MRI of Large Intraosseous Lesions in Patients with Inflammatory Arthritis

Giant Intraosseous Cyst-Like Lesions of the Metacarpal Bones in Rheumatoid Arthritis

The purpose of this study was to illustrate the clinical and imaging properties of giant intraosseous cyst-like lesions (GICLs) of the metacarpal bones extending beyond the central diaphysis in rheumatoid arthritis (RA) patients on magnetic resonance (MR) images. A keyword search was conducted to extract GICLs of the metacarpal bones out of MR reports in RA patients. There were nine GICLs extending from the subchondral bone region beyond the central diaphysis of the metacarpal bones on MR images in eight subjects with RA (seven females, one male). The age range was from 60 to 87 years with a median age of 65.5 years. The average disease duration was 13.1 years. As for the disease activity, one was low, six were moderate and one was high. None of the nine lesions were visible on radiography. The Steinbrocker stage distribution was as follows: I (n = 3), II (n = 2), and III (n = 3). Intraosseous cyst-like lesion of the metacarpal bones on MR images is a relatively rare manifestation in patients with long-standing RA. Although the lesion seems to be derived from subcortical bone break, it is not necessarily erosive in nature.

MRI and ultrasound of the hands and wrists in rheumatoid arthritis. I. Imaging findings

The management of patients with rheumatoid arthritis (RA) has rapidly evolved with the development of newer disease-modifying drugs and the recognition that long-term damage can be mitigated by an earlier and more-informed use of these medications. Historically, radiographs were the mainstay of imaging in RA patients, but radiographic joint narrowing and erosions are late and insensitive findings in the disease. MRI (with intravenous contrast agent) and ultrasound (with power Doppler interrogation) of the hands and wrists are able to demonstrate erosions earlier and with greater sensitivity than radiographs. More importantly, these imaging studies also depict synovitis and active soft-tissue inflammation, which represents a precursor to structural damage. Additionally, MRI can show inflammation within the bones (osteitis), which is proving to be the most important prognosticator of an aggressive disease course. Part I of this review discusses the imaging techniques, pitfalls, definitions, and comparative studies of MRI and ultrasound for identifying and quantifying erosions, synovitis, and osteitis. Part II will demonstrate how these imaging findings influence the clinical management of RA patients throughout their disease course, from presentation through clinical remission.

Recommendations for the Use of Ultrasound and Magnetic Resonance in Patients With Spondyloarthritis, Including Psoriatic Arthritis, and Patients With Juvenile Idiopathic Arthritis

OBJECTIVE

To develop evidence-based recommendations on the use of ultrasound (US) and magnetic resonance imaging in patients with spondyloarthritis, including psoriatic arthritis, and juvenile idiopathic arthritis.

METHODS

Recommendations were generated following a nominal group technique. A panel of experts (15 rheumatologists and 3 radiologists) was established in the first panel meeting to define the scope and purpose of the consensus document, as well as chapters, potential recommendations and systematic literature reviews (we used and updated those from previous EULAR documents). A first draft of recommendations and text was generated. Then, an electronic Delphi process (2 rounds) was carried out. Recommendations were voted from 1 (total disagreement) to 10 (total agreement). We defined agreement if at least 70% of participants voted≥7. The level of evidence and grade or recommendation was assessed using the Oxford Centre for Evidence Based Medicine levels of evidence. The full text was circulated and reviewed by the panel. The consensus was coordinated by an expert methodologist.

RESULTS

A total of 12 recommendations were proposed for each disease. They include, along with explanations of the validity of US and magnetic resonance imaging regarding inflammation and damage detection, diagnosis, prediction (structural damage progression, flare, treatment response, etc.), monitoring and the use of US guided injections/biopsies.

CONCLUSIONS

These recommendations will help clinicians use US and magnetic resonance imaging in patients with spondyloarthritis and juvenile idiopathic arthritis.

MRI and ultrasonography for diagnosis and monitoring of psoriatic arthritis

Imaging techniques such as magnetic resonance imaging (MRI) and ultrasound (US) have been increasingly used in psoriatic arthritis (PsA) providing additional clues to the pathogenesis of this peripheral, axial and dermatologic disease. This has improved our understanding of the disease and can be used to aid diagnosis and then to follow outcomes of treatment. Both imaging modalities have highlighted the differing involvement of PsA when compared with rheumatoid arthritis (RA) with a significant burden of entheseal disease, flexor tenosynovitis (occurring alone or as part of dactylitis) and other extra-capsular inflammatory changes. MRI scanning has also highlighted the link between the nail and the distal interphalangeal (DIP) joint confirming previous clinical observations. Imaging studies in psoriasis patients have discovered a high level of subclinical inflammatory change but the clinical importance of such findings has not yet been defined. The potential use of MRI and US to monitor treatment outcomes has encouraged research in this field. In MRI, the PsA MRI Score (PsAMRIS) has been developed with promising initial validation. In US, work is ongoing with the OMERACT group to define key pathologies and to develop scoring systems. A few scoring systems are available for enthesitis scoring using US which are further being developed and refined. Further improvements in technologies in both of these fields offer exciting possibilities for future research. New MRI techniques offer the chance to image previously 'dark' structures such as tendons which is key in spondyloarthritides (SpA). Sonoelastography may also improve our understanding of tendon involvement in SpA. Whole-body multi-joint MRI allows a 'snapshot' of inflammation in PsA including joints, entheses and spinal involvement. Three-dimensional US should improve reliability and comparability of US scoring reducing inter-operator variability. The latest machines offer real-time fusion imaging employing US machines with an in-built virtual navigator system linked to previous MRI acquisitions. All of these new techniques should aid our understanding of PsA and our ability to objectively measure response to therapy.

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 rheumatoid arthritis and its differentiation from other joint abnormalities

The introduction of disease-modifying antirheumatic drugs has created new demands on imaging to early identify patients with rheumatoid arthritis and opened new prospects in therapeutic management of patients with aggressive disease. Therefore, new imaging modalities such as magnetic resonance imaging and ultrasound have developed during the past few years in this field. In some cases, both magnetic resonance imaging and ultrasound may be also useful in making the distinction between early rheumatoid arthritis and other joints abnormalities, including early psoriatic arthritis. This article will review key aspects of important advances in imaging in rheumatoid arthritis, particularly focusing on magnetic resonance imaging and ultrasound.

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.

Ultrasonography, magnetic resonance imaging, radiography, and clinical assessment of inflammatory and destructive changes in fingers and toes of patients with psoriatic arthritis

The aim of the present study was to assess ultrasonography (US) for the detection of inflammatory and destructive changes in finger and toe joints, tendons, and entheses in patients with psoriasis-associated arthritis (PsA) by comparison with magnetic resonance imaging (MRI), projection radiography (x-ray), and clinical findings. Fifteen patients with PsA, 5 with rheumatoid arthritis (RA), and 5 healthy control persons were examined by means of US, contrast-enhanced MRI, x-ray, and clinical assessment. Each joint of the 2nd–5th finger (metacarpophalangeal joints, proximal interphalangeal [PIP] joints, and distal interphalangeal [DIP] joints) and 1st–5th metatarsophalangeal joints of both hands and feet were assessed with US for the presence of synovitis, bone erosions, bone proliferations, and capsular/extracapsular power Doppler signal (only in the PIP joints). The 2nd–5th flexor and extensor tendons of the fingers were assessed for the presence of insertional changes and tenosynovitis. One hand was assessed by means of MRI for the aforementioned changes. X-rays of both hands and feet were assessed for bone erosions and proliferations. US was repeated in 8 persons by another ultrasonographer. US and MRI were more sensitive to inflammatory and destructive changes than x-ray and clinical examination, and US showed a good interobserver agreement for bone changes (median 96% absolute agreement) and lower interobserver agreement for inflammatory changes (median 92% absolute agreement). A high absolute agreement (85% to 100%) for all destructive changes and a more moderate absolute agreement (73% to 100%) for the inflammatory pathologies were found between US and MRI. US detected a higher frequency of DIP joint changes in the PsA patients compared with RA patients. In particular, bone changes were found exclusively in PsA DIP joints. Furthermore, bone proliferations were more common and tenosynovitis was less frequent in PsA than RA. For other pathologies, no disease-specific pattern was observed. US and MRI have major potential for improved examination of joints, tendons, and entheses in fingers and toes of patients with PsA.

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

Rheumatoid arthritis (RA) is a common disease that affects 1% of the population. With the advent of disease-modifying therapies, it became particularly important to detect RA as early as possible. In this article, we discuss the role of magnetic resonance imaging (MRI) in the imaging of early RA. Imaging of soft tissues manifestations, which precede the development of osseous erosions, is discussed. We also review the role of MRI in establishing correct diagnosis in cases of arthritis, which do not demonstrate classical clinical presentation. The role of MRI in the follow-up of RA is addressed.

The role of tumor necrosis factor alpha in down-regulation of osteoblast Phex gene expression in experimental murine colitis

BACKGROUND & AIMS

Reduced bone mass is a common complication of inflammatory bowel disease (IBD), although the mechanisms that contribute to osteopenia are not completely understood. Tumor necrosis factor alpha (TNF-alpha) is up-regulated in patients with IBD and has detrimental effects on osteoblasts. Phex gene is expressed predominantly in osteoblasts, and its disruption results in defective bone mineralization. The aim of this study was to evaluate whether TNF-alpha regulates Phex gene expression thus contributing to the abnormal bone metabolism observed in IBD.

METHODS

Phex gene expression was evaluated in calvaria of 6-7-week-old mice administered with trinitrobenzene sulfonic acid (TNBS) with or without neutralizing anti-TNF-alpha antibody, dietary curcumin, or systemically with recombinant TNF-alpha. TNF-alpha-treated UMR-106 osteoblasts were also examined. Phex promoter activity was assayed in transiently transfected TNF-alpha-treated UMR-106 cells.

RESULTS

Compared with control animals, Phex messenger RNA (mRNA) expression decreased by 40%-50% in both TNBS colitis and TNF-alpha-injected mice. Dietary curcumin and anti-TNF-alpha antibody counteracted the detrimental effect of TNBS on Phex gene expression. TNF-alpha-treated UMR-106 cells showed a concentration-dependent and transcriptionally mediated decrease in Phex mRNA and gene promoter activity, with the -133 to -74 bp region of the Phex promoter likely involved in the mechanism of TNF-alpha action. Coinciding with decreased Phex protein level, TNF-alpha drastically reduced mineralization in UMR-106 osteoblasts.

CONCLUSIONS

Acute colitis and TNF-alpha decrease Phex mRNA and protein expression via a transcriptional mechanism. TNF-alpha-mediated reduction in Phex protein is at least in part responsible for inhibition of osteoblast mineralization, and the described mechanism may contribute to the abnormal bone metabolism associated with IBD.

Magnetic resonance imaging in psoriatic arthritis: a review of the literature

Psoriatic arthritis is a diverse condition that may be characterized by peripheral inflammatory arthritis, axial involvement, dactylitis and enthesitis. Magnetic resonance imaging (MRI) allows visualization of soft tissue, articular and entheseal lesions, and provides a unique picture of the disease process that cannot be gained using other imaging modalities. This review focuses on the literature on MRI in psoriatic arthritis published from 1996 to July 2005. The MRI features discussed include synovitis, tendonitis, dactylitis, bone oedema, bone erosions, soft tissue oedema, spondylitis/sacroiliitis and subclinical arthropathy. Comparisons have been drawn with the more extensive literature describing the MRI features of rheumatoid arthritis and ankylosing spondylitis.

Giant-cell tumours of bone of the hand and wrist: a review of imaging findings and differential diagnoses

Giant-cell tumour of bone (GCTOB) is a benign, locally aggressive, primary bone tumour. Involvement of the distal radius accounts for between 10 and 12% of cases of GCTOB, with the bones of the hand and wrist being rarely affected. GCTOB most commonly affects skeletally mature patients between the ages of 20 and 40 years, with the peak incidence being in the third decade. Women are affected slightly more commonly than men. GCTOB involving the bones of the hand most commonly occurs in a central location, which differs from the usual eccentric location seen in GCTOB at other sites. The radiographic features of GCTOB in the hand and wrist are presented. The role of bone scintigraphy, computed tomography and magnetic resonance imaging is discussed. Evaluation of the postoperative patient is also addressed, including the role of dynamic contrast-enhanced magnetic resonance imaging. A comprehensive review of the potential differential diagnoses that should be considered when GCTOB is suspected in the hand and wrist is also presented.