Original articleMagnetic resonance imaging quantification of hand synovitis in patients with rheumatoid arthritis treated with infliximab
Introduction
Rheumatoid arthritis (RA) is a chronic inflammatory disease with prominent joint manifestations. Joint involvement starts with synovial hyperplasia that progresses to synovitis and pannus formation, a highly cellular inflammatory tissue [1], [2]. Pannus erodes cartilage and bone leading to articular destruction and ankylosis [1], [2]. Articular involvement of the hand and wrist is the presenting site in approximately 70% of the patients with RA and frequently reflects the patient's overall disease condition [3], [4]. Conventional radiograms of the hand and wrist have been widely used in the diagnostic work up and follow-up of patients with RA [5]. However, conventional radiograms can only evaluate joint space changes, osteoporosis and erosive lesions [6]. The ultrasound, though it depicts synovium—and when coupled to color Doppler, assesses tissue vascularity—it evaluates superficial structures and image acquisition is operator dependent [7], [8]. Magnetic resonance (MR) imaging evaluates bone lesions (oedema, cysts and erosions), depicts inflammatory synovium in joints and tendon sheaths and distinguishes between active inflammatory and chronic fibrotic synovial tissue [7]. A grading system and/or volume estimation methods used for the evaluation of synovial membrane hypertrophy have been found to be useful for the evaluation of disease activity and response to treatment [9], [10], [11]. Anti-tumor necrosis factor-alpha (TNF-alpha), namely infliximab, is a chimeric monoclonal antibody that inhibits the proinflammatory cytokine TNF-alpha [12]. Moreover, anti-TNF-alpha reduces synovial membrane neo vascularization by decreasing the circulating levels of cytokine vascular endothelial growth factor, which is a major angiogenetic factor [12]. Response to treatment with infliximab has been evaluated by clinical and laboratory assessment as well as by serial radiographs [12]. There are few studies that have used MR imaging for the evaluation of response to infliximab therapy in RA patients [13], [14].
The purpose of the study was to investigate, in patients with refractory RA, the response to infliximab therapy by assessing with MR imaging changes in the volume of the active inflammatory tissue (VEIT) in the dominant hand and wrist.
Section snippets
Methods
Sixteen patients with RA according to the American College of Rheumatology (ACR) criteria were enrolled in the study [15]. There were 13 female and 3 males aged from 21–73 years, mean age 49.5 (17.0) years. The average disease duration was 10.5 (8.0) years (range 2–29 years) at the beginning of the study. Of the 16 patients, 10 were positive for IgM rheumatoid factor (RF). The patients were refractory or did not tolerate at least two disease modifying antirheumatic drugs (DMARDs). The current
Results
After 1 year of treatment, a significant reduction of the ESR, CRP, DAS-28 and VEIT was noted (Table 1). Moreover, all patients but two achieved the 20% ACR response criteria, while 9 (56.25%) and 5 (31.25%) patients achieved the 50% and 70% ACR response criteria, respectively. The two patients who after treatment did not achieve 20% ACR response criteria, on MR imaging follow up showed some increase instead of decrease of VEIT.
Only before treatment, the volume of the enhancing inflammatory
Discussion
TNF-alpha is a potent proinflammatory cytokine, which has been found in significant amounts in the synovial tissue and synovial fluid. TNF-alpha plays a critical role in the progression of synovitis and articular matrix degradation in RA patients [19]. Infliximab, a TNF-alpha inhibitor, has emerged as a key treatment for RA and other rheumatic diseases [20], [21], [22], [23], [24]. Results from several well-designed, controlled clinical trials using infliximab therapy with concomitant use of
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