In Practice
By Professor Johan L. Bloem, MD, Chairman of the Radiology Department, Musculoskeletal Imaging Project Leader, and Wouter Stomp, MD, Researcher, Radiology Department, Leiden University Medical Center
Rheumatoid arthritis (RA) is a chronic
RA is a systemic disease affecting
treated in a very early stage in order to
inflammatory and autoimmune disorder
multiple organ systems. It is two to
prevent further damage—rather than
that most often affects the small joints
three times more common in women
just treating symptoms. The key factor
in hands and feet. RA primarily afflicts
than in men and generally occurs
driving this move is the adoption of
the synovial lining of the joints, causing
between the ages of 40 and 60.
Tumor Necrosis Factor-alpha blockers,
a painful swelling that can eventually result in bone erosions and joint deformity. In addition to causing joint problems,
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Treatment options have expanded greatly in the past few decades and this disease is increasingly being
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which have only become widely available in the last decade. One of the major problems with early treatment is
AUTUMN 2011
In Practice
The Impact of a Dedicated MSK MR System in the Diagnosis and Prognosis of Rheumatoid Arthritis
Professor Johan L. Bloem, MD is a Professor, Director of the Residency Program, and Chairman of the Department of Radiology at Leiden University Medical Center.
identifying RA patients among the
we asked patients from the early
unable to maintain an awkward position
much larger group of early arthritis
arthritis clinic to help determine the
required with imaging on a full-body
patients. MR is a very sensitive imaging
role of MR for non-specific early
system. With the dedicated extremity
technique that may play an important
arthritis. Over a period of two years,
MR scanner, they can comfortably sit
role in this identification process.
patients with a possible diagnosis of
in a chair next to the scanner.
For many years, radiographs have been the standard imaging technique to follow RA progression. However, radiographs only show structural bone
RA will be examined with MR at several time intervals. Currently, the first patients are receiving their one-year follow-up examination.
We are acquiring several images of the wrist and metacarpophalyngeal joints: coronal T1 and T2-weighted images, and coronal and axial fat-suppressed
damage in the form of erosions, which
As one of the first institutions in Europe
T1-weighted images. The images are
are a relatively late event in the disease.
to implement a dedicated 1.5T extremity
then evaluated for the presence of
MR, in addition to erosions, also directly
MR from GE Healthcare, much effort has
bone erosions, bone marrow edema,
shows synovitis (inflammation of the
gone into optimizing the sequences
synovitis, and tenosynovitis. Evaluation
synovial membrane), tenosynovitis
and protocols for optimal image quality
is standardized by using the OMERACT
(inflammation of the fluid-filled cover
and imaging times. The images we
RAMRIS (Outcome Measures in
called the synovium that surrounds
obtain from the dedicated scanner
Rheumatology Clinical Trials/
a tendon), and subchondral changes.
have a very high quality, often surpassing
Rheumatoid Arthritis Magnetic
These inflammatory features are the
that of full-body 1.5T systems for
Resonance Imaging Score), which
main process in RA. As a further
MSK applications.
was developed for MR in RA.
One critical issue is the availability of scan
The clinical cases presented on the
capacity on our whole-body magnets.
following pages demonstrate the
By using the dedicated extremity MR,
clinical utility and excellent image
patients can be scanned in the same
quality of the high-field, dedicated
week, and often on the same day as
extremity MR. We prefer to utilize this
their initial visit.
scanner for our patient evaluations
advantage, MR has been shown to be more sensitive to erosions than conventional radiographs.1,2,3,4 The absence of erosions on MR has a high (80%) negative predictive value for developing RA.5,6,7 At the outpatient clinic of the rheumatology department at Leiden University Medical Center (Leiden, Netherlands),
Patient comfort is another important factor. Arthritis patients present with
based on scanner availability, patient comfort and high-quality imaging.
painful, swollen joints and are sometimes
Wouter Stomp, MD is a researcher in the radiology department at Leiden University Medical Center.
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Case 1 Early stage of pathology: Patient suffers from painful feet, right shoulder, and proximal interphalangeal joints (PIP) 4; treated with Arthrotec, Celebrex. Physical exam demonstrated swelling and pain PIP 4. Differential diagnosis of RA, reactive arthritis, and undifferentiated arthritis. Prior X-ray demonstrates minimal erosive changes of the first carpometacarpal joint and scaphotrapezial joint (Figure 1). MR findings Figure 1. X-ray demonstrates minimal erosive changes of the first carpometacarpal joint and scaphotrapezial joint.
Coronal T1-weighted (Figure 2A), and coronal (Figure 2B) and axial (Figure 2F) T1-weighted, fat-suppressed, MR
Figure 2. MR findings for early-stage RA.
images of the wrist show multiple erosions in the carpal bones, including a large erosion in the capitate bone. MR of the metacarpal phalangeal joints (MCP) is unremarkable (Figure 2C, Figure 2D). Coronal T2-weighted MR (Figure 2E)
Figure 2A. Wrist coronal T1
Figure 2B. Wrist coronal T1 fat-suppressed
Figure 2C. MCP coronal T1
of the forefoot shows bone marrow edema proximal and distal of the first metatarsal phalangeal joint (MTP).
Figure 2D. MCP coronal T1 fat-suppressed
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Figure 2E. MTP coronal T2-weighted MR
Figure 2F. Wrist axial T1 fat-suppressed
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In Practice
Patient history
Figure 3. MR findings for synovitis and bone marrow edema.
Case 2 Patient history Synovitis and bone marrow edema; seronegative polyarthritis; possible RA; differential diagnosis of gout or polymyalgia rheumatic. Patient treated with Arcoxia, started on Methotrexate. Physical exam shows pain and swelling of the wrist, MCP 1,2,3 and PIP 3,5. X-ray demonstrates normal hands Figure 3B. Wrist axial T1 fat-suppressed
without erosions. MR findings Coronal (Figure 3A) and axial (Figure 3B) fat-suppressed, T1-weighted images show synovitis of the radio-ulnar,
Figure 3A. Wrist coronal T1 fat-suppressed
radiocarpal, intercarpal, and carpometacarpal joints with tenosynovitis of the flexor tendons. Several small erosions are observed in the carpal bones. The MCP joints (Figure 3E, Figure 3F) appear normal. Coronal T1 (Figure 3C) and T2-weighted (Figure 3D) MR images of the forefoot show an erosion in the third proximal
Figure 3C. Foot coronal T1
Figure 3D. Foot coronal T2 fat-suppressed
Figure 3E. MCP coronal T2-weighted MR
Figure 3F. MCP coronal T1 fat-suppressed
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phalanx with no other abnormalities.
AUTUMN 2011
Case 3
Figure 4. MR findings for late-stage RA.
Patient history Late stage RA, seropositive erosive RA. Patient complained of symptoms for destruction of the MCP joints. Patient treated with Methotrexate since Figure 4A.
September 2010; physical exam
Figure 4B.
shows swelling of MCP 2. MR findings Coronal (Figure 4E–H) and axial (Figures 4A–D, Figure 4F) T1-weighted, fat-suppressed MR shows extensive synovitis with joint destruction in the Figure 4C.
wrist, including the first, second, third,
Figure 4D.
and fifth MCP, and fifth PIP joint. Figure 4. MR findings for late-stage RA.
Figure 4E.
Figure 4F.
Figure 4G.
References:
Figure 4H.
4. Haugen I K, Boyesen P, Slatkowsky-Christensen B, et al. Comparison of features by MRI and radiographs of the interphalangeal finger joints in patients with hand osteoarthritis. Ann Rheum Dis doi:10.1136/annrheumdis-2011-200028.
1. Chen T S, Cruess III JV, Ali M, Troum O M. Magnetic Resonance Imaging Is More Sensitive Than Radiographs in Detecting Change in Size of Erosions in Rheumatoid Arthritis. HYPERLINK “http:// www.ncbi.nlm.nih.gov/pubmed/16881098” \l “#” \o “The Journal of rheumatology.” J Rheumatol. 2006 Oct;33(10):1957-67. Epub 2006 Aug 1.
5. McQueen F M, Benton M, Crabbe J, et al. What is the fate of erosions in early rheumatoid arthritis? Tracking individual lesions using x rays and magnetic resonance imaging over the first two years of disease. Ann Rheum Dis 2001;60:859-868.
2. Duer-Jensen A, Vestergaard A, Dohn U M, et al. Detection of rheumatoid arthritis bone erosions by two different dedicated extremity MRI units and conventional radiography. Ann Rheum Dis 2008;67:998-1003 doi:10.1136/ard.2007.076026
6. McQueen F M, Dalbeth N. Predicting joint damage in rheumatoid arthritis using MRI scanning. Arthritis Research & Therapy 2009, 11:124 (doi:10.1186/ar2778) 7. Ostergaard M, Ejbjerb B, Szkudlarek M. Imaging in early rheumatoid arthritis: roles of magnetic resonance imaging, ultrasonography, conventional radiography and computed tomography. Best Practice & Research Clinical Rheumatology 2005.19(1):91-116.
3. Ejbjerb B J, Vestergaard A, Jacobsen S, Thomsen H, Ostergaard M. Conventional Radiography Requires a MRI-estimated Bone Volume Loss of 20% to 30% to Allow Certain Detection of Bone Erosions in Rheumatoid Arthritis Metacarpophalangeal Joints. Arthritis Research & Therapy. 2006;8(3):R59 © 2006 BioMed Central, Ltd. Posted: 04/07/2006
Johan (Hans) L. Bloem, MD, is a Professor, Director of the Residency Program, and Chairman of the Department of Radiology at Leiden University Medical Center. He is an active member in various professional organizations including ESR, RSNA, ISS, ESSR, ISMRM, ESMRMB, and Erasmus (EMRI). Professor Bloem’s research focus is on musculoskeletal radiology in the areas of oncology and degenerative and inflammatory joint disease. He has received numerous grants, regularly lectures at international meetings, and published 11 books, nine educational audio-visual programs, and 147 scientific articles in the published peer-reviewed literature. Wouter Stomp, MD, is a researcher in the radiology department at Leiden University Medical Center, pursuing his PhD on the use of MR for the early detection of rheumatoid arthritis. Dr. Stomp earned his medical degree at Rijksuniversiteit Groningen and completed an internship and extracurricular internship in radiology at Deventer Hospital. He also completed a pediatric surgery internship at Wilhelmina Children’s Hospital. The Leiden University Medical Center (LUMC) is one of eight university medical centers in the Netherlands and employs 7,000 people. Patient care is focused on highly specialized and top-level clinical care, including organ transplants, cardiovascular interventions, and all types of bone marrow transplants. The research conducted in the LUMC is both fundamental and patient- and care-oriented. A considerable portion of the research focuses on the translation from fundamental research to use in patient care. The Department of Radiology has a longstanding tradition in scientific research at the interface of technological innovations and healthcare. The aim is to develop imaging technologies that can be used in patients for diagnostic purposes or as instruments to increase the understanding of diseases.
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In Practice
15 years; X-ray demonstrates extensive