Diagnostic usefulness of synovial vascular morphology in chronic arthritis. A systematic survey of 100 cases

doi:10.1053/sarh.2002.50004

Seminars in Arthritis and Rheumatism

Volume 32, Issue 6, June 2003, Pages 378-387

https://doi.org/10.1053/sarh.2002.50004 Get rights and content

Abstract

Objectives: To assess the diagnostic usefulness of the systematic analysis of synovial vascular morphology in various inflammatory, early, and longstanding arthropathies, and to examine the validity of the vascular patterns in predicting the evolution of a group of patients with undifferentiated arthritis (UA). Methods: One hundred patients who underwent rheumatologic arthroscopy of a symptomatic joint (85 knees, 11 wrists, 3 elbows, 1 metacarpophalangeal joint) were evaluated. The same observer, blinded to patient diagnosis, analyzed the video recordings of the arthroscopies. Vascular morphology was classified into 3 patterns: straight, tortuous, and mixed. Results: Eighty-one patients had inflammatory arthritis: 35 rheumatoid arthritis (RA), 16 psoriatic arthritis (PsA), 13 spondyloarthropathies (SpA), and 17 UA. Forty-nine percent of patients with RA had a straight pattern, 28% a mixed, and 23% a tortuous one. The sensitivity rate of the straight pattern for RA was 77% and the specificity rate was 70%. Seventy-six percent of RA patients with a straight pattern were rheumatoid factor positive (RF+) against 25% of RA patients with a tortuous pattern. The odds ratio for RA associated to straight compared with tortuous pattern was 57.3 (95% confidence interval, 6.6 to 499.5; P < .001). Patients with PsA and SpA shared the same pattern and were analyzed as 1 group. Ninety-three percent of patients with PsA/SpA had a tortuous pattern, 4% a straight pattern, and 3% a mixed pattern. The sensitivity rate of the tortuous pattern for PsA/SpA was 61% and the specificity rate was 95%. During 2 years of follow-up, 6 of 17 patients with UA were definitely diagnosed: 4 RA (2 RF+ and straight pattern; 2 with a tortuous pattern, 1 with RF+ and HLA-B27+); 1 SpA and 1 PsA, both with a tortuous pattern. No differences in vascular patterns were observed according to disease duration. Our results indicate that vascular patterns are not modified by disease modifying antirheumatic drug (DMARD) treatment. The other 19 patients had osteoarthritis (n = 8) and calcium pyrophosphate dihydrate crystal deposition disease (n = 11) and their predominant vascular pattern was tortuous-like. Conclusions: Arthroscopic assessment of synovial vascular changes in chronic arthritis may be of diagnostic and pathogenetic interest, although differences between published studies suggest a need for consensus in evaluating vascular patterns. A straight pattern is strongly associated with RF + RA whereas a tortuous pattern is generally associated with PsA or SpA; these associations are independent of disease duration. The vascular pattern likely does not change qualitatively with DMARD therapy. The application of this technique to the diagnosis or prognosis of patients with UA may be a complementary tool for the treatment of these patients, but larger, prospective studies are necessary to confirm this hypothesis. Semin Arthritis Rheum 32:378-387. © 2003 Elsevier Inc. All rights reserved.

Section snippets

Patients

The first consecutive 100 patients from the database of the Rheumatological Arthroscopy Unit were selected: 81 patients with active inflammatory arthritis (39 with early arthritis), 8 patients with OA, and 11 patients with CPPD disease. CPPD disease was diagnosed by radiologic chondrocalcinosis and episodic monarthritis with CPPD crystals in synovial fluid.

In the inflammatory group, 35 patients had RA according to American College of Rhuematology (formerly, American Rheumatology Association)

Results

Thirty-nine of 81 patients with inflammatory arthritis had ≤12 months duration. Eighty-five knees, 11 wrists, 3 elbows, and 1 MCP joint were studied. The distribution of patients according to diagnosis showed no significant differences in disease duration, and no differences were found in the distribution of the vascular patterns (straight, tortuous, and mixed) between patients with less or more than 12 months of disease (Table 1).

Discussion

This study systematically analyzed the vascular changes that occur in the synovial membrane in early and longstanding inflammatory arthritis, as well as noninflammatory arthropathies. Our results suggest that vascular changes in inflammatory arthritis do not depend on disease duration or DMARD therapy. Rather, the synovial vessel morphology seems to be more related to the type of arthritis. This also seems to be true in joints other than the knee, but the number of cases is too low to for

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Citation Excerpt :
A possible explanation could be that the early signal curve characteristics are more strongly influenced by synovial vascularity and capillary permeability, whereas the late enhancement is more dependent on contrast diffusion processes (29). Histological studies have shown that, in PsA, the vessel wall is markedly thickened (30,31) which restricts diffusion of contrast media into the synovium. Histopathology revealed proliferative synovial change in acute EOA similar to that of rheumatoid arthritis with lymphocytic and neutrophilic infiltration, synovial hypertrophy, and pannus formation explaining also the similarities of the present data acquired in patients with EOA with those of Schwenzer et al (13) acquired in patients with rheumatoid arthritis.
To investigate the diagnostic value of high-resolution dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) for assessment of synovitis in erosive osteoarthritis (EOA) of the hand and compare the results with those acquired in its potential mimic, the psoriatic arthritis (PsA).
Twenty-six patients (17 PsA, 9 EOA) were examined at 3 T. The time course of synovial contrast uptake was measured by ROI analysis using a three-dimensional encoded spoiled gradient-echo sequence. Characteristic parameters of synovial uptake curves (time to peak [TTP], peak value, mean transit time [MTT], area under the curve [AUC], and maximum upslope) of PsA and EOA patients were compared using gamma variate analysis and calculation of the late relative enhancement 15 minutes after contrast administration.
Enhancement curves of PsA and EOA patients paralleled each other at comparable levels in the early phase after contrast injection without statistical difference in the following calculated characteristic curve parameters: TTP, peak value, MTT, AUC, and maximum upslope. However, significant difference was found in the late relative enhancement 15 minutes after contrast injection (P = .0275) with higher values in EOA patients.
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^*: Juan D. Cañete, MD PhD: José R. Rodríguez, MD: Georgina Salvador, MD: Antonio Gómez-Centeno, MD: J. Muñoz-Gómez, MD FRCP(Ed): Raimón Sanmartí, MD: Arthritis Unit, Rheumatology Department, Institut Clínic de l'Aparell Locomotor (ICAL), Hospital Clínic de Barcelona, and Institut d'Investigacions Biomédiques Agustí Pí i Suñer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain.

^*: Supported by a grant from Fondo de Investigaciones Sanitarias (Ministerio de Sanidad, Spain), Proyecto FIS 1548/01.

^**: Address reprint requests to Juan D. Cañete, MD PhD, Arthritis Unit, Rheumatology Department, Hospital Clínic, Villarroel, 170, 08036 Barcelona, Spain.

^***: 0049-0172/03/3206-0003$30.00/0

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Diagnostic usefulness of synovial vascular morphology in chronic arthritis. A systematic survey of 100 cases*,*,**,***

Abstract

Section snippets

Patients

Results

Discussion

Dev Biol

Synovial biopsy in arthritis research: five years of concerted European collaboration

Ann Rheum Dis

Analysis of the cellular infiltrates and expression of cytokines in synovial tissue from patients with rheumatoid arthritis and reactive arthritis

J Pathol

Differential Th1/Th2 cytokine patterns in chronic arthritis: interferon gamma is highly expressed in synovium of rheumatoid arthritis compared with seronegative spondyloarthropathies

Ann Rheum Dis

Synovial tissue macrophage populations and articular damage in rheumatoid arthritis

Arthritis Rheum

Immunohistological analysis of synovial tissue for differential diagnosis in early arthritis

Rheumatology

Angiogenesis in the pathogenesis of inflammatory joint and lung diseases

Arthritis Res

Survey of arthroscopy performed by rheumatologists

Rheumatology

Distinct vascular patterns of early synovitis in psoriatic, reactive, and rheumatoid arthritis

Arthritis Rheum

Matrix metalloproteinase 9, Apoptosis, and vascular morphology in early arthritis

Arthritis Rheum

Diagnostic usefulness of synovial vascular morphology in chronic arthritis. A systematic survey of 100 cases,,,*