Ultrasound pathologies in rheumatoid arthritis
Esperanza Naredo Madrid, Spain
Disclosures Speaker fees from Abbvie, Roche, BMS, Pfizer, UCB, Novartis, Lilly, Janssen
AGENDA
Definition and detection of US synovitis, tenosynovitis and paratenonitis Definition and detection of US bone erosions and tendon damage
+
RA
Synovitis Tenosynovitis Paratenonitis
Diagnostic hallmark Disease Activity hallmark Disease severity predictor
Bone erosions Tendon damage Ligament damage Cartilage damage
Diagnostic hallmark Disease Severity hallmark
Synovitis
Synovitis components
Synovial hypertrophy
Synovial fluid
Synovial vascularization
B-mode (GS)
B-mode (GS)
Doppler
OMERACT definitions Synovial fluid (effusion): abnormal hypoechoic or anechoic intra-articular material that is displaceable and compressible but does not exhibit Doppler signal Synovial hypertrophy: abnormal hypoechoic intraarticular tissue that is non displaceable and poorly compressible which may exhibit Doppler signal
GS Synovitis = SH + effusion
GS Synovitis = SH + effusion
Sinovitis EG: HS + derrame
Synovitis, GS
GS & Doppler synovitis
Synovitis, Doppler
Synovitis, GS
Synovitis, Doppler
Synovitis, GS
Synovitis, GS
Synovitis, Doppler
Synovitis, Doppler
What is the added value of US over clinical assessment of synovitis? US more sensitive than clinical assessment
Kane D. J Rheumatol 2003. Knee Karim Z. Arthritis Rheum 2004. Knee Wakefield RJ. Ann Rheum Dis 2004. Multiple joints Scheel AK. Ann Rheum Dis 2005. Hand joints Naredo E. Ann Rheum Dis 2005. Multiple joints Salaffi F. Rheumatology 2009. Multiple joints Filer A. Ann Rheum Dis 2010. Multiple joints
Joint level
B-mode
Patient level
Doppler
Grade 0
Grade 2
Grade 1
Grade 3
OMERACT; semiquantitative score 0-3
Grade 0
Grade 1
Grade 2
Grade 3
OMERACT; semiquantitative score 0-3
Hau M, Qvistgaard E, Terslev L, Taylor PC, Albrecht K, Carotti M
J Rheumatol 2011
OMERACT 10, May 2010
Comprehensive
Validation
Reduced
Results Reduced joint count good validity issues; 12-joint count (Naredo, et al. Arthritis Rheum 2008) 7-joint count (Backhaus M, et al. Arthritis Rheuma 2009) 6-joint count (Perricone C, et al. Rheumatology 2011; Iagnocco A, et al. Rheumatology 2015) • Responsiveness increased if bilateral evaluation
12 joints 6 joints
7 joints
• Validated reduced assessments; • 12 joints (bilateral elbow, wrist, MCP2, MCP3, knee, ankle) • 7 joints (unilateral wrist, MCP2, MCP3, PIP2, PIP3, MTP2, MTP5) • 6 joints (bilateral wrist, MCP2, knee)
• 14 joints (bilateral wrist, MCP2, MCP3, PIP2, PIP3, MTP2, MTP5) • 18 joints (bilateral shoulder, elbow, wrist, MCP1, MCP4, PIP2, knee, MTP3, MTP5) (D´Agostino MA, et al. Ann Rheum Dis 2015) • 7/14 joints & 2/4 tendons (elbow, wrist, MCP1, MCP2. PIP3, MTP1, MTP2, ECU, TPT) (Aga AB, et al. Ann Rheum Dis 2015) • 9/18 joints & 2/4 tendons (elbow, wrist, MCP1, MCP2. MCP5, PIP3, MTP1, MTP2, MTP5, ECU, TPT) (Aga AB, et al. Ann Rheum Dis 2015)
Tenosynovitis
OMERACT definitions
Tenosynovitis on B-mode: abnormal anechoic and/or hypoechoic (relative to tendon fibers) tendon sheath widening which can be related both to the presence of tenosynovial abnormal fluid and/or hypertrophy Tenosynovitis on Doppler mode: presence of peri-tendinous Doppler signal within the synovial sheath, seen in two perpendicular planes, excluding normal nutrient vessels in mesotenon or vinculae, only if the tendon shows peritendinous synovial sheath widening on B-mode
Where? Peripheral joints (hand, foot) Doppler more sensitive in supeficial joints
Peripheral joints (hand, foot) PD more sensitive in supeficial joints
Long
Grey-scale synovitis: synovial hypertrophy + effusion
Wrist, 6th extensor compart (ECU)
Trans
Tenosynovitis, GS
trans, 2nd ext comp wrist, long
Tenosynovitis, GS
trans, peroneal, long
Tenosynovitis, Doppler
trans, 2nd ext comp wrist, long
Tenosynovitis, GS, dynamic
Long Grey-scale synovitis: synovial hypertrophy + effusion
Wrist, flexor tendons, long
Joint level
B-mode
Patient level
Doppler
Score 0
Score 2
Score 1
Score 3
OMERACT; semiquantitative score 0-3
Score 0
Score 1
Score 2
Score 3
OMERACT; semiquantitative score 0-3
Paratenonitis
US definition
Abnormal hypoechoic halo (transverse) or line (longitudinal) surrounding a tendon without synovial sheath (and contour irregularities)
Paratenonitis, GS
Long Finger extensor tendon, long
Paratenonitis, Doppler
Long Finger extensor tendon, long
Peritenon inflammation (paratenonitis finger extensor tendons) highly characteristic of PsA (vs RA) Gutierrez M, et al. Ann Rheum Dis 2011 Lin Z, et al. Am J Med Sci 2015 Zabotti A, et al. Clin Exp Rheumatol 2016
Bone erosions
OMERACT definitions
Bone erosion: an intraarticular discontinuity of the bone surface that is visible in 2 perpendicular planes
Where? Accessible joints 2nd and 5th MCP, PIPs, 5th MTP Dorsal, palmar, radial/ulnar, lateral/medial
Long Grey-scale synovitis: synovial hypertrophy + effusion
MTP, dorsal
Trans
Where? Accessible joints Ulnar styloid process
Trans
What is the added value of US over radiographic detection of bone erosions?
US more sensitive than XR
• • • • • • • •
Wakefield RJ. Arthritis Rheum 2000. MCP Weidekamm C. Arthritis Rheum 2003. Wrist, MCP, PIP Szkudlarek M. Arthritis Rheum 2004. MTP Scheel AK. Arthritis Rheum 2005. MCP, PIP Szkudlarek M. Arthritis Res Ther 2006. MCP, PIP Funck-Brentano T. Rheumatology 2009. MCP, MTP Filer A. Ann Rheum Dis 2010. MCP, MTP Døhn UM. Ann Rheum Dis 2010. MCP (CT)
Size: Wakefield RJ. Arthritis Rheum 2000. Small erosion < 2 mm, moderate 2-4 mm, large > 4 mm
Kane D, 2004. Filippucci E. Rheumatology 2004 and 2010. Very small < 1 mm, small 1-2 mm, moderate 2-4 mm, large > 4 mm
Szkudlarek M. Arthritis Rheum 2003
MCP, PIP, MTP, semiquanttative score 0-3 0= regular bone surface 1= irregularity of the bone surface seen in two planes 2= defect in the surface of the bone seen in two planes 3= extensive bone defect
Tendon damage
OMERACT definitions
Tendon damage: internal and/or peripheral focal tendon defect (ie, absence of fibres) in the region enclosed by tendon sheath, seen in two perpendicular planes
Tendon damage
TPT, trans and long
Tendon damage
Finger flexor tendon, trans
OMERACT: semiquantitative score 0-2. Bruyn G, et al. ARD 2013
CONCLUSION US is an accurate and valuable tool for assessing inflammation and damage in IA
+
