Whole-body MR imaging in psoriatic arthritis: Additional value for therapeutic decision making

https://doi.org/10.1016/j.ejrad.2009.06.020Get rights and content

Abstract

Purpose

In psoriatic arthritis (PsA) multiple locations may show inflammatory changes not always readily accessible to clinical exam. Often, clinical exam is inconclusive and the decision to initiate or adapt therapy is difficult. Whole body (WB)-MRI may help in this situation by providing a comprehensive overview of affected areas/joints. The purpose of this study was to make a proof of concept whether WB-MRI in psoriatic arthritis is feasible and can provide additional information compared to clinical examination alone with regard to therapeutic decision making in patients with PsA and inconclusive clinical situation.

Materials and Methods

30 patients with PsA and diffuse musculoskeletal pain were examined. A WB-MRI protocol was implemented on a 1.5 Tesla scanner using coronal and sagittal STIR- (TR: 5800, TE: 54, matrix 3842 pixels, FOV 400 mm) and pre- and steady-state-post-Gadolinium-VIBE sequences (TR: 9.82, TE: 4.53, matrix 384 × 307 pixels, FOV: 400 mm). MRI was evaluated for image quality and inflammatory findings by two readers in consensus and compared to clinical exam.

Results

The WB-MR-exam was well tolerated by all patients. Image quality was rated good to excellent in 26 of 30 patients (86.6%). WB-MRI detected significantly (p < 0.001) more areas of synovitis/enthesitis than clinical exam except for the hands and feet. MRI was able to detect unknown destructive bony changes in 10 patients (53%). In 22 patients (73.3%) the therapy regimen was modified, in 18 patients (62%) TNF-alpha-inhibitors were started.

Conclusion

Whole-body MRI (WB-MRI) may be integrated in the diagnostic work-up of patients with psoriatic arthropathy facilitating individual adaptation of therapeutic strategy.

Introduction

Psoriasis vulgaris is recognized as one of the most common autoimmune diseases [1], [2]. Approximately 10–30% of patients with psoriasis develop PsA [2]. PsA is an inflammatory disease with a broad spectrum of inflammatory changes in multiple locations of the body, ranging from axial to peripheral disease. Its prevalence is estimated from 0.3 to 1% [3]. The main musculoskeletal findings are enthesitis and adjacent soft tissue inflammation, synovitis, osteitis, dactylitis, new bone formation and bony destruction [4], [5].

Over the last years magnetic resonance imaging (MRI) is becoming the imaging method of choice for the initial diagnosis since it has the possibility to detect early and even subtle inflammatory changes [6], [7], [8], [9], [10], [11], [12]. Early administration of disease modifying anti-rheumatic drugs (DMARD) and especially tumor necrosis factor alpha (TNF-α)-inhibitors have proven to be highly effective anti-rheumatic drugs which can stop erosive changes and prevent joint damage. Therefore today, they are used as potent medication in active PsA [13], [14], [15] and thus, early diagnosis and exact assessment of disease severity are mandatory for a fast initiation of these therapies.

There is no doubt that clinical examination is the basis of the diagnostic process. However, often, clinical examination, especially of enthesitis, is inconclusive and the decision to initiate or adapt therapy is difficult [16], [17]. Therefore, there is a need for an adjunct diagnostic tool providing a comprehensive overview of the multiple locations possibly affected by PsA—information which may be provided by MRI.

So far, the assessment of multiple organs/body regions by MRI was restricted by long examination times since the patient had to be repositioned, and/or coils had to be changed several times. Today, new technical improvements such as continuous table movement, multichannel MR systems and new coils design allow the assessment of various organ systems within one MRI exam in a reasonable scan time. However, only few studies are dealing with WB-MRI in the diagnostic process of musculoskeletal diseases [18], [19], e.g. in polymyositis[20], muscular dystrophy [21], [22], multiple myeloma [23] or in ankylosing spondylitis [24]. To the best of our knowledge there are no studies published concerning disease specific imaging with a suitable WB-MRI protocol in patients with PsA so far.

The purpose of this study was to make a proof of concept that WB-MRI in patients with PsA and inconclusive clinical situation is technically feasible and clinically useful and can provide additional information compared to clinical examination alone with regard to therapeutic decision making.

Section snippets

Study population

30 patients (13 female, 17 male, mean age 47 [25–78] years) with confirmed PsA according to the Moll and Wright criteria [25]/CASPAR [26] criteria with diffuse, multifocal musculoskeletal pain without clear clinical correlation and partially elevated inflammation parameters under standard therapy were included in the study. In all patients further therapeutic approach was unclear after clinical exam. The study is in compliance with the Helsinki Declaration and was approved by the University's

Image quality

Image quality of the axial skeleton was rated good to excellent in 26 of the 30 patients (86.6%), image quality of hands and feet was rated good in 16 patients (53%). On the chosen four-point scale image quality of the axial skeleton was rated with a mean value of 3.71 (SD 0.6), image quality of the peripheral joints with a MV of 2.39 (SD 0.74). Image contrast of the spine and pelvis was rated with a MV of 3.75 (SD 0.44), image contrast of the extremities had a mean value of 2.36 (SD 0.73). In

Discussion

Early diagnosis and exact assessment of disease severity and extent in patients with active PsA are mandatory. This counts especially since TNF-α-inhibitors have proven to be highly effective anti-rheumatic drugs and are available as potent medication [13], [14], [15]. In general clinical practice, inflammatory joints/regions in patients with PsA are assessed by clinical exam and radiography. However, clinical exam, especially of enthesitis, is often inconclusive and the exact assessment of the

Conclusion

A WB-imaging protocol comprising the examination of all major joints/affected regions in PsA is feasible with very good image quality, within reasonable imaging time and with good patient acceptance. WB-MRI provides assessment of disease extent and activity within one examination and improves the detection of inflammatory changes in PsA, especially of enthesitis, in locations which are difficult to assess clinically and when there is only subtle inflammatory activity. WB-MRI may become a

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