratory parameters.

METHODS

Twenty-seven patients with RA were investigated using Tc-dextran joint scintigraphy. The images were evaluated semi-quantitatively and the regional uptakes of the radiopharmaceutical were calculated for the knee, wrist and ankle joints. The clinical and laboratory parameters were collected and fully analysed. An articular Ritchie index (a tender joint score), the number of swollen joints (Sw), the number of tender joints, the morning stiffness (h), the total Ritchie articular index (R), the visual analogue scale (VAS) and the Disease Activity Score (DAS) were determined for all patients.

RESULTS

Compared with controls, patients with RA had significantly higher regional Tc-dextran uptake in the knee, wrist and ankle joints (P=0.001). The regional Tc-dextran uptake showed no correlation with the patient's age, gender, duration of disease, number of swollen joints (Sw), number of tender joints, morning stiffness (h), VAS, total Ritchie articular index and DAS, or any laboratory parameters. There was a significant correlation between the regional Tc-dextran uptake for individual joints and the articular Ritchie index of the right and left wrist (r=0.42, P=0.03; r=0.45, P=0.02), right and left knee (r=0.66, P<0.0001; r=0.80, P<0.0001) and right and left ankle (r=0.47, P=0.014; r=0.76, P<0.0001), respectively.

CONCLUSIONS

This study demonstrates that Tc-dextran scintigraphy is a sensitive method to detect active joint inflammation and could be useful in the management of patients with RA.

99m Tc-HMPAO labelled leukocyte scintigraphy in patients with rheumatoid arthritis: a comparison with disease activity

The aim of this study was to test the applicability of 99mTc-hexamethylpropylene amine oxime (99mTc-HMPAO) labelled leukocyte joint scintigraphy in the assessment of disease activity in 21 patients with rheumatoid arthritis, and to compare leukocyte scintigraphy with the Disease Activity Score (DAS), a validated activity index developed by the European League Against Rheumatism (EULAR). Twenty-one patients with rheumatoid arthritis were investigated by using 99mTc-HMPAO labelled leukocyte joint scintigraphy. The clinical and laboratory data were recorded, and the DAS was calculated and compared with the scintigraphic results in each case. A relatively high DAS score (4.71+/-1.07) was found in the majority of patients. The degree of accumulation of 99mTc-HMPAO leukocytes showed no correlation with a patient's age, gender, duration of disease, use of disease modifying anti-rheumatic drugs (DMARDs), visual analogue scale (VAS), Richie index, DAS, or any laboratory parameters. In contrast, a significant correlation was found between the global regional accumulation of the labelled leukocytes of the hands and feet, and the swollen-joint count. It is concluded that radiolabelled leukocyte scintigraphy could become one of the promising methods in the assessment of disease activity in patients with rheumatoid arthritis.

Orthopedic pathology of the lower extremities: scintigraphic evaluation in the thigh, knee, and leg

Radionuclide imaging (RI) of the osseous and nonosseous structures of the thigh, knee, and leg provide important diagnostic and prognostic information upon which the orthopedic surgeon can base treatment planning and management decisions. 99mTc-MDP scintigraphy is essential in overuse injuries such as stress fractures and shin splints. RI is important in assessing complications of trauma. It is the only imaging modality able to assess the magnitude of physeal stimulus caused by femoral fractures and to predict a favorable or unfavorable outcome of leg length by semiquantitative analysis; SPECT imaging can detect and locate decreased metabolism associated with posttraumatic closure of the physeal plate to predict growth arrest and deformities. Three-phase bone imaging (TPBI) is essential to differentiate hypervascular from avascular nonunions and follow delayed union. In osteonecrosis of the knee, bone scintigraphy precedes radiography changes even in stage l of the disease. 99mTc-MDP and 99mTc-HIG imaging are powerful tools in determining the outcomes of osteoarthritis and rheumatoid arthritis, respectively. Bone scintigraphy can also detect chronic ligament and acute and chronic meniscal lesions. The combined use of TPBI, gallium-67 citrate imaging, and indium-111 or 99mTc-HMPAO labeled leukocytes is important to diagnose and differentiate acute from chronic osteomyelitis, and to detect infected knee prostheses. Thallium-201 chloride imaging and 99mTc-sestamibi imaging have an important role in the assessment of tumor response to chemotherapy and in the quantification of tumor viability.

Neutrophil trafficking into inflamed joints in patients with rheumatoid arthritis, and the effects of methylprednisolone

OBJECTIVE

To investigate the trafficking of circulating blood neutrophils and synovial fluid neutrophils in rheumatoid arthritis (RA) patients and the influence of a 1,000-mg intravenous pulse of methylprednisolone succinate (MP).

METHODS

Neutrophils were isolated from the circulation and from the knee synovial compartments of subjects with RA. Circulating neutrophils were labeled with technetium-99 hexametazime (99mTc-HMPAO) and reinjected intravenously. Synovial fluid neutrophils were labeled from indium-111 oxine and reinjected into the knee from which they were isolated. Gamma camera images were obtained at intervals up to 24 hours post MP. Each patient had a baseline study (no MP) and a study in which MP was administered either 4 hours before (2 patients), 10 minutes before (1 patient), or 30 minutes to 1.5 hours after (6 patients) injection of the radiolabeled neutrophils. Subsequent analysis allowed quantitation of the neutrophil uptake into and clearance from the knee as a function of time.

RESULTS

Nine patients who had not received glucocorticoids in the previous 3 months were studied. MP significantly decreased neutrophil ingress in 13 of the 16 knees studied (almost total inhibition in 5 knees), and this occurred within 1.5 hours of MP administration in all except 1 knee. At 24 hours after MP administration, there was a significant increase in visual analog scale (VAS) scores for well-being and significant decreases in scores on the modified Health Assessment Questionnaire (P<0.05), tender joints (P<0.005), VAS for pain (p<0.005), and generalized stiffness (P<0.005), as well as a decrease in the C-reactive protein level (P<0.05). MP had no effect on neutrophil egress (2 patients). Two additional patients who were receiving oral glucocorticoids were studied. One of them was clinically unresponsive to oral prednisolone, and MP had no effect on neutrophil ingress. The other patient showed no neutrophil ingress during the baseline study. This was confirmed by the presence of a noninflammatory synovial fluid at arthrocentesis.

CONCLUSION

Neutrophil ingress into and egress from inflamed joints can be accurately monitored using radiolabeled neutrophils and quantitative gamma camera imaging. MP rapidly and substantially decreases neutrophil ingress into inflamed joints. In contrast, MP has no effect on neutrophil egress from the joint.

New agents for scintigraphy in rheumatoid arthritis

Radiopharmaceuticals have been used as investigative tools for the detection and treatment of arthritis activity in rheumatoid arthritis (RA) since the 1950s. Against the background of the pathophysiology of RA, the current status of joint scintigraphy and possible future developments are reviewed. Both non-specific (radiolabelled leucocytes and technetium-99m labelled human immunoglobulin) and specific targeting radiopharmaceuticals (including radiolabelled antibodies) are considered. The use of radiopharmaceuticals in the detection of arthritis activity has the advantages of allowing direct imaging of joints by means of whole-body scintigraphy and of joints that are difficult to assess clinically or radiographically. Promising results have been obtained with radiolabelled anti-CD4 and anti-E-selectin antibodies and with somatostatin receptor imaging, but more data are available regarding 99mTc-IgG scintigraphy, which differentiates between the various degrees of arthritis activity and thus facilitates the choice of antirheumatic drug. Newer promising approaches to the imaging of RA include the use of radiolabelled J001 and cytokines, though studies on these are limited at present.

Intraarticular corticosteroids for chronic arthritis in children: efficacy and effects on cartilage and growth

OBJECTIVES

To assess the efficacy and effects on cartilage and statural growth of intraarticular corticosteroid (IAS) therapy for chronic arthritis in children and adolescents.

METHODS

We examined 21 children and adolescents with chronic arthritis (median duration, 8 months) that did not respond to nonsteroidal antiinflammatory drugs. The 21 joints injected with triamcinolone-hexacetonide were examined before and 7 weeks after IAS therapy by gadolinium-enhanced magnetic resonance imaging; 14 joints were also examined 13 months after IAS therapy.

RESULTS

All joints treated with IAS had improvement. Magnetic resonance imaging showed long-lasting suppression of inflammation and pannus without evidence of toxic effects on cartilage. Statural growth was not affected.

CONCLUSION

In experienced hands, IAS therapy may be a safe and effective tool in the treatment of chronic arthritis in childhood. Long-term follow-up is mandatory.

Evaluation of possible interference of anti-inflammatory drugs upon scintigraphic imaging with macrophage targeting 99mTc-J001X: effects of methylprednisolone, dexamethasone, indomethacin and methotrexate

J001X, an acylated poly-(1,3)-galactoside isolated from Klebsiella pneumoniae proteoglycan, has been developed to target cells from the monocyte-macrophage lineage. Recent experimental work and initial clinical trials have proved the potential of this molecule labeled with 99mTc for the scintigraphy of inflammatory foci. In a model of radiation-induced inflammation in pigs, the scintigraphic contrast was observed to be very sensitive to a single injection of methylprednisolone given 12 h before scintigraphy. The present study was undertaken to confirm this effect and to estimate the possible interference of various anti-inflammatory agents on the in vivo targeting of macrophages by J001X. Methylprednisolone, dexamethasone, indomethacin and methotrexate used at an immunosuppressive dose were tested to assess the possible risk of false-negative examinations in patients thus treated. Analysis of the results indicated that among the four drugs tested, only methylprednisolone at 0.5-1 mg/kg could interfere with J001X scintigraphy.