RPS 810 - Imaging in metabolic and inflammatory arthropathies

Author Block: S. Lavalle¹, A. Montana², Y. Dal Bosco², F. Aiello³, R. Foti², G. Privitera², R. Foti², P. Romeo²; ¹Milan/IT, ²Catania/IT, ³Enna/IT
Purpose: Detection of synovitis is essential for assessing rheumatoid arthritis (RA) activity and changing the therapy. This study aim to evaluate the level of agreement and correlation between DAS 28 (Disease activity score 28) and contrast-enhanced ultrasound (CEUS) and Superb microvascular imaging (SMI) in the classification of disease severity index in patients with RA who did not respond to second-line biologic therapy.
Methods or Background: SMI and CEUS were applied to 25 patients with active RA not respond to second-line biologic therapy. We evaluate the radiocarpal joint of both wrists. Differences in positive synovial vascularity (SV) and its semi-quantitative scale were observed, and the correlations of SMI and CEUS results with DAS-28.
Results or Findings: The results indicate that CEUS method shows high-moderate agreement with DAS 28 clinical method (Kappa = 0.406), 95% CI (0.1916, 0.5854), p = 0.00584, while SMI has weaker agreement (Kappa = 0.121) 95% CI (0.0098, 0.2466), p = 0.0846 (Kappa = 0.121). The correlation between CEUS and SMI is very strong (ρ = 0.828), CI 95% (0.6911, 0.9044), suggesting that the two radiological methods tend to produce very similar classifications, although CEUS is more in line with the gold standard. The Wilcoxon signed-rank test showed significant differences between DAS 28 and each of the two radiological methods, with CEUS appearing closer to the clinical method
Conclusion: Use of CEUS to detect vessels in the synovium and visualization of local SV is the method that most correlates with disease severity in relation to DAS 28 in patients with synovial arthritis who do not respond to second-line biologic therapy compared with SMI.
Limitations: Small sample size and the need for larger multicenter studies to confirm our findings.
Funding for this study: No funding
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information: Not applicable

Author Block: Y. Yaraşir, G. Ayan, H. Avci, L. Kılıç, Ü. Aydingöz, U. Kalyoncu, A. E. Yildiz; Ankara/TR
Purpose: Ascertaining whether synovium or synovioentheseal complex (SEC) is predominantly involved and pattern of any degeneration would help radiologists in distinguishing inflammatory hand arthritis (IHA). We aimed to characterize the role of MRI in reaching specific diagnosis in IHA.
Methods or Background: Patients aged ≥18 years with suspicious IHA in at least one joint (but not treated other than with NSAIDs) were consecutively enrolled in this prospective study. 3T-MRI with a fine-tuned protocol was utilized, whereby differential diagnoses were made according to the predominant involvement of synovium or SEC, and/or specific degenerative findings. Physical examination, laboratory and imaging findings, treatment response, and already-established rheumatological classification criteria were used to reach final diagnosis.
Results or Findings: Of 80 patients initially enrolled, 57 (42 females; mean age, 54 [range, 28-79]) constituted the final group with eventual clinical diagnoses of 11 psoriatic arthritis (PsA), 14 rheumatoid arthritis (RA), 11 erosive osteoarthritis and/or calcium pyrophosphate dihydrate deposition disease, 21 arthritis with distal interphalangeal joint involvement (ADIPI) not otherwise classified into any group. MRI revealed no difference between PsA and ADIPI groups, except for nail-bed enthesitis. Comparison between PsA and RA disclosed that enthesitis (p=0.033) and periarticular soft tissue edema (p=0.042) were more frequent in PsA. When ADIPI and PsA groups were combined, enthesitis and periarticular soft tissue edema were more common than in other groups (p<0.001). Those with enthesitis were 24 times more likely to be in the PsA+ADIPI group than those without enthesitis (95% CI: 2.6–63.3). Accurate classification rate of the model was 83.7%, and area under the curve (AUC) value was 0.81.
Conclusion: SEC inflammation and periarticular edema on MRI are strong predictors of PsA, especially in patients with DIP arthritis who don’t meet rheumatological classification criteria.
Limitations: Small sample size
Funding for this study: Funding was provided by Hacettepe University Scientific Research Projects Coordination Unit
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: Our study was approved by Hacettepe University Clinical Studies Ethics Committee (2021/23-20)

Author Block: S. Sedaghat¹, P. Leutz-Schmidt¹, J. Park², E. Fu², H. Jang²; ¹Heidelberg/DE, ²Davis/US
Purpose: This study aims to establish quantitative magnetic resonance imaging (qMRI) as a precise, noninvasive tool for evaluating hemosiderin deposition in hemophilic arthropathy (HA) of the knee.
Methods or Background: This prospective study included nine ex-vivo knee synovial tissues from HA patients and the same tissues from healthy controls. All tissues underwent standardized qMRI protocols using quantitative susceptibility mapping (QSM), based on ultrashort echo time MRI, which was optimized to detect and quantify hemosiderin deposits. Also, standard MRI sequences were employed. The HA tissues were processed histologically using Perl’s Prussian Blue (PPB) staining to identify iron contents. Several regions of interest were drawn in each tissue. Using specialized algorithms, voxel-wise magnetic susceptibility was calculated to assess iron deposition within the knee tissues objectively.
Results or Findings: qMRI demonstrated high sensitivity in detecting and quantifying hemosiderin deposition, whereas conventional imaging showed no abnormalities. The estimated susceptibility values (ESVs) showed significant differences between HA and control samples. HA tissues presented a mean ESV of 0.48 ± 1.08 ppm and control tissues of 0.13 ± 0.12 ppm (p<0.05). A significant linear correlation was found between the iron level quantified by histology and the ESV estimated by QSM (R = 0.908, p < 0.01). There was a significant difference in the susceptibility in high load (HL) tissues compared to low load (LL) tissues (ESV = 5.57 ± 1.23 ppm for HL vs. 0.57 ± 0.85 ppm for LL, p<0.001).
Conclusion: This study establishes qMRI, particularly QSM, as a noninvasive and highly sensitive technique for quantifying hemosiderin in HA of the knee. By providing an objective measure of hemosiderin deposition, qMRI offers potential as a tool for early diagnosis and disease monitoring in patients with hemophilic arthropathy.
Limitations: Main limitation: ex-vivo study design.
Funding for this study: This study was funded by the National Institutes of Health (NIH R01AR078877) and the Deutsche Forschungsgemeinschaft (DFG SE 3272/1-1)
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: The Institutional Review Board (IRB) of the University of California San Diego approved the study.

Author Block: M. Di Diego, D. Perla, A. Infante, A. M. Costantini, M. L. Angeli, C. Gullì, G. Ferrara; Rome/IT
Purpose: The primary endpoint is to evaluate the additional diagnostic information obtained from ZTE sequences added to the standard MRI protocol (particularly compared to T1-weighted images) for improved assessment of bone structures in diabetes-related foot disease. Secondary endpoints include assessing accuracy compared to CT in the evaluation of bone alterations and investigating interobserver agreement between three musculoskeletal radiologists with different expertise.
Methods or Background: This retrospective single-center study analyzed 32 MRIs with ZTE sequences from 31 patients (22 males, 10 females; age range: 49-87 years) from March 2024 to September 2024. Inclusion criteria included patients >18 years old with a confirmed diagnosis of diabetes mellitus. In 11 cases, comparison between ZTE sequences and CT bone imaging was possible.
Results or Findings: ZTE sequences compared to standard MRI protocol (particularly to T1-weighted images) were superior in identifying soft tissue air (43% vs 31%), bone pneumatosis (19% vs 9%), bone erosions (77% vs 67%), bone exposure (20% vs 15%), bone sclerosis (49% vs 41%), periosteal reaction (19% vs 17%), and bone fragments (39% vs 25%). Compared to CT, ZTE demonstrated high sensitivity (75-100%) and specificity (92-100%) for all musculoskeletal alterations analyzed. Interobserver agreement between musculoskeletal radiologists was excellent (k-range 0.82).
Conclusion: ZTE sequences provided additional musculoskeletal information compared to T1-weighted MRI sequences, particularly for the morphological evaluation of bones affected by diabetes-related foot disease. This is crucial when hypointensity on T1-weighted images reduces the ability to visualize bone structures and their alterations. Moreover, the high sensitivity and specificity values compared to CT suggest that ZTE is a valid alternative. The interobserver agreement for the qualitative evaluation of ZTE sequences was excellent, indicating the ease of interpretation.
Limitations: Small sample size.
Funding for this study: None
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information: None

Author Block: P. Del Nido Recio, J. D. Aquerreta, A. Paternain Nuin, M. R. López De La Torre Carretero, M. Jiménez Vázquez, C. Mbongo, C. Urtasun Iriarte, D. A. Zambrano, M. B. Barrio Piqueras; Pamplona/ES
Purpose: This study aims to analyze whether the upgrade Doppler activity, when comparing SMI and PD, is significantly different in Rheumatoid Arthritis (RA), compared to other arthropathies.
Methods or Background: Between May 2023 and April 2024, we prospectively analyzed a cohort of 57 joints of 21 different patients. Most of them were previously diagnosed with RA and other arthropathies, such as Osteoarthritis, Psoriatic Arthritis, Gout, etc. PD and SMI imaging were obtained in all joints and the individual grades for Doppler Activity were registered for each joint with active synovitis, raging from 0 to 3, according to the EULAR - OMERACT US Score. Mann-Whitney U test was applied to calculate means in independent samples. Two-tailed p-values of <0.05 were considered statistically significant.
Results or Findings: 21 joints of 8 patients with RA and 36 joints of 13 patients with other arthropathies were studied. Metacarpophalangeal joints were the most frequently analyzed in the RA group (11), and interphalangeal joints were the most frequently analyzed in the other group (18). When comparing Doppler activity, the mean PD was significantly higher in the RA group compared to the other group (1.14 vs. 0.75, p = 0.043). When upgrading the Doppler activity with SMI, we did not find statistically significant differences (2.52 vs 2.69, p = 1.04). Nevertheless, when comparing the mean of the difference between SMI and PD, it was significantly lower in the RA group (1.38 vs. 1.94, p = 0.016).
Conclusion: Our results indicate that a higher upgrade between PD and SMI exams is more likely seen in arthropathies such as oligoarthritis, Psoriatic Arthritis or Gout, rather than in RA.
Limitations: The number of patients.
Interobserver variability.
The degree of arthritis and type of treatment.
Funding for this study: No funding was received for this study.
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information: The study received institutional review board approval and written informed consent was obtained from all participants

Author Block: V. Yaman, A. E. Yıldız, B. Fırlatan, H. Avcı, O. Karadağ, U. Kalyoncu, Ü. Aydingöz; Ankara/TR
Purpose: Recent (2019) criteria that supplement classic DISH criteria were developed to diagnose this condition at an earlier stage. The aims of the present study were to investigate the prevalence of the early-stage (ES-DISH) as well as classic (late-stage) (LS-DISH) disease and to determine pelvic enthesophyte status in patients with ES-DISH and LS-DISH.
Methods or Background: 636 consecutive patients aged ≥18 years who underwent thorax CT during October 2023 in a tertiary medical center were retrospectively evaluated. CTs were scored according to 2019 DISH criteria by two independent observers. Pelvic (including parasacroiliac) enthesophytes in patients who also had a simultaneous abdomen CT were examined by a musculoskeletal radiologist blinded to patients’ DISH status as well as clinical information, yielding a personal “pelvic enthesophyte load score” (PELS). Malignancy and metabolic syndrome data from patients were also analyzed.
Results or Findings: Prevalences of ES-DISH and LS-DISH were 16.7% and 15.4%, respectively. Intra- and interobserver agreement were “almost perfect” (ICC = 0.88; 95% CI, 0.77–0.99) and “substantial” (ICC = 0.73; 95% CI, 0.68–0.78), respectively. Mean ages (and age range) of “no DISH”, ES-DISH, and LS-DISH subgroups were 55.1 (18–86), 65.5 (46–90), and 69.2 (48–96), respectively. DISH prevalence was similar in patients without and with cancer. When age was factored in, frequency of metabolic syndrome in DISH patients did not differ significantly compared to those without DISH. Mean±SD PELS were 6.2±3.5, 8.9±3.4 and 10.1±3.2 in “no DISH”, ES-DISH and LS-DISH groups. Logistic regression analysis yielded an overall accuracy of 68% for PELS in predicting DISH status.
Conclusion: This study demonstrated that prevalence of DISH doubled when ES-DISH criteria were used. Pelvic enthesophytes are more profusely seen in ES- or LS-DISH than in patients without DISH.
Limitations: Retrospective study
Funding for this study: No funding was received for this study.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: This study was approved by Hacettepe University Clinical Studies Ethics Committee (SBA 24/166).