AB0599 THE VALUE OF ULTRASOUND IN GCA FOLLOW-UP: RESULTS FROM A SCOTTISH SINGLE CENTRE

Background

Ultrasound (USS) is important diagnostically in GCA, but its value during follow-up is unclear1. In our centre, ad hoc follow-up USS has been performed routinely.

Objectives

To describe how USS appearances i) changed over time (at defined timepoints), ii) correlated with clinical relapse (at any time), iii) were affected by tocilizumab.

Methods

Patients diagnosed with GCA in NHS Lanarkshire, November 2018 - October 2021, were included. Treatment was in accordance with international guidelines2. Follow-up visit data included clinical status (remission, stable, relapse), treatment, and (when USS performed) temporal artery (TA) and axillary artery (LV) intima media thickening (IMT) (TA+ = IMT ≥0.5MM; LV+ = IMT >1mm). Follow-up USS were compared to baseline, pre-relapse or pre-tocilizumab.

Results

55 patients were diagnosed with GCA; mean (SD) age 73.1 (8.0) years; 31 female (56.4%). Mean (SD) follow-up was 63.8 (40.6) weeks. All patients had baseline USS [48 positive (TA+ or LV+)], 7 negative; 36 (65.5%) had ≥1 follow-up USS. 7 patients had USS at 6-12 weeks; all were clinically stable; all had positive baseline USS; at 6-12 weeks, 3/7 remained TA+, 1/7 remained LV+ (TA-LV+). 25 patients had USS at 16-36 weeks; 9/25 were in remission, 11/25 stable, 5/25 relapsing. Of remission patients, 7/9 had positive baseline USS; at 16-36 weeks, 2/7 remained TA+. Of stable patients, all had positive baseline USS; at 16-36 weeks, 4/11 remained TA+, 3/11 remained LV+. Of relapsing patients, 5/5 had positive baseline USS; at 16-36 weeks, 2/5 remained TA+, 1/5 LV remained LV+. 15 patients had USS at 42-62 weeks; 8/15 were in remission, 3/15 stable, 4/15 relapsing. Of remission patients, 7/8 had positive baseline USS; at 42-62 weeks, 3/7 remained TA+. Of stable patients, 3/3 had positive baseline USS; at 42-62 weeks, 1/3 was TA-LV+, 1/3 remained TA+LV+. Of relapsing patients, 4/4 had positive baseline USS (3/4 TA+, 1/4 LV+); at 42-62 weeks, all were TA-LV+. The Table 1 below provides additional detail for each timepoint. 11 patients in total had clinical relapse (any time) and contemporaneous USS; mean (SD) time to relapse was 36.6 (18.3) weeks; median (IQR) prednisolone dose 7mg (4,9). At relapse, 2/11 were TA+LV+, 6/11 LV+, 3/11 TA-LV-. Comparing relapse USS to most recent USS pre-relapse, 4/11 were newly LV+, while other positive findings were seen previously. 11 patients treated with tocilizumab had ≥1 USS post-initiation [at mean (SD) 27.1 (16.7) weeks]. 5/11 were LV+ pre-tocilizumab, 6/11 TA+. At follow-up, all were in remission or stable; 4/5 remained LV+, 4/6 remained TA+.

Table 1.

Follow-up and corresponding baseline ultrasound results, at defined timepoints, grouped by clinical status.

Baseline ultrasoundFollow-up ultrasoundTimeClinical statusNaTA+LV-LV+TA-TA+LV+TA-LV-TA+LV-LV+TA-TA+LV+TA-LV-6-12 weekAll stable76010310316-36 weekAll251706264015Remission960122007Stable1170404304Relapse54010210242-62 weekAll15111213516Remission860113005Stable320100111Relapse431000400

a.Number of patients scanned.

Conclusion

While many patients had rapid normalisation of USS changes with treatment, others remained abnormal despite stable disease or remission, including at approx. 12 months follow-up. Ad hoc follow-up scans therefore appear unreliable in isolation, but the value of systematic longitudinal scanning warrants further study. Emergence of LV positivity was seen in several cases of relapse and may characterise an evolution in disease phenotype. Positive USS findings largely persisted at approx. 6 months despite disease control on tocilizumab.

References

[1]Dejaco et al, ARD 2018.

[2]Hellmich et al, ARD 2020.

Disclosure of Interests

Andrew Melville Grant/research support from: Dr Melville is a MRC GSK EMINENT clinical training fellow, with project funding outside the submitted work., Anna Ciechomska Speakers bureau: Dr Ciechomska has received speaker, travel and registration fee sponsorship from Novartis, Abbvie, Chugai Pharma, Colgene, Roche and Lilly.

P292 Follow up of giant cell arteritis patients with ultrasound: can cranial giant cell arteritis phenotype evolve towards large vessel vasculitis?

Background/Aims

Ultrasound (US) is well-established in diagnosis of giant cell arteritis (GCA) but its value in follow-up is not yet adequately defined. The large vessel vasculitis (LVV) phenotype of GCA has less favourable outcomes and more often requires steroid-sparing treatment compared to the cranial phenotype. Evolution towards LVV might account for first-line treatment failure and impact on further therapeutic decisions. Here we review follow-up data from the NHS Lanarkshire GCA service and describe several relevant cases.

Methods

We performed a retrospective review of routine clinical and ad hoc US data from the NHS Lanarkshire GCA service between November 2018 and October 2021. Patients with cranial GCA at baseline and no involvement of large vessels were identified; demographic and clinical data of those who later developed US signs of LVV were reviewed. US positivity was defined by temporal artery intima media thickness (IMT) ≥0.5mm or LV IMT >1.0mm.

Results

53 patients were diagnosed with GCA during the study period. At initial visit, 35 had cranial GCA on US, 12 had LVV, 6 were US negative. Five patients with cranial GCA developed US signs of LVV during follow-up. One of these was in remission clinically and had borderline IMT of 1.0mm. The other four had clinical relapse with mean LV IMT of 1.8mm (range 1.6-2.2); relapses occurred at mean 40 weeks (range 29-53), on prednisolone doses 0-15mg; all were subsequently commenced on steroid-sparing treatment (Table).

Conclusion

Cranial and LVV phenotypes of GCA may represent different stages of disease. US can be used to confirm evolution to LVV; identification of LVV US signs may explain clinical relapse and support the introduction of steroid sparing treatment.

Disclosure

A. Ciechomska: Other; Speaker, travel and registration fee sponsorship from Novartis, Abbvie, Chugai Pharma, Colgene, Roche and Lilly. A.R. Melville: Other; Dr Melville is a Medical Research Council (MRC) and GlaxoSmithKline (GSK) Experimental Medicine Initiative to Explore New Therapies clinical training fellow.

P304 Performance of the Southend GCA Probability Score on the NHS Lanarkshire fast track pathway

Background/Aims

Fast track GCA pathways (GCA FTP) with use of confirmatory ultrasound are growing in popularity, but the burden of referrals can overwhelm services and represents a barrier to timely assessment. The Southend GCA Probability Score (GCAPS) has shown promise in determining pre-test probability and may have a role in triage, but there is limited data supporting its use in external cohorts. We evaluated the performance of GCAPS in patients assessed on the NHS Lanarkshire GCA FTP.

Methods

Consecutive patients assessed on the GCA FTP between November 2018 and August 2021 were included. All underwent GCAPS assessment as part of routine care. GCAPS risk groups were defined as follows: low risk ≤8, medium risk 9-12, high risk ≥13. GCA diagnoses were supported by USS +/- TAB and confirmed at 6 months. Overall performance of GCAPS in distinguishing GCA / non-GCA final diagnoses was assessed by ROC analysis. Test characteristics for different GCAPS binary cut-offs were also determined.

Results

176 patients were included in total; mean age 69.0 years (SD 9.8), 63.6% female, median GCAPS 10 (IQR 8, 14). 54 patients were diagnosed with GCA, including 0/57 low risk patients, 3/60 medium risk patients (5.0%), and 51/59 high risk patients (86.4%). ROC analysis for total GCAPS in distinguishing GCA/non-GCA gave an AUC of 0.973 (95% CI 0.951 - 0.999). A GCAPS cut-off of ≥ 13 had the highest accuracy for GCA diagnosis (93.8%), with 94.4% sensitivity and 93.4% specificity. A GCAPS cut-off of ≥ 10 captured all cases of GCA (100.0% sensitivity), with 64.8% specificity.

Conclusion

Performance of GCAPS as a risk stratification tool in our cohort was excellent. GCAPS may have additional roles in screening FTP referrals and guiding empirical glucocorticoid therapy. No patients with GCAPS <10 had GCA; this is consistent with previously published data and suggests specialist review and/or USS may not be required in this group. By contrast, most patients with GCAPS ≥13 had GCA, and this group is most likely to benefit from empirical glucocorticoid treatment while awaiting confirmation. Patients with GCAPS between these values should undergo prompt assessment to minimise the risk of missed diagnoses, or overtreatment.

Disclosure

A.R. Melville: Other; Dr Melville is a Medical Research Council and GlaxoSmithKline Experimental Medicine Initiative to Explore New Therapies clinical training fellow, with project funding outside the submitted work. K. Donaldson: Other; Speaker fees from Menarini Pharma UK. A. Ciechomska: Other; Speaker, travel and registration fee sponsorship from Novartis, Abbvie, Chugai Pharma, Colgene, Roche and Lilly.

Validation of the Southend giant cell arteritis probability score in a Scottish single-centre fast-track pathway

OBJECTIVE

The aim was to provide external validation of the Southend GCA probability score (GCAPS) in patients attending a GCA fast-track pathway (GCA FTP) in NHS Lanarkshire.

METHODS

Consecutive GCA FTP patients between November 2018 and December 2020 underwent GCAPS assessment as part of routine care. GCA diagnoses were supported by US of the cranial and axillary arteries (USS), with or without temporal artery biopsy (TAB), and confirmed at 6 months. Percentages of patients with GCA according to GCAPS risk group, performance of total GCAPS in distinguishing GCA/non-GCA final diagnoses, and test characteristics using different GCAPS binary cut-offs were assessed. Associations between individual GCAPS components and GCA and the value of USS and TAB in the diagnostic process were also explored.

RESULTS

Forty-four of 129 patients were diagnosed with GCA, including 0 of 41 GCAPS low-risk patients (GCAPS <9), 3 of 40 medium-risk patients (GCAPS 9-12) and 41 of 48 high-risk patients (GCAPS >12). Overall performance of GCAPS in distinguishing GCA/non-GCA was excellent [area under the receiver operating characteristic curve, 0.976 (95% CI 0.954, 0.999)]. GCAPS cut-off ≥10 had 100.0% sensitivity and 67.1% specificity for GCA. GCAPS cut-off ≥13 had the highest accuracy (91.5%), with 93.2% sensitivity and 90.6% specificity. Several individual GCAPS components were associated with GCA. Sensitivity of USS increased by ascending GCAPS risk group (nil, 33.3% and 90.2%, respectively). TAB was diagnostically useful in cases where USS was inconclusive.

CONCLUSION

This is the first published study to describe application of GCAPS outside the specialist centre where it was developed. Performance of GCAPS as a risk stratification tool was excellent. GCAPS might have additional value for screening GCA FTP referrals and guiding empirical glucocorticoid treatment.

Recommendations for rheumatology ultrasound training and practice in the UK

OBJECTIVE

The aim of this paper is to present a UK-based consensus of principles and recommendations to guide rheumatology US training and practice.

METHOD

A Delphi process was conducted involving 19 US experts representing each of the 14 regions of the UK. A working group of experienced British Society for Rheumatology Ultrasound Special Interest Group (BSRUSSIG) members made seven proposals that were presented to the whole group for further discussion. This resulted in minor modifications and seven preliminary recommendations. Members were then asked to anonymously agree or disagree with each recommendation using an electronic ballot. A threshold of 75% was used to determine consensus agreement. Results were collated by an independent chairperson and presented to the BSRUSSIG in a face to face meeting where agreement for each recommendation was ratified and an action plan agreed for dissemination of the results and future development work.

RESULTS

Using a validated process, experts in rheumatology US have worked through an iterative process and have unanimously agreed seven recommendations for rheumatology training and practice. These cover a hierarchy of practice indications, education and training, including the need for practitioners to demonstrate lifelong learning, as well as a commitment to support mentors and trainers through the BSRUSSIG.

CONCLUSION

These are the first specific education and practice recommendations for rheumatology US in the UK and have been developed and endorsed by the BSRUSSIG. We intend that these proposals will help to support and validate rheumatology US practice and inform the development of future rheumatology training curricula and education programmes.

Scottish rheumatology sonography course: five-year experience of delivering a mentorship-model rheumatology ultrasound training programme accredited by the consortium for the accreditation of sonographic education

BACKGROUND AND AIMS

Ultrasound training for rheumatology practice in the UK is variable. Currently, there is no agreed minimum standard for training in ultrasound applied to rheumatology patient management. We present our experiences of implementing a competency driven ultrasound training, focused on hands and feet.

METHODS AND RESULTS

The Rheumatology Sonography Course (RSC) was developed by the Scottish Rheumatology Ultrasound Group in collaboration with Glasgow Caledonian University. The RSC is delivered via a blended learning approach and includes training workshops, mentorship and clinical competency assessments. Mentors are supported and developed within their role. 31 trainees have enrolled on the course between 2014 and 2019. To date, 22 (71%) have completed. Change of job role was the main factor leading to non-completion. Thirteen mentors have supported the training and assessment of RSC trainees. All trainees reported positively that ultrasound training via the RSC model fulfilled their learning needs.

CONCLUSION

The RSC is a feasible ultrasound training model for rheumatology practitioners. Whilst it provides a robust training framework, mentorship fees and university overheads increase the cost. The RSC provides motivation to mentors to train external trainees and supports the development of new ultrasound-based rheumatology services.

Implementation and role of modern musculoskeletal imaging in rheumatological practice in member countries of EULAR

Objectives

To document the current training, implementation and role of modern musculoskeletal imaging techniques: ultrasound, magnetic resonance imaging, computed tomography and positron emission tomography, among rheumatologists in the member countries of the EULAR.

Methods

English-language questionnaires for each imaging modality developed by a EULAR task force were sent out to national and international scientific societies as well as imaging experts in the given modalities involved in research and/or training. The surveys were distributed via an online survey tool (SurveyMonkey). Simple descriptive and summary statistics were calculated from the responses.

Results

More than 90% of ultrasound (US) experts reported the availability of a US unit in their department. Suspicion of rheumatoid arthritis and spondyloarthritides were the main clinical indications for performing US for diagnostic purposes. Suspicion of sacroiliitis and degenerative spine disease were the most common indications to perform magnetic resonance imaging (MRI) or computed tomography (CT) for diagnostic purposes, while positron emission tomography was mainly performed to diagnose large vessel vasculitis and to investigate fever of unknown origin. The reported percentage of rheumatologists performing US was highly variable, ranging from more than 80% in 6% of countries to less than 10% in 15% of countries. The majority of experts (77%) reported that their national rheumatology societies organise musculoskeletal US courses, while courses in MRI or CT organised by the national rheumatology societies were less commonly reported (29% and 8%, respectively).

Conclusions

Rheumatologists in Europe utilise modern imaging techniques; however, access to the techniques and training offered is varied.

Ultrasound image of malignant bone tumors in children. An analysis of nine patients diagnosed in 2011-2016

Introduction: The diagnostic process of bone tumors, including malignant ones, is based on conventional radiological methods, such as radiography and computed tomography, and with precise assessment of local advancement in magnetic resonance imaging. Ultrasonography is not included in the diagnostic algorithms as a tool suitable to detect this type of pathology. More and more frequent usage of musculoskeletal ultrasound in children as the first imaging method or, in some cases, as the only diagnostic method, makes it necessary to be familiar with sonographic presentation of bone tumors to suggest this diagnosis early enough and, after its verification, start treatment without a significant delay. Aim: The aim of this study was to determine changes in the sonographic image that might indicate a bone malignancy and suggest the need to extend the diagnostic process in this direction. Material and method: This article discusses 10 bone tumors in 9 children who had an ultrasound scan performed at the beginning of the diagnostic process before the histopathological diagnosis was established and treatment initiated. The assessment involved ultrasonographic features indicating the presence of a tumor. Results: In the group of 9 patients, 8 malignant bone tumors were diagnosed in ultrasonography and later verified histopathologically: 4 osteosarcomas and 4 Ewing’s sarcomas. In one case, two bone tumors were detected in ultrasonography without specification of their nature (malignant/benign, primary/secondary). Conclusions: In the analyzed cases, ultrasonography enabled the correct diagnosis of a focal bone lesion, and in most cases (8/9) it presented an image that suggested its malignant nature and the necessity of further diagnosis and treatment.

Inter & intra-observer reliability of grading ultrasound videoclips with hand pathology in rheumatoid arthritis by using non- sophisticated internet tools (LUMINA study)

AIM

To evaluate the inter- and intraobserver agreement of a group of European rheumatologist ultrasonographers in grading musculoskeletal ultrasound videoclips posted on the Internet by using a non-sophisticated electronic environment.

METHODS

Forty short movie clips (less than 30 secs) were made available over the Internet to all participants. Normal and pathological RA hand joints and tendons were included in the movie clips. In the first phase 30 investigators from European countries were invited to evaluate the clips and to interpret/grade them. No instruction session was held prior to the initiation of the study. For synovitis the requested scoring system included 0 to3 grades and for tenosynovitis a binary variable 0/1; separate evaluations were performed for gray scale (GS) and Power Doppler (PD) examinations. In the second phase the responders were asked to grade the same clips in a different order without having access to their first grading scale. Light's k and Cohen's k were used to analyse inter- and intraobserver reliability.

RESULTS

Twenty two European rheumatologists agreed to finalise both study phases. Mean Cohen's κ for intraobserver reliability was 0.614/0.689 for tenosynovitis GS/PD and 0.523/0.621 for synovitis GS/PD. Light's k for interobserver reliability was 0.503 for tenosynovitis evaluation and 0.455 for global (synovitis and tenosynovitis) evaluation. Mean global overall agreement was 84.95% (90.2% for global synovitis).

CONCLUSIONS

An over-the-net US evaluation and grading has shown moderate to good reliability. The results could be improved if a training session is added at the beginning of the study.

[Magnetic resonance imaging of the hand in rheumatoid arthritis]

The aim of the study was to show the magnetic resonance (MR) images of changes in hands of patients with rheumatoid arthritis (RA). The SE sequence T1-weighted (TR600, TE15) and fat-suppressed (A-250, TR1155, TE22) were obtained with 3 mm coronal scans and matrix 256 x 512, both before and after contrast medium administration. Knee coil was used. The images in both sequences of the following changes were obtained: bone erosions, synovitis, periarticular oedema, joint effusion, tendonitis and bone marrow oedema. The administration of intravenous contrast was found very useful. Changes of the joint synovium in osteoarthritis were characterised to differentiate them from changes due to RA. The authors suggest that MR imaging--because of its exceptional diagnostic value--may become a basic imaging method in evaluation of patients with RA.

[Ultrasonography of the hand in rheumatoid arthritis]

Authors present the ability of ultrasonography and Color and power Doppler sonography in evaluation of the hand structures in patients with rheumatoid arthritis. Imaging of bony contours allows to identify bone erosions. Thickness, oedema and presence of increased blood flow (hyperaemia) in the synovium in joints and tendon sheaths are characteristic features of an active inflammation. Changes of the tendon structure indicate its damage. US allows to image the carpal tunnel structures, to visualise changes of the median nerve in the carpal tunnel syndrome and gives possibilities to find the cause of its compression.

[The assessment of the value of ultrasound and magnetic resonance imaging in diagnosing hand joint arthritis]

The main imaging investigation used in diagnosing rheumatoid arthritis is radiography of the hands and feet. It allows visualisation of bone erosions--typical of the disease. However, bone erosions occur during the later stages of the rheumatoid arthritis and are preceded by synovitis. The aims of the study were to use ultrasound (US) and magnetic resonance imaging (MRI) in examining joints in patients suffering from chronic arthritis, and also to assess the value of these methods in diagnostics. In 61 patients with chronic arthritis (39 with rheumatoid arthritis--RA, and 22 with another etiology arthritis), plain radiography, US and MRI of the hands was performed. MRI and US were more sensitivity in visualisation of bone erosions than plain radiography. Both methods showed synovitis in all patients with RA. In detecting bone erosions in the hand joints MRI and US are more sensitive methods than plain radiography. Both methods detect synovitis and tenosynovitis. Inflammatory changes shown using the MRI and US are more intensive in RA than in patients suffering from another etiology arthritis.

MRI evaluation of pathological changes taking place in the hand in patients with rheumatoid arthritis

The aim of this study was to use magnetic resonance imaging (MRI) to evaluate the pathological changes taking place in the hands of patients with rheumatoid arthritis (RA), and to attempt to characterize early and persistent changes. 42 patients were examined, including 31 women and 11 men in age from 23 to 75, the duration of illness ranged from 1 month to 27 years (average 7.1 years). The MRI examination was performed using a 1,5 T Magnetom 63 SP whole body system. The SE sequence was used in T1-weighted (TR600, TE15) and fat-suppressed images (A-250, TR1155, TE22), obtained with 3 mm scans, matrix 256 x 512. A knee coil was used. In 30 patients erosion was detected on the joint surfaces of the bones, including 7 patients whose erosion was not visible in plain ordinary x-ray photos. In 31 patients bone marrow edema was detectable, including 6 patients in whom advanced pathological changes were absent. In all patients signs were discovered of thickening of the synovial membrane with (30 of 42) or without (12 of 42) the presence of pannus. Periarticular effusion was observed in all patients, and in 6 patients it occurred together with bone marrow edema. Tendonitis was visible in 25 patients who were in an advanced stage of the disease. For 7 patients, the MR examinations prompted an upgrading of the diagnosed phase of rheumatoid arthritis to a more advanced stage, due to the detection of erosion. In patients with a less advanced stage of the disease, MR examination revealed 11 more joints with pathological changes (periarticular effusion) than were detected by ordinary physical examination. Magnetic Resonance Imaging seems to be the examination of choice in patients with rheumatoid arthritis at an unclear or early stage.

[Aphasia without alexia after surgical treatment of aneurysm of the right middle cerebral artery--incomplete lateralization of verbal functions?]

The authors present a case of aphatic disorders after surgical treatment of the right middle cerebral artery aneurysm. A prominent dissociation of verbal function was noticed.