Developing standards for MRI evaluation of joints in children with juvenile idiopathic arthritis utilizing the temporomandibular joint as a model

The treatment of a patient with juvenile idiopathic arthritis (JIA) is best monitored with standardized and validated tools to measure joint changes over time. Treatment approaches are best indicated if the clinicians are aware of the structural status of the joint at a given time, especially in anatomically deep joints for which clinical assessment is limited. Magnetic resonance imaging (MRI) is of utmost importance for assessment of deep joints and extra-articular soft tissue of the entire body for which ultrasound may be suboptimal. Because the distinction between pathologic and physiologic joint changes on MRI is key for proper diagnosis and treatment of patients with arthropathies, a comprehensive standardized approach is needed to effectively measure outcomes of growing joints of children with JIA. Such an approach is essential for both clinical assessment and to conduct clinical trials in patients with JIA treated in different centers around the world. To meet this need, several international imaging collaborative research groups have been developing MRI scales over the past years, including the MRI in JIA (JAMRI) special interest group within the Outcome Measures in Rheumatology (OMERACT) research network. This manuscript reviews the efforts of the OMERACT JAMRI working group to generate and validate pediatric MRI scoring systems for different joints in children with JIA that can have ubiquitous utilization anywhere in the world. In particular, it describes the different steps of development and validation of an MRI scale using the TMJ as a model.

MRI of the temporomandibular joint in children with juvenile idiopathic arthritis: protocol and findings

Contrast-enhanced magnetic resonance imaging (MRI) is the technique of choice for diagnosis and monitoring of temporomandibular joint (TMJ) disorders in patients with juvenile idiopathic arthritis (JIA), as it is able to visualize both soft tissue and osteochondral changes. Approximately 40% of children with JIA develop inflammatory and chronic osteochondral changes observable on imaging, which if left untreated can lead to significant facial growth impairment, including facial asymmetry and retrognathia. MRI of the TMJ plays a paramount role in diagnosis and treatment monitoring in JIA since early signs of TMJ involvement are difficult to detect clinically and with physical examination. Findings of TMJ arthritis may be classified into acute and chronic domains. Early or acute manifestations include joint effusion, bone marrow edema, synovial thickening, and increased joint enhancement. With disease progression, there are characteristic osteochondral changes, including deformity of the mandibular condyle with shortening of the mandibular ramus, bone erosions, and disk abnormalities. In this pictorial essay, we describe a consensus MRI protocol for the study of the TMJ and illustrate the degree of normal and pathological MRI findings using currently available MRI scoring systems of the TMJ developed for JIA.

Multiparametric MRI evaluation of bone sarcomas in children

Osteosarcoma and Ewing sarcoma are the most common bone sarcomas in children. Their clinical presentation is very variable depending on the age of the patient and tumor location. MRI is the modality of choice to assess these bone sarcomas and has an important function at diagnosis and also for monitoring recurrence or tumor response. Anatomic sequences include T1- and T2-weighted images and provide morphological assessment that is crucial to localize the tumor and describe anatomical boundaries. Multiparametric MRI provides functional information that helps in the assessment of tumor response to therapy by using different imaging sequences and biomarkers. This review manuscript illustrates the role of MRI in osteosarcoma and Ewing sarcoma in the pediatric population, with emphasis on a functional perspective, highlighting the use of diffusion-weighted imaging and dynamic contrast-enhanced MRI at diagnosis, and during and after treatment.

Myocardial involvement in children with post-COVID multisystem inflammatory syndrome: a cardiovascular magnetic resonance based multicenter international study-the CARDOVID registry

BACKGROUND

Recent evidence shows an association between coronavirus disease 2019 (COVID-19) infection and a severe inflammatory syndrome in children. Cardiovascular magnetic resonance (CMR) data about myocardial injury in children are limited to small cohorts. The aim of this multicenter, international registry is to describe clinical and cardiac characteristics of multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19 using CMR so as to better understand the real extent of myocardial damage in this vulnerable cohort.

METHODS AND RESULTS

Hundred-eleven patients meeting the World Health Organization criteria for MIS-C associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), having clinical cardiac involvement and having received CMR imaging scan were included from 17 centers. Median age at disease onset was 10.0 years (IQR 7.0-13.8). The majority of children had COVID-19 serology positive (98%) with 27% of children still having both, positive serology and polymerase chain reaction (PCR). CMR was performed at a median of 28 days (19-47) after onset of symptoms. Twenty out of 111 (18%) patients had CMR criteria for acute myocarditis (as defined by the Lake Louise Criteria) with 18/20 showing subepicardial late gadolinium enhancement (LGE). CMR myocarditis was significantly associated with New York Heart Association class IV (p = 0.005, OR 6.56 (95%-CI 1.87-23.00)) and the need for mechanical support (p = 0.039, OR 4.98 (95%-CI 1.18-21.02)). At discharge, 11/111 (10%) patients still had left ventricular systolic dysfunction.

CONCLUSION

No CMR evidence of myocardial damage was found in most of our MIS-C cohort. Nevertheless, acute myocarditis is a possible manifestation of MIS-C associated with SARS-CoV-2 with CMR evidence of myocardial necrosis in 18% of our cohort. CMR may be an important diagnostic tool to identify a subset of patients at risk for cardiac sequelae and more prone to myocardial damage.

CLINICAL TRIAL REGISTRATION

The study has been registered on ClinicalTrials.gov, Identifier NCT04455347, registered on 01/07/2020, retrospectively registered.

Utility of sonography for identifying metastatic cervical adenopathy in children with differentiated thyroid carcinoma at presentation

BACKGROUND

No study has evaluated the diagnostic accuracy of sonography for the depiction of metastatic cervical adenopathy in children with differentiated thyroid carcinoma at presentation or determined which sonographic features are most useful.

OBJECTIVE

To evaluate the diagnostic accuracy of sonography for identifying metastatic cervical adenopathy in children with differentiated thyroid carcinoma at presentation and to determine the most useful sonographic features.

MATERIALS AND METHODS

We evaluated cervical lymph node sonography and histology in children with proven thyroid carcinoma in a 10-year period. We excluded children in whom a preoperative sonogram was not available and those who did not have surgical resection of lymph nodes. We used histology as the gold standard. On sonography, we analyzed the size, shape, echotexture and vascularity of the lymph nodes and correlated these findings with the histology.

RESULTS

We reviewed sonograms and histology of resected lymph nodes in 52 children and adolescents with proven differentiated thyroid carcinoma (33 females; ages 5-18 years, mean 13.2 years). Metastatic cervical lymph node disease was proved on histology in 33/52 (64%) of our patients at presentation. Sonographic findings correctly predicted whether the nodes were histologically involved with metastatic disease in 42/52 (81%). Sensitivity of sonography was 79%, specificity 84%, positive predictive value (PPV) 90%, negative predictive value (NPV) 70% and accuracy 81%. A significant association was seen between round shape (P=0.0002), abnormal echotexture (P≤0.0001) and vascularity (P≤0.0001), and abnormal lymph node histology. Importantly, in 11/26 (47%) patients with sonographic and histologically proven abnormal nodes, the nodes were normal in size and shape and the presence of metastatic involvement was recognized sonographically only on the basis of abnormal echogenicity and vascularity.

CONCLUSION

Sonography has a high accuracy, specificity and PPV for identifying metastatic cervical lymph node involvement in children with differentiated thyroid carcinoma at presentation. Most of the abnormal lymph nodes were round in shape and had abnormal echogenicity and vascularity. Importantly, this paper emphasizes that in children, nodes with histologically proven metastases from differentiated thyroid carcinoma can be normal in size and shape. In these patients the presence of metastatic involvement might be recognized sonographically only on the basis of abnormal echogenicity and vascularity.

Association of Bone Edema with the Progression of Bone Erosions Quantified by Hand Magnetic Resonance Imaging in Patients with Rheumatoid Arthritis in Remission

Objective.

To evaluate the association of synovitis, bone marrow edema (BME), and tenosynovitis in the progression of erosions quantified by hand magnetic resonance imaging (MRI) at 1 year in patients with early rheumatoid arthritis (RA) in remission.

Methods.

A total of 56 of 196 patients with early RA in remission at 1 year and with available MRI data at baseline and at 12 months were included. MRI images were assessed according to the Rheumatoid Arthritis Magnetic Resonance Imaging Scoring (RAMRIS) system. Persistent remission was defined as 28-joint Disease Activity Score-erythrocyte sedimentation rate ≤ 2.6 and/or Simplified Disease Activity Index ≤ 3.3 and/or the new boolean American College of Rheumatology/European League Against Rheumatism remission criteria for a continuous period of at least 6 months. Progression of bone erosions was defined as an increase of 1 or more units in annual RAMRIS score for erosions compared to baseline.

Results.

At 1 year, the majority of patients with RA in sustained remission showed some inflammatory activity on MRI (94.6% synovitis, 46.4% BME, and 58.9% tenosynovitis) and 19 of the 56 patients (33.9%) showed MRI progression of bone erosions. A significant difference was observed in MRI BME at 1 year, with higher mean score in patients with progression compared to nonprogression of erosions (4.8 ± 5.6 and 1.4 ± 2.6, p = 0.03).

Conclusion.

Subclinical inflammation was identified by MRI in 96.4% of patients with RA in sustained clinical remission. Significantly higher scores of BME after sustained remission were observed in patients with progression of erosions compared to patients with no progression. The persistence of higher scores of BME may explain the progression of bone erosions in patients with persistent clinical remission.

Repair of erosions in patients with rheumatoid arthritis treated with etanercept: magnetic resonance imaging findings after 1 year of follow-up

OBJECTIVES

To monitor repair of bone erosions using magnetic resonance imaging (MRI) in patients with rheumatoid arthritis (RA) during etanercept combination therapy.

METHOD

The study population comprised 29 RA patients [biologic-naïve, 28-joint Disease Activity Score (DAS28) ≥ 3.2] starting etanercept combination therapy with disease-modifying anti-rheumatic drugs (DMARDs) and completing the 1-year study period with the same treatment. Clinical and laboratory assessments and MRI of the hand were performed at baseline and at 1 year. MRI findings were scored by two readers using the Rheumatoid Arthritis MRI Scoring System (RAMRIS). Both readers were blind to the chronological order of the MRI scans, the identity of the patients, and clinical and other imaging data. Tenosynovitis was also scored. The intra- and inter-reader intraclass correlation coefficients (ICCs) were calculated, along with the sensitivity to change with the smallest detectable difference (SDD). Repair of erosions was defined as a RAMRIS score of at least 1 point lower than baseline.

RESULTS

The mean RAMRIS score for erosions did not change but all other inflammatory MRI parameters decreased significantly. In 19 patients, the RAMRIS score for erosions remained unchanged after 1 year. In five patients the score decreased after 1 year, although the decrease exceeded the SDD in only one patient (3.4%).

CONCLUSIONS

Etanercept combined with DMARDs stopped the progression of erosions, as measured by the RAMRIS, in 82.8% of our RA patients and occasional repair of bone erosions occurred after 1 year of treatment.

Primary seminal vesicle adenocarcinoma

We describe the case of a 48-year-old male with primary seminal vesicle carcinoma. Although most malignant lesions involving the seminal vesicles are the result of secondary spread from other tumors, primary seminal vesicle carcinoma must be considered in the differential diagnosis, as the prognosis for this condition is dismal. Magnetic resonance imaging plays a crucial role in assessment, as it can exquisitely depict the anatomy of this region and define the extent of a seminal vesicle lesion.

[Delayed diagnosis of a diaphragmatic hernia in a patient on mechanical ventilation]

Traumatic rupture of the diaphragm is uncommon. Its early diagnosis is a challenge in diagnostic imaging. We present the case of a male multiple trauma patient in whom a left diaphragmatic hernia was discovered on weaning from mechanical ventilation 23 days after admission. We discuss the key imaging features of diaphragmatic rupture based on its physiopathology and thoracoabdominal pressure gradients. Very few cases of radiologically documented diaphragmatic hernias masked by mechanical ventilation have been reported.

[Congenital heart disease in adults: the contribution of multidetector CT]

Congenital heart disease is relatively common among adults. Patients' conditions have generally been diagnosed previously and imaging tests are requested for follow-up or for complications of the anomaly or of its surgical correction. Classically, these patients were studied with echocardiography and cardiac catheterization, but multidetector CT and magnetic resonance imaging have changed the approach because these techniques show the anatomy of heart defects and their correction very clearly. We emphasize the importance of multidetector CT as a complementary technique for the study of congenital heart disease that is newly discovered in adults or for the follow-up of congenital heart disease that was surgically corrected during childhood. When vascular anomalies are present outside the heart or after palliative surgery, multidetector CT shows anatomical details that are difficult or impossible to see with echocardiography. We also emphasize the frequent association between pulmonary hypertension and congenital heart disease that can debut in adults.