Use of Magnetic Resonance Imaging to Identify Immune Checkpoint Inhibitor–Induced Inflammatory Arthritis

Abstract

IMPORTANCE Immune checkpoint inhibitors (ICIs) have transformed the treatment paradigm for an ever-increasing number of cancers. However, their use has also led to the emergence of immunerelated adverse events, such as ICI-induced inflammatory arthritis. A reproducible, reliable, and accessible modality is needed to assess and distinguish early ICI-induced inflammatory arthritis and help in management. Magnetic resonance imaging (MRI) of joints may be helpful for early diagnosis, guiding therapeutic decision-making, and identifying patients at high risk for erosive disease.OBJECTIVE To assess the role of MRI of joints in patients with ICI-induced inflammatory arthritis. DESIGN, SETTING, AND PARTICIPANTSThis retrospective case series included patients enrolled at the National Institutes of Health Clinical Center in Bethesda, Maryland. Patients were evaluated by the rheumatology consultation service between December 27, 2016, and May 28, 2019. A retrospective health record review was performed to determine demographic characteristics, clinical characteristics of inflammatory arthritis and malignant tumors, and imaging findings. Inclusion criteria were patients who were enrolled on various institutional review board-approved protocols of ICIs, developed joint-related symptoms, and had MRI data for at least 1 joint. Data were analyzed from EXPOSURES Undergoing MRI of at least 1 joint. MAIN OUTCOMES AND MEASURESAll MRIs were reviewed for synovitis, tenosynovitis, bone marrow edema, and soft tissue conditions. RESULTS A total of 8 patients (mean [SD] age, 58.8 [5.2] years; 6 women and 2 men) between the ages of 50 and 65 years who were undergoing ICI therapy for a variety of malignant tumors were included in this study. Only 1 patient was receiving combined ICI therapy. The results of 13 separate MRI examinations were reviewed. The most commonly performed MRIs were of the hands and wrists (9 MRIs), followed by knee examinations (3 MRIs). Tenosynovitis and synovitis were frequently seen in the hands and wrists. Bone marrow edema and erosions were also found in 3 patients, suggesting early damage. In larger joints (ie, knees and ankles), joint effusions and synovial thickening were characteristic. Most patients (5 patients) were treated with corticosteroids and had good responses.In patients with high-risk features on MRI imaging (eg, bone marrow edema, erosions), diseasemodifying antirheumatic drug therapy was also discussed as a treatment option.CONCLUSIONS AND RELEVANCE These findings suggest that advanced imaging may help to distinguish ICI-induced inflammatory arthritis from other causes of joint pain, aid in identifying (continued)

Rheumatic Manifestations in Patients Treated with Immune Checkpoint Inhibitors

“…Our data deriving from imaging and histology place myo-fasciitis as a central pathophysiologic feature of ICI-induced musculoskeletal manifestations and could pinpoint a subgroup of patients with arthritis-like presentation, mostly involving, however, tendons and myo-fascia. In a subsequent study reporting MRI data in ICI-induced inflammatory arthritis [24], eight patients were retrospectively evaluated. Tenosynovitis and synovitis of hands and wrists was a common finding, while a few patients were also found to have osseous erosions indicating a worse prognosis.…”

Rheumatic Manifestations and Diseases From Immune Checkpoint Inhibitors in Cancer Immunotherapy

“…In MRI and musculoskeletal ultrasonography tests, imaging always shows tenosynovitis, Doppler-positive synovitis, erosive disease, and joint effusions ( 26 , 32 ). In a retrospective study of MRI in ICI-induced inflammatory arthritis ( 33 ), it is common to find tenosynovitis and synovitis in hands and wrists, while osseous erosions were found only in a few patients, which might indicate a worse prognosis. In other cases, joint pain and swelling also can result from tumor progression rather than ICIs ( 34 ).…”

Expert Perspective: Immune Checkpoint Inhibitors and Rheumatologic Complications

“…Ultrasound can demonstrate objective evidence of inflammatory arthritis, including synovitis detected by Doppler signal, te nosynovitis, and enthesophytes (30). Magnetic resonance imaging (MRI) may show synovitis, tenosynovitis, bone marrow edema, and erosions (31). In PMR, ultrasound may show subdeltoid and subacromial bursitis, trochanteric bursitis, or biceps tenosynovitis (32,33).…”