Practical Aspects of Ultrasonography Assessment in Rheumatoid Arthritis

Practical Aspects of Ultrasonography Assessment in Rheumatoid Arthritis Dr. Andrew K. Brown Senior Lecturer & Consultant Rheumatologist

Content Practical RA Assessment Advantages of ultrasonography Potential roles for ultrasound imaging in RA Fluid vs. hypertrophy Optimise assessment Scoring (GS, PD) Best joints for synovitis Definition Quantification Pitfalls Best joints for erosions

Advantages of ultrasonography Patient friendly Safe, no radiation Multiple joints Multiple time points Bone & soft tissue Performed in clinic Dynamic, real-time Comparison with contralateral side Less expensive

Potential roles for imaging in RA Early / sub-clinical Diagnosis Extent of disease Disease activity Outcome Prognosis Established Disease activity Monitoring Therapy decisions Remission Outcome

Value of US in clinical practice 1. Diagnostic uncertainty Joint vs. bursal vs. soft tissue fluid collection Breidahl 1996; De Maeseneer 1998; Jacobson 1998; Koski 1992; Koski 1990; Nazarian 1998 2. Clinical impact 53% change in site specific diagnosis 56% change in management Karim 2001

3. Reclassification of oligoarthritis Early untreated oligoarthritis (n=80) 644 symptomatic joints 826 asymptomatic joints 185 clinical synovitis 459 no clinical synovitis 147 (79%) US synovitis 150 (33%) US synovitis 107 (13%) US synovitis 29/80 (36%) reclassified as polyarthritis based on US Wakefield. Ann Rheum Dis, 2004

4. US-guided aspiration & injection Localisation of pathology Accurate needle placement Some data reporting improved outcome Balint 2002; Brophy 1995; Cicak 1992; Cunnane 1996; Eustace 1997; Farin 1995; Farin 1996; Fessell 2000; Grassi 2001; Grassi 2002; Kamel 2000; Kane 1998; Kane 2001; Karim 2004; Komppa 1985; Koski 2000; McGonagle 1997; McGonagle 1999; Qvistgaard 2001; Raza 2003

5. RA Clinical Remission Brown A&R 2006,2008 N=107 RA clinical remission vs. controls Irrespective of remission criteria, most had synovitis Asymptomatic RA patients 96% MRI synovitis; 46% BME 73% US SH; 43% PD Most RA patient in clinical remission have synovitis 19% damage progression at one year Baseline imaging (PDUS) predicts subsequent damage progression

Synovial hypertrophy vs. fluid

Synovial fluid OMERACT 2005: Abnormal hypoechoic or anechoic (relative to subdermal fat, but sometimes may be isoechoic or hyperechoic) intraarticular material that is displaceable and compressible but does not exhibit Doppler signal.

Synovial hypertrophy OMERACT 2005: Abnormal hypoechoic (relative to subdermal fat, but sometimes may be isoechoic or hyperechoic) intra-articular material that is non-displaceable and poorly compressible and which may exhibit Doppler signal. SH Metacarpal head Proximal phalanx

Synovial hypertrophy vs. fluid Optimise image Two planes Anisotropy Echogenicity Compression Displaceable Dynamic assessment Doppler

GSSH practical tips Circumferential assessment Multiple planes Compare sides Don t press too hard! Dynamic assessment Lots of gel Beware artefact, anisotropy

Doppler practical tips Always use Doppler Colour or power Doppler Beware artefact, flash Freq 3.5 12.5; PRF 750-1000; low WF, gain If NO Doppler Check settings Slow down, steady hand Reduce compression - blanching stand off gel pad, lots of gel!! Use multiple planes? less active / chronic disease

Scoring in RA Joint by joint Synovitis Grey scale synovial hypertrophy Semi-quantitative 0 3 scale Power Doppler vascularity Semi-quantitative 0 3 scale Quantitative pixel count Erosions

Synovial Hypertrophy Grey scale Semi-quantitative scoring Grade 0: normal Grade 1: SH within non-descended joint capsule Grade 2: SH extending above the joint ( hollow ) Grade 3: SH extending above the joint ( dome ) Capsule Capsule Bones & joint

Normal Grade 1 SH MCP longitudinal US - MCP3 Normal dorsal scan Grade 2 SH Grade 3 SH

Power Doppler Scoring Semi-quantitative scoring Grade 0: no PD signal Grade 1: single vessel PD signal Grade 2: increased flow <50% synovium Grade 3: increased flow >50% synovium Pixel count software = SQS

Normal Grade 1 PD MCP longitudinal US - MCP3 Normal dorsal scan Grade 2 PD Grade 3 PD

Synovitis - Which joints to scan? Early untreated oligoarthritis (n=80) 644 symptomatic joints 826 asymptomatic joints 185 clinical synovitis 459 no clinical synovitis 147 (79%) US synovitis 150 (33%) US synovitis 107 (13%) US synovitis 29/80 (36%) reclassified as polyarthritis based on US Wakefield. Ann Rheum Dis, 2004

Synovitis - Which joints to scan? Feasibility?? Naredo et al, Arthritis Rheum 2008 GSSH + PDUS 44 joint count (124 sites); 0m & 6m; n=160; ERA biologic Rx 12 joints (24 sites): 100% patients with GSSH identified 91% PD signal

Synovitis - Which joints to scan? Naredo et al - 12 joints (24 sites): 2nd MCP Dorsal side Palmar side 3rd MCP Wrist Dorsal side Palmar side Dorsal carpal recess Elbow Knee Ankle Anterior recess Posterior recess Suprapatellar recess Lateral parapatellar recess Anterior tibiotalar recess Medial tendon sheaths Lateral tendon sheaths

Erosions

OMERACT 2005: An intra-articular discontinuity of the bone surface which is visible in 2 perpendicular planes Metacarpal head ER Proximal phalanx ER

US detects more erosions in more patients At least a dozen papers Increase sensitivity by 2-7x erosions per patient vs. radiographs Lower sensitivities relate to multiple joint assessments wrist associated degenerative change advanced disease

Bone erosion quantification Present / absent Number Volume / size Measurement of breadth and depth Semi-quantative (0, 1, 2, 3) Small, medium, large Reproducibility of longitudinal evaluation? Role for 3D or 4D US assessment?

Bone erosion pitfalls Can occur in normals Ask about trauma Common at the humeral head Cortical break visible in two planes Anatomy of metacarpal neck Beware degenerative changes especially osteophytes Think about clinical patterns of OA is it really an erosion in MTP1, PIPJ, carpus??

Synovial hypertrophy Erosion Erosion Metacarpal JS Proximal phalanx How would you interpret this image?

Bone erosion early vs. late RA Early disease Useful Diagnosis, prognosis Validity: US = MRI = CT = longitudinal XR Late disease Can be challenging Large, multiple, erosions Degenerative change

Bone erosion where? Ulnar styloid Second MCPJ (radial aspect) Third MCPJ Fifth MTPJ (lateral aspect)

Summary Practical RA Assessment Potential roles for imaging in RA Advantages of ultrasonography Fluid vs. hypertrophy Optimise assessment Scoring (GS, PD) Best joints for synovitis Definition Quantification Pitfalls Best joints for erosions

Questions????