Magnetic resonance imaging of the wrist in early rheumatoid arthritis reveals progression of erosions despite clinical improvement

162

Objective. To explore the presence of changes resembling rheumatoid arthritis erosions and synovitis in metacarpophalangeal (MCP) and wrist joints of healthy individuals on magnetic resonance imaging (MRI) and to compare the MRI findings with conventional radiographic, clinical, and biochemical findings.Methods. Twenty-eight healthy individuals were studied. Contrast-enhanced MRI and conventional radiography of the dominant wrist and second through fifth MCP joints were performed, coupled with standard clinical assessments and biochemical analyses. MR images were evaluated according to the latest OMER-ACT (Outcome Measures in Rheumatology Clinical Trials) recommendations with respect to synovitis, erosions, and bone marrow edema.Results. Conventional radiography revealed erosion-like changes in 1 of 224 MCP joint bones (0.4%) and in 1 of 420 wrist joint bones (0.2%). MRI depicted low-grade erosion-like changes in 5 of 224 MCP joint bones (2.2%) and in 7 of 420 wrist joint bones (1.7%), but postcontrast enhancement within the lesion was detected in only 8.3% of these. MRI depicted low-grade synovitis-like changes in 10 of 112 MCP joints (8.9%) and in 8 of 84 assessed wrist areas (9.5%), while only minimal early synovial enhancement was detected by dynamic MRI. Three subjects had elevated serum levels of C-reactive protein, and these subjects displayed 44.5% of the synovitis-like changes and 41.7% of the erosion-like changes. Bone marrow edema-like changes were not found in any joints.Conclusion. Changes resembling mild synovitis or small bone erosions are occasionally found in the MCP and wrist joints of healthy controls. Signs of synovitis on dynamic MRI, enhancement within bone erosion-like changes, and signs of bone marrow edema appear rarely or are absent in healthy controls. These signs may thus prove to be very specific in the distinction between arthritic and normal joints.Conventional radiography is the standard reference method for assessing destructive skeletal changes in rheumatoid arthritis (RA) and is part of the American College of Rheumatology (formerly, the American Rheumatism Association) 1987 revised criteria for the classification of RA (1). Magnetic resonance imaging (MRI) is more sensitive for the detection of synovitis and bone erosions in RA than are conventional radiography and clinical assessment (2-4). However, the specificity of the MRI findings in this context remains to be established.A review of the literature describing erosions, synovitis, and bone marrow edema in wrist and metacarpophalangeal (MCP) joints on MRI revealed that very few studies have assessed the prevalence of these findings in healthy persons (Table 1). To our knowledge, only one reported study had the primary aim of describing signs of arthritis in healthy persons. Investigators in that study only examined signs of synovitis in wrist joints (5).Studies involving healthy controls are often perSupported by the Danish Rheumatism Association.

Section: Discussioncontrasting

confidence: 68%

Magnetic resonance imaging of wrist and finger joints in healthy subjects occasionally shows changes resembling erosions and synovitis as seen in rheumatoid arthritis

Ejbjerg

Narvestad

Rostrup

et al. 2004

162

“…An inception cohort of 42 patients with early RA has been studied since symptom onset. Details of recruitment, baseline demographics, and clinical assessments have been previously described (8,9). Briefly, all patients fulfilled the 1987 American College of Rheumatology (formerly, the American Rheumatism Association) criteria for RA (16) and had symptoms for 6 months or less (median 4 months) at the time of entry into the study.…”

Section: Methodsmentioning

confidence: 99%

“…We and other investigators have studied MRI as a potential tool for prognostication in RA (8)(9)(10)(11)(12)(13). For the past 6 years, we prospectively studied a cohort of patients with early RA, monitoring their clinical and radiographic progression as well as the MRI appearance of their dominant wrists.…”

mentioning

confidence: 99%

Bone edema scored on magnetic resonance imaging scans of the dominant carpus at presentation predicts radiographic joint damage of the hands and feet six years later in patients with rheumatoid arthritis

McQueen¹,

Benton²,

Perry³

et al. 2003

387

226

Objective. Magnetic resonance imaging (MRI) is capable of revealing synovitis and tendinitis in early rheumatoid arthritis (RA), as well as bone edema and erosion. These features are visible before radiographic joint damage occurs. We sought to examine whether MRI of one body region (the wrist) can be used to predict whole-body radiography scores reflecting joint damage at 6 years.Methods. We conducted a 6-year prospective study of a cohort of patients who fulfilled the criteria for RA at presentation, using clinical parameters, radiographs, and MRI scans of the dominant wrist. Of the 42 patients enrolled at baseline, full MRI, radiographic, and clinical data were available for 31 at 6-year followup. MRI scans were scored by 2 radiologists, using a validated scoring system. Radiographs of the hands and feet were graded using the modified Sharp scoring method. MRI and radiography scores obtained at baseline and 6 years were compared, and baseline MRI scores were examined for their ability to predict radiographic outcome at 6 years.Results. At 6 years, the total Sharp score correlated significantly with the total MRI score and the MRI erosion score (r ‫؍‬ 0.81, P < 0.0001 and r ‫؍‬ 0.79, P < 0.0001, respectively). The 6-year Sharp score also correlated with the baseline total MRI and MRI erosion scores (r ‫؍‬ 0.56, P < 0.0001 and r ‫؍‬ 0.33, P ‫؍‬ 0.03, respectively). MRI synovitis and bone edema scores remained constant for the group as a whole over 6 years, but bone erosion scores progressed (P ‫؍‬ 0.0001), consistent with radiographic deterioration. Erosions on 6-year MRI scans were frequently preceded by MRI bone edema at baseline (odds ratio 6.5, 95% confidence interval 2.78-18.1). Regression models indicated that the baseline MRI bone edema score was predictive of the 6-year total Sharp score (P ‫؍‬ 0.01), as was the C-reactive protein (CRP) level (P ‫؍‬ 0.0002). Neither shared epitope status nor swollen or tender joint counts predicted radiographic outcome in this cohort. A model incorporating baseline MRI scores for erosion, bone edema, synovitis, and tendinitis plus the CRP level and the erythrocyte sedimentation rate explained 59% of the variance in the 6-year total Sharp score (R 2 ‫؍‬ 0.59, adjusted R 2 ‫؍‬ 0.44). Conclusion. MRI scans performed at the first presentation of RA can be used to help predict future radiographic damage, allowing disease-modifying therapy to be targeted to patients with aggressive disease.

“…In several studies of early RA, more bone erosions have been detected by MRI than by radiography (9,10), and a higher frequency of erosive progression in individual joints has been observed (11)(12)(13). All MRI studies of RA patients have focused on 1 or 2 joint regions-most frequently the wrist and/or the second through fifth metacarpophalangeal (MCP) joints.…”

mentioning

confidence: 99%

The smallest detectable difference and sensitivity to change of magnetic resonance imaging and radiographic scoring of structural joint damage in rheumatoid arthritis finger, wrist, and toe joints: A comparison of the omeract rheumatoid arthritis magnetic resonance imaging score applied to different joint combinations and the sharp/van der heijde radiographic score

Ejbjerg

Vestergaard

Jacobsen

et al. 2005

108

Objective. To compare 2 magnetic resonance imaging (MRI) approaches and radiographic evaluation according to the Sharp/van der Heijde method with respect to sensitivity to change in joint destruction in patients with rheumatoid arthritis (RA).Methods. Thirty-five RA patients and 9 healthy controls underwent MRI and radiography on 2 occasions 1 year apart. Conventional radiographs of the hands, wrists, and forefeet were evaluated according to the Sharp/van der Heijde method. MRIs of unilateral wrist and second through fifth metacarpophalangeal (MCP) joints ("few-joints approach") and of bilateral wrist and MCP joints plus unilateral metatarsophalangeal (MTP) joints ("many-joints approach") were assessed for bone erosions according to the scoring system recommended by the OMERACT (Outcome Measures in Rheumatology Clinical Trials) group. The smallest detectable differences (SDDs) of the radiography and MRI scores were computed based on reevaluation of one-third of the study population.Results. Progressive joint destruction, i.e., an increase in score after the followup period, was observed more frequently with the MRI "many-joints approach" (30 subjects) and "few-joints approach" (25 subjects) than with the Sharp/van der Heijde radiographic method (9 subjects) (P < 0.001 by chi-square analysis). No significant difference between the MRI approaches was observed. When only subjects with a change greater than the SDD were considered, progression was revealed with the MRI "many-joints approach," the MRI "few-joints approach," and radiography in 15, 13, and 5 RA subjects, respectively. With both MRI approaches, significantly more subjects with progression were detected than were detected by radiography (P < 0.05).Conclusion. MRI, regardless of whether it covers unilateral wrist and MCP joints or bilateral wrist and MCP joints plus unilateral MTP joints, is significantly superior to radiography of the hands, wrists, and forefeet with respect to detection of progressive joint destruction in RA.