Anne Duer-Jensen

The OMERACT Psoriatic Arthritis Magnetic Resonance Imaging Scoring System (PsAMRIS): Definitions of Key Pathologies, Suggested MRI Sequences, and Preliminary Scoring System for PsA Hands

This article describes a preliminary OMERACT psoriatic arthritis magnetic resonance image scoring system (PsAMRIS) for evaluation of inflammatory and destructive changes in PsA hands, which was developed by the international OMERACT MRI in inflammatory arthritis group. MRI definitions of important pathologies in peripheral PsA and suggestions concerning appropriate MRI sequences for use in PsA hands are also provided.

Bone edema on magnetic resonance imaging is an independent predictor of rheumatoid arthritis development in patients with early undifferentiated arthritis

OBJECTIVE To study magnetic resonance imaging (MRI) as a tool for early diagnosis of rheumatoid arthritis (RA) in patients with early undifferentiated arthritis (UA). METHODS Patients (n = 116) without a specific rheumatologic diagnosis, but with ≥2 tender joints and/or ≥2 swollen joints among the metacarpophalangeal, proximal interphalangeal, wrist, or metatarsophalangeal (MTP) joints for >6 weeks but <24 months, underwent clinical, biochemical, conventional radiographic, and MRI examinations and were followed up for >12 months for the final diagnosis of RA or non-RA. Based on univariate analyses, clinical, biochemical, and imaging parameters were selected for inclusion as explanatory variables in multiple logistic regression analysis, with development of RA as the dependent variable. A prediction model was developed, and its performance was tested and compared with that of a previous model developed by van der Helm-van Mil et al (the vdHvM model). RESULTS Of the 116 patients with early UA, 27 (23.3%) developed RA. When the prediction model was applied, which included as explanatory variables presence of hand arthritis, positivity for rheumatoid factor (RF), morning stiffness lasting >1 hour, and the Outcome Measures in Rheumatology Clinical Trials MRI summary score for bone edema in the MTP and wrist joints, the outcome of RA or non-RA was correctly identified in 82% of the patients (sensitivity 81%, specificity 82%). Another cutoff value for the prediction index in the model would allow a higher specificity (98%) and higher accuracy (83%), but lower sensitivity (36%). With the vdHvM model, RA/non-RA was predicted in 60.2% of the population. CONCLUSION MRI evidence of bone edema in the MTP and wrist joints is an independent predictor of future RA in patients with early UA. A prediction model that includes the variables clinical hand arthritis, morning stiffness, positivity for RF, and bone edema on MRI in the MTP and wrist joints correctly identified the development or lack of development of RA in 82% of patients.

Detection of rheumatoid arthritis bone erosions by two different dedicated extremity MRI units and conventional radiography

Objectives: To compare the ability of two different dedicated extremity MRI (E-MRI) units and conventional radiography (CR) for identifying bone erosions in rheumatoid arthritis (RA) metacarpophalangeal (MCP) and wrist joints. Methods: CR and two MRI examinations (using 0.2 T Esaote Artoscan and 0.2 T portable MagneVu MV1000 units) of 418 bones in the dominant wrist and second to fifth MCP joints of 15 patients with RA and 4 healthy controls were performed and evaluated blindly for bones being visible and for erosions. Results: In MCP joints, MagneVu visualised 18.5% of bones entirely and 71.1% were 67–99% visualised. In wrists, MagneVu visualised 1.5% of bones entirely, 39.8% were 67–99% visualised and 19% were not visualised at all. Artoscan and CR visualised all bones entirely. Artoscan, MagneVu and CR found 22, 19 and 15 bones with erosions in MCP joints and 66, 40 and 13 bones with erosions in wrist joints, respectively. With the previously validated Artoscan unit as standard reference, MagneVu and CR had sensitivities of 0.82 and 0.55, respectively, in MCP joint bones and 0.41 and 0.14 in wrist bones. Specificities of CR and MagneVu were comparable (0.82–0.99). The MagneVu unit was particularly more sensitive than CR for metacarpal heads and carpal bones. MagneVu MRI and CR detected 100% and 89%, respectively, of large erosions (Outcome Measures in Rheumatoid Arthritis Clinical Trials–Rheumatoid Arthritis MRI Scoring System (OMERACT-RAMRIS) score >1 on Artoscan) in MCP joints and 69% and 15.8% of large erosions in wrists. Conclusions: Both E-MRI units detected more erosions than CR, in particular due to a higher sensitivity in metacarpal heads and carpal bones. The MagneVu unit detected fewer erosions than the Artoscan unit due to a lower average image quality and a smaller proportion of bones being visualised.

Testing an OMERACT MRI Scoring System for Peripheral Psoriatic Arthritis in Cross-sectional and Longitudinal Settings

Objective. Magnetic resonance imaging (MRI) is increasingly used to measure articular inflammation and damage in patients with psoriatic arthritis (PsA). We evaluated the reliability of a new OMERACT PsA MRI scoring system, PsAMRIS, in PsA fingers. Methods. In 2 separate studies, MRI scans were obtained from patients with clinical evidence of synovitis or dactylitis of the fingers. For the first cross-sectional study, images were obtained at one timepoint. For the second longitudinal study, images were obtained at 2 timepoints, 6 weeks apart. Scans were scored using PsAMRIS in an international multireader setting, for synovitis, tenosynovitis, periarticular inflammation, bone edema, bone erosions, and bone proliferation. Results. Global status scores from both datasets revealed moderate to high reliability for scoring most features, although reliability was poor for periarticular inflammation in the cross-sectional study. Change scores that reflected inflammatory activity also exhibited moderate to good reliability in the longitudinal exercise, despite there being very little absolute change in MRI synovitis or tenosynovitis observed in this dataset. At the distal interphalangeal joints, reliability for change scores was acceptable only for synovitis and tenosynovitis. Conclusion. Further development and testing of the PsAMRIS is planned to improve its performance as a clinical and research tool to identify and measure pathology in peripheral joint PsA.

Does low-field dedicated extremity MRI (E-MRI) reliably detect bone erosions in rheumatoid arthritis? A comparison of two different E-MRI units and conventional radiography with high-resolution CT scanning

Objectives: To compare the ability of two different E-MRI units and conventional radiography (CR) to identify bone erosions in rheumatoid arthritis (RA) metacarpophalangeal (MCP) and wrist joints with CT scanning as the standard reference method. Methods: 20 patients with RA and 5 controls underwent CR, CT and two E-MRI examinations (Esaote Biomedica Artoscan and MagneVu MV1000) of one hand during a 2-week period. In all modalities, each bone of the wrist and MCP joints was blindly evaluated for erosions. MagneVu images were also assessed for the proportion of each bone being visualised. Results: 550 bones were examined. CT, Artoscan, MagneVu and CR detected 188, 116, 55 and 45 bones with erosions, respectively. The majority were located in the carpal bones. The sensitivity of the Artoscan for detecting erosions was higher than that of the MagneVu and CR (MCP joints: 0.68, 0.54 and 0.57, respectively; wrists: 0.50, 0.23 and 0.29). Corresponding specificities for detecting erosions were 0.94, 0.93 and 0.99, respectively, in the MCP joints and 0.92, 0.98 and 0.98 in the wrist. The MagneVu allowed visualisation of 1.5 cm of the ventral-dorsal diameter of the bone. In the wrist, 31.6% of bones were visualised entirely and 37.9% of bones were 67–99% visualised. In MCP joints, 84.2% of bones were visualised entirely and 15.8% of bones were 67–99% visualised. Conclusion: With CT as the reference method for detecting erosions in RA hands, the Artoscan showed higher sensitivity than the MagneVu and CR. All imaging modalities had high specificities. The better performance of the Artoscan should be considered when selecting an imaging method in RA.

Whole-body MRI assessment of disease activity and structural damage in rheumatoid arthritis: first step towards an MRI joint count

OBJECTIVE The aim of this study was to investigate the ability of whole-body MRI (WBMRI) to visualize inflammation [synovitis, bone marrow oedema (BME) and enthesitis] and structural damage in patients with RA. METHODS The 3T WBMR images were acquired in a head-to-toe scan in 20 patients with RA and at least one swollen or tender joint. Short Tau Inversion Recovery and pre- and post-contrast T1-weighted images were evaluated for readability and the presence/absence of inflammation (synovitis, BME and enthesitis) and structural damage (erosions and fat infiltrations) in 76 peripheral joints, 30 entheseal sites and in the spine. RESULTS The readability was >70% for all individual joints, except for the most peripheral joints of the hands and feet. Synovitis was most frequent in the wrist, first tarsometatarsal, first CMC joints and glenohumeral joints (67-61%); BME in the wrist, CMC, acromioclavicular and glenohumeral joints (45-35%) and erosions in the wrist, MTP and CMC joints (19-16%). Enthesitis at ≥ 1 site was registered in 16 patients. BME was frequently seen in the cervical (20%) but not the thoracic and lumbar spine, while fat infiltrations and erosions were rare. The intrareader agreement was high (85-100%) for all pathologies. The agreement between WBMRI and clinical findings was low. CONCLUSION Peripheral and axial inflammation and structural damage at joints and entheses was frequently identified by WBMRI, and more frequently than by clinical examination. WBMRI is a promising tool for evaluation of the total inflammatory load of inflammation (an MRI joint count) and structural damage in RA patients.

Update on research and future directions of the OMERACT MRI inflammatory arthritis group.

The OMERACT Magnetic Resonance Imaging (MRI) Task Force has developed and evolved the psoriatic arthritis MRI score (PsAMRIS) over the last few years, and at OMERACT 10, presented longitudinal evaluation by multiple readers, using PsA datasets obtained from extremity MRI magnets. Further evaluation of this score will require more PsA imaging datasets. As well, due to improved image resolution since the development of the original rheumatoid arthritis MRI scoring system (RAMRIS), the Task Force has worked on semiquantitative assessment of joint space narrowing, and developed a reliable method as a potential RAMRIS addendum, although responsiveness will need to be evaluated. One of the strengths of MRI is the ability to detect subclinical synovitis, so the group worked on obtaining low disease activity/clinical remission datasets from a number of international centers and presented cross-sectional findings. Subsequent longitudinal evaluation of this unique resource will be a major continuing focus for the group.

The OMERACT MRI Inflammatory Arthritis Group: Advances and Future Research Priorities

The OMERACT magnetic resonance imaging (MRI) in inflammatory arthritis group previously developed the rheumatoid arthritis MRI score (RAMRIS) for use in clinical studies, evaluated the use of extremity MRI, and initiated development of a psoriatic arthritis MRI score (PsAMRIS). At OMERACT 9 the group looked at clarifications of applying the RAMRIS, and presented data from a study examining how the contrast agent gadolinium affects RAMRIS outcomes. Much of the group’s effort has been aimed at the iterative development of its PsA score, and reported exercises examining this score demonstrated encouraging results, allowing subsequent presentation of a preliminary PsAMRIS. The large amount of data presented were followed by discussions with the wider audience highlighting constructive suggestions for future research priorities, including further feasibility studies, understanding imaging remission, and further improvements to PsAMRIS.

Patterns of Magnetic Resonance Imaging Bone Erosion in Rheumatoid Arthritis — Which Bones Are Most Frequently Involved and Show the Most Change?

Objective. To investigate by magnetic resonance imaging (MRI) which bones in wrists and metacarpophalangeal (MCP) joints most frequently show bone erosions, and which most frequently demonstrate erosive progression, in early and established rheumatoid arthritis (RA). Methods. MRI datasets from 258 RA patients [126 with early RA (disease duration < 6 months)] were analyzed, of whom 223, including 126 with early RA, had 1-year followup MRI. All patients had MRI of one wrist, whereas 86 patients had additional images of 2nd–5th MCP joints, and 46 patients additional images of the contralateral wrist. MRI were evaluated blinded by one reader, according to the OMERACT RA MRI scoring system (RAMRIS) for erosions, and presence/absence of erosions was noted in each bone, as was presence/absence of erosive progression. Results. The capitate, ulna, lunate, triquetrum, and scaphoid were the 5 bones with both most frequent baseline erosions and most frequently demonstrated erosive progression. No bones were without erosions. Patterns of erosions and progression were similar in early and established RA. No major difference between dominant and nondominant wrists was detected. In the fingers, the 2nd–3rd MCP joint most frequently displayed erosions and erosive progression. Conclusion. The distribution and frequency of bone erosion and erosive progression as detected by MRI in RA wrists and MCP joints were identified. No pattern differences between early versus established disease and dominant versus nondominant sides were detected. No bones showed erosive progression. Thus, no self-evident simplification of the RAMRIS erosion score was identified. Bone involvement patterns may be considered, when joints are selected for MRI protocols for clinical trials and practice.

Using MRI Synovitis to count involved Joints in the ACR/EULAR 2010 RA criteria increases their Sensitivity and Specificity

Objectives In a prospective cohort study of patients with undifferentiated arthritis (UA) to investigate the ability of ACR/EULAR 2010 criteria with or without different MRI variables to diagnose RA, considering ACR 1987 criteria as gold standard reference Methods 119 pts (≥2 tender/swollen joints in MCP, PIP, wrist or MTP joints for >6 wks but <24 mths) without a rheumatological diagnosis, underwent clinical (68SJC/68TJC), biochemical, X-ray and MRI (unilateral wrist, MCP, PIP and MTP, scored by OMERACT RAMRIS (MTP not scored for synovitis (syn))) examinations and were followed for >12 mths. Sensitivity, specificity, accuracy, positive/negative predictive value (PPV/NPV) for diagnosing RA by 1) using ACR/EULAR 2010 criteria with and without including MRI syn, 2) substituting 68SJC/68TJC with MRI syn or 3) incorporating MRI bone oedema (BE) in the criteria are shown in Table. Results ACR/EULAR criteria with MRI syn variables included, gave a slight increase in sensitivity (Table, row 2-4) compared to without MRI (row 1). BE increased the sensitivity even more, highest with BE in wrist and/or MTP joint (row 5-8). Highest sensitivity, specificity, agreement and PPV were demonstrated when 68SJC/68TJC was replaced with counting only joints with MRI syn (row 9-11). Using syn ≥1 as cut-off (row 9) the sens, spec, accuracy, PPV and NPV were all higher than using the criteria based on clinical examination (row 1). Conclusions When fulfilment of the ACR 1987 criteria at follow-up is considered the gold standard reference, substituting IJC with MRI synovitis in joints of one hand, markedly increases the sensitivity and specificity of the ACR/EULAR 2010 criteria in UA. Disclosure of Interest None Declared