MR Imaging Manifestations of Rheumatoid Arthritis: An Educational Review

Transcription

1 MR Imaging Manifestations of Rheumatoid Arthritis: An Educational Review Poster No.: C-1598 Congress: ECR 2013 Type: Educational Exhibit Authors: R. J. Makanji, R. Kedar, S. Anderson, N. Prakash, N. Rao; Tampa, FL/US Keywords: Musculoskeletal bone, Musculoskeletal joint, Musculoskeletal soft tissue, MR, Education, Arthritides, Education and training, Inflammation DOI: /ecr2013/C-1598 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 30

2 Learning objectives 1. Briefly discuss the epidemiology, pathophysiology and clinical presentation of rheumatoid arthritis 2. Review the common and uncommon imaging manifestations of rheumatoid arthritis on MRI with radiographic correlation when appropriate 3. Briefly review differential diagnostic considerations with regards to the MRI findings in rheumatoid arthritis Background Epidemiology: - Prevalence of RA % in general population - In 2005, approximately 1.5 million US adults (0.6%) had RA - The most recent US data on incidence of RA is from the Rochester Epidemiology Project: From , 41 per 100,000 people were diagnosed with RA each year Increased incidence with age: 8.7 per 100,000 people among those aged compared with 54 per 100,000 among those aged # 85 years Incidence peaked among people aged years: 89 per 100,000 From 1995 to 2007 rates increased by 2.5% each year among women but there was a small decrease (0.5%) in men Pathophysiology - It is thought that RA is triggered by a combination of genetic and stochastic random events, with repeated activation of innate immunity leading to RA Page 2 of 30

3 - Genetic susceptibility to RA is most importantly linked to HLA major histocompatability genes although many other minor genes including cytokine promoters and T cell signaling genes also contribute - However, genes are not the only influence as studies have shown a concordance rate for identical twins of only 12-15% - Smoking is thought to represent one of the most important environmental stimuli contributing to RA, increasing risk by 20 to 40 fold - An important element is the induction of the peptidyl arginine deiminase (PAD) enzymes, which convert arginine to citrulline In RA it appears that increased citrullination leads to the production of anticitrullinated protein antibodies, contributing to the clinical manifestations of disease Clinical Presentation - Chronic inflammatory disease manifesting as damage of synovial-lined joints as well as extra-articular manifestations - Typically found in metacarpophalangeal, proximal metatarsophalangeal joints, as well as in the wrists and knee interphalangeal and - Articular and periarticular manifestations include joint swelling and tenderness to palpation, with morning stiffness - Extra-articular involvement includes: Rheumatoid nodules Pulmonary fibrosis Renal amyloidosis Vasculitis Other visceral involvement - The natural history of RA varies although three possible disease courses are noted: Page 3 of 30

4 Monocyclic: Have one episode which ends within 2-5 years of initial diagnosis and does not reoccur. This may result from early diagnosis and/or aggressive treatment Polycyclic: The level of disease activity fluctuates over the course of the condition Progressive: RA continues to increase in severity and is unremitting Radiographs are relatively insensitive in the detection of early osseous erosions Magnetic resonance imaging (MRI) has been shown to be useful in the clinical management of RA: Can detect preerosive synovitis Can identify early bone damage prior to radiographic manifestations Has been shown to predict future bone damage In this presentation we review various MRI manifestations of RA, specifically: Erosions Pannus and Synovitis Marrow Edema Rice Bodies Tenosynovitis Bursitis Effusions Imaging findings OR Procedure details Bone Erosions: - Due to proliferative synovium Page 4 of 30

5 - Definition on MRI: Sharply marginated bone lesion, juxtaarticular in location and with evidence of a cortical break seen on at least one plane - Early erosions will be seen at the bare areas of the joint, that is the intra-articular portion which is not covered by articular cartilage - While RA is a bilateral symmetric disease, erosions are less commonly bilateral compared with synovitis and tenosynovitis - Commonly involved bones include: nd rd Radial aspect of 2 Lateral aspect of 5 metatarsal bone Capitate, triquetrum, lunate bones and 3 metacarpal bones th - MRI Findings Loss of normal signal intensity on T1 weighted images Hyperintense signal on T2 weighted images Enhancement on post contrast imaging - Figures 1 through 10 demontrate characteristic erosions associated with RA Pannus & Synovitis: - Pannus is essentially a proliferative synovitis and is the earliest pathologic abnormality seen in RA - Typically bilateral - MRI Definition: An area within the synovial compartment demonstrating greater than average post-gadolinium enhancement with thickness of the synovium greater than normal - Figures 11 through 18 demontrate findings of pannus and synovitis Page 5 of 30

6 Marrow Edema: - Has been shown to precede the development of bone erosions - MRI Definition: Lesion within the trabecular bone with ill defined margins, near its insertion on the synovial membrane - Can occur alone or adjacent to bone erosions - Figure 19 demonstrates marrow edema in the setting of RA Rice Bodies: - Nonspecific response to chronic synovial inflammation - Initially described in tuberculous arthritis - Pathogenesis unclear although it may be related to microinfarction of the synovium with release of tissue into the joint or detachment of hypertrophied synovium - Figures 20 and 21 demonstrate rice bodies in the setting of RA Tenosynovitis: - Commonly seen in RA and usually bilateral - Any tendon can be involved although commonly seen in Flexor digitorum Extensor digitorum Extensor carpi ulnaris - Manifested by thickening of the synovium with marked enhancement on post-gadolinium imaging Page 6 of 30

7 - Figures 22 to 27 show a variety of different manifestations of tenosynovitis in the setting of RA Bursitis: - Common finding although many patients may be asymptomatic - In the feet it is typically seen between or beneath metatarsal heads, commonly in second or third intermetatarsal web spaces: May be difficult to differentiate from a Morton's neuroma - Shows enhancement on post-contrast imaging - Manifested by thickening of the synovium with marked enhancement on post-gadolinium imaging - Figures 28 and 29 demonstrate two different types of bursitis associated with RA Effusion: - Increased fluid within the synovial compartment of a joint - Commonly seen in conjunction with soft tissue edema and tenosynovitis - Can be distinguished from synovitis on MRI due to lack of enhancement on postgadolinium imaging - Figures 30 and 31 demonstrate two effusions associated with RA Differential Diagnosis: - Osteoarthritis (OA) Typically involves proximal and distal interphalangeal joints (PIP and DIP) Page 7 of 30

8 Characterized by osteophyte formation Typically asymmetric No erosions are seen - Erosive Osteoarthritis Central erosions are a hallmark resulting in "gull-wing" appearance, as opposed to marginal erosions in RA Typically occurs in an OA distribution with marginal osteophytes and erosions at the DIP and PIP joints - Psoriatic Arthritis Soft tissue edema of a digit ("sausage digit") Fluffy periostitis is seen Characterized by bone proliferation and erosions, whereas RA is a purely erosive disease Favors DIP joints although may involve others A Look to the Future: - MRI has been shown to demonstrate changes of RA earlier compared to radiographs - The impact of MR imaging in RA in the future will hopefully be related to its predictive benefits and ability to monitor and gauge treatment response and effectiveness The ability to measure synovial volume may help determine the efficacy of therapies designed to decrease the rate of structural damage Many rheumatologists believe that synovitis is the main abnormality in RA, and therefore measuring synovial volume may prove beneficial as a longterm clinical endpoint - Sonography is increasingly being utilized in the management of RA, specifically in evaluating cartilage damage, bone erosions and synovitis - Visualization of synovial microvascular blood flow as a sign of inflammation by ultrasound has become an important tool to monitor disease progression Page 8 of 30

9 - The development of biological therapies for the treatment of RA has introduced the exciting possibility of utilizing this technology in imaging - Several monoclonal antibodies and their fragments, including anti-tnf-alpha, anticd20, anti-cd3, anti-cd4 and anti-e-selectin antibody, have been radiolabelled mainly with (99m)Tc or (111)In - Scintigraphy with these radiolabelled antibodies may allow for: Better staging of the disease and diagnosis of the state of activity by early detection of inflamed joints that might be difficult to assess clinically The possibility to perform evidence-based biological therapy to identify whether an antibody will localize to the site of RA before using the same unlabelled antibody therapeutically This may have both clinical and economic implications as biological therapies can be associated with severe side-effects and are considerably expensive Images for this section: Fig. 1 Page 9 of 30

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28 Conclusion 1. Rheumatoid arthritis is typically thought of as an autoimmune disease presenting with erosions and synovitis/pannus formation of the hands and wrist 2. In this educational exhibit we demonstrated the not infrequent presence of pathology in other joints as well as numerous other (albeit less common) MR imaging manifestations of rheumatoid arthritis including tenosynovitis, bursitis and rice bodies 3. These findings are particularly well seen by MRI and should be looked for in a patient with a history of rheumatoid arthritis References 1. Abd El-Azeem M, Taha HA, El-Sherif AM Role of MRI in evaluation of hip joint involvement in juvenile idiopathic arthritis. The Egyptian Rheumatologist 2012; 34: Boutry N, Morel M, Flipo RM, et al. Early rheumatoid arthritis: a review of MRI and sonographic findings. AJR Am J Roentgenol 2007; 189: Center for Disease Control and Prevention. Rheumatoid Arthritis. arthritis/basics/rheumatoid.htm. Accessed December Conaghan PG, Bird P, McQueen F, et al. The OMERACT MRI inflammatory arthritis group: advances and future research priorities. J Rheumatol 2009; 36: Emery P. Magnetic resonance imaging: opportunities for rheumatoid arthritis disease assessment and monitoring long-term treatment outcomes. Arthritis Res 2002; 4:S6-S10 6. Grassi W, Davies A, Boumendil O. Recent Trends and Technology Advances in Rheumatoid Arthritis Clinical Ultrasonography and Power Doppler Imaging European Musculoskeletal Review 2011; 6: Grassi W, De Angelis R, Lamanna G, et al. The clinical features of rheumatoid arthritis. Eur J Radiol 1998; 27:S18-24 Page 28 of 30

29 8. Helmick CG, Felson DT, Lawrence RC, et al. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part I. Arthritis Rheum 2008; 58: Lundström E, Källberg H, Alfredsson L, et al. Gene-environment interaction between the DRB1 shared epitope and smoking in the risk of anti-citrullinated protein antibody-positive rheumatoid arthritis: all alleles are important. Arthritis Rheum 2009; 60: Makrygiannakis D, Hermansson M, Ulfgren AK, et al. Smoking increases peptidylarginine deiminase 2 enzyme expression in human lungs and increases citrullination in BAL cells. Ann Rheum Dis 2008; 67: Malviya G, Conti F, Chianelli M, et al. Molecular imaging of rheumatoid arthritis by radiolabelled monoclonal antibodies: new imaging strategies to guide molecular therapies. Eur J Nucl Med Mol Imaging : Myasoedova E, Crowson CS, Kremers HM, et al. Is the incidence of rheumatoid arthritis rising?: results from Olmsted County, Minnesota, Arthritis and rheumatism 2010; 62: Nagasawa H, Okada K, Senma S, et al. Tenosynovitis with rice body formation in a non-tuberculosis patient: a case report. Ups J Med Sci 2009; 114: Narváez JA, Narváez J, De Lama E, et al. MR imaging of early rheumatoid arthritis. Radiographics 2010; 30: Østergaard M, Peterfy C, Conaghan P, et al. OMERACT Rheumatoid Arthritis Magnetic Resonance Imaging Studies. Core set of MRI acquisitions, joint pathology definitions, and the OMERACT RA-MRI scoring system. J Rheumatol 2003; 30: PL Munk, LO Marchinkow, WC Torreggiani, et al. Rheumatoid Arthritis: Survey of Magnetic Resonance Imaging Features in the Musculoskeletal System. J HK Coll Radiol 2002;5: Silman AJ, Hochberg MC. Epidemiology of the Rheumatic Diseases. 2nd ed. New York, NY: Oxford University Press; 2001 Page 29 of 30

30 18. Tehranzadeh J, Ashikyan O, Dascalos J, et al. MRI of large intraosseous lesions in patients with inflammatory arthritis. AJR Am J Roentgenol 2004; 183: Weerakkody Y, Dixon A, et al. Accessed December 30, Wissman RD. Rheumatoid tenosynovitis with rice-body formation. Appl Radiol 2007; 36:44-45 Personal Information Rikesh J. Makanji, M.D. Musculoskeletal Radiology Fellow University of South Florida Morsani College of Medicine Contact: Rmakanji@health.usf.edu Page 30 of 30