The role of magnetic resonance imaging in the early diagnosis of rheumatoid arthritis

Reliability and longitudinal validity of computer-assisted methods for measuring joint damage progression in subjects with rheumatoid arthritis

OBJECTIVE

To compare the metric properties of a computer-assisted erosion segmentation volume measurement with scoring using the Rheumatoid Arthritis Magnetic Resonance Imaging Score (RAMRIS) in a longitudinal cohort of patients with rheumatoid arthritis (RA).

METHODS

Thirty-two sets of baseline and 2-year followup magnetic resonance imaging (MRI) of metacarpal phalangeal 2-5 joints of patients with RA were scored using RAMRIS and segmented using OSIRIS software. The smallest detectable difference (SDD), standardized response mean (SRM), and paired t-test were used to evaluate the sensitivity to change. Eleven of the 32 patients' MRI were segmented by both readers to evaluate interreader agreement. The 28-joint Disease Activity Score (DAS28) and Sharp erosion scores further evaluated construct and longitudinal validity.

RESULTS

Reliability of erosion progression by computer-assisted volume measurement was superior to RAMRIS [intrareader interclass correlation coefficient (ICC) 0.97 (0.94-0.99) vs 0.52 (0.22-0.73)] and interreader ICC of volume measurement was 0.85 (0.53-0.96). Computer-assisted volume measurements identified 10 of 32 patients who progressed more than the SDD progression, whereas RAMRIS identified only 4 of 32 patients (p = 0.0013). By a paired t-test, however, all MRI measures progressed significantly over 2 years (irrespective of treatment arm) and there was little difference by SRM. Construct correlational validity of the MRI methods was 0.47-0.90 for status scores and 0.33-0.81 for progression. There was no relationship between the average DAS28 and erosion progression by any imaging method.

CONCLUSION

Computer-assisted measurement of erosion volume has good performance metrics. It had excellent intrareader and interreader reliability and was more sensitive to change than RAMRIS in this group of patients. www.ClinicalTrials.gov, NCT00451971.

The role of MRI in musculoskeletal practice: a clinical perspective

This clinical perspective presents an overview of current and potential uses for magnetic resonance imaging (MRI) in musculoskeletal practice. Clinical practice guidelines and current evidence for improved outcomes will help providers determine the situations when an MRI is indicated. The advanced competency standard of examination used by physical therapists will be helpful to prevent overuse of musculoskeletal imaging, reduce diagnostic errors, and provide the appropriate clinical context to pathology revealed on MRI. Physical therapists are diagnostically accurate and appropriately conservative in their use of MRI consistent with evidence-based principles of diagnosis and screening.

Cyst-like lesions in finger joints detected by conventional radiography: comparison with 320-row multidetector computed tomography

OBJECTIVE

Many rheumatologists and radiologists routinely assess conventional radiographs of the hands, and it is often unclear how to proceed if radiography reveals only cyst-like lesions (CLLs), with otherwise normal findings. The present study was undertaken to evaluate the use of 320-row multidetector computed tomography (MDCT) of the hands in the further assessment of CLLs of metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints identified on conventional radiography.

METHODS

MCP and PIP joints (n = 1,120 joints) of 56 consecutive patients (44 women [mean age 55 years, range 31-72 years] and 12 men [mean age 57 years, range 37-77 years]) were prospectively scored for the presence of cysts, CLLs, and erosions of the PIP and MCP joints, first on conventional radiographs, then on MDCT. Scoring was performed by 2 independent readers under blinded conditions. Intraclass correlation coefficients were calculated.

RESULTS

By conventional hand radiography, 13 patients (total of 260 joints assessed) were identified as having CLLs in 1 or more joints (total of 36 joints [11 PIP and 25 MCP]). By MDCT, the findings in 19 of 36 joints (53%) were diagnosed as erosions, while 7 of 36 (19%) were confirmed as true cysts, and 10 joints (28%) were normal (false positive). Among the patients with CLLs, 10 of 224 joints with no abnormality seen radiographically had erosions as seen on MDCT. Interreader agreement for erosions was 0.854 (95% confidence interval [95% CI] 0.831-0.874) by conventional hand radiography and 0.952 (95% CI 0.943-0.959) by MDCT.

CONCLUSION

Our results indicate that radiographic appearance of cyst-like lesions may actually represent erosions and should lead to initiation of further imaging tests.

[Early arthritis: action desired - treatment required]

Rheumatoid Arthritis (RA) is the most prevalent inflammatory joint disease in adults and shows a destructive course in most cases. The outcome of the disease - functional decline and invalidity - necessitates an early therapy. Recent studies demonstrate that the initiation of the treatment with a disease modifying antirheumatic drug (DMARD) treatment within the first three months after the onset of symptoms is crucial for sustained improvement of prognosis as well as therapeutic success and outcome. In the early stage of the disease, the criteria for the classification of Rheumatoid Arthritis (RA) are frequently not met. Up to over 50% of the patients show an arthritis, which cannot be classified and therefore is seen as undifferentiated arthritis (UA). Early therapeutic intervention appears to prevent the chronification of the disease; thus an early and appropriate disease modifying therapy is mandatory. Age, gender, involvement of the hands, positive rheumatoid factor, as well as the detection of anti cyclic-citrullinated peptide antibodies (anti-CCP Ab) are predictors of the development of RA. Beside conventional X-rays, there are other imaging methods such as magnetic resonance tomography imaging, Power-Doppler or contrast medium enhanced sonography, which may enable the detection not only of synovitis but also of erosive lesions at very early stages. Those patients suffering from UA carry a high risk for the development of a destructive arthritis as seen in RA, and therefore should be treated with an adequate DMARD. In these cases methotrexate is still the drug of first choice.

MRI for assessing erosion and joint space narrowing in inflammatory arthropathies

The superior soft tissue contrast and multiplanar capability of magnetic resonance imaging has contributed to earlier diagnosis and implementation of effective treatment for a variety of arthropathies. Owing to overlapping clinical signs and symptoms, MRI plays a role in delineating the features and stages of these conditions. With the advent of disease-modifying therapies, it is important to diagnose inflammatory arthropathy as early as possible. In this chapter, we discuss the pathophysiology of bone erosion and joint space narrowing, as well as the role of MRI in the imaging of the seropositive and seronegative inflammatory arthropathies.