Arthritis & Rheumatism, Volume 62,
November 2010 Abstract Supplement
Abstracts of the American College of
Rheumatology/Association of Rheumatology Health Professionals
Annual Scientific Meeting
Atlanta, Georgia November 6-11, 2010.
Rheumatoid Arthritis Patients in Clinical Remission Manifest Persistent Joint Inflammation on Histology and Imaging.
Anandarajah1, Allen P., Thiele2, Ralf G., Monu4, Johnny, Seo3, Gwy-Suk, Bokhari3, Aqiba, Ritchlin5, Christopher T.
Disease remission in rheumatoid arthritis (RA) has been defined clinically as the absence of evidence of disease activity. Several studies have shown, however, that patients in remission have persistent synovitis on ultrasound (US) and Magnetic Resonance Imaging (MRI). A central question is whether abnormal imaging findings in remission represent active joint inflammation.
To examine if patients in American College of Rheumatology (ACR) remission have persistent inflammation on histological analysis of synovial tissues and abnormal findings on ultrasound (US) and/ or magnetic resonance imaging (MRI),.
13 synovial (joints) specimens were obtained from 12 RA patients in clinical remission as defined by the revised ACR criteria. Synovial specimens were obtained during surgical procedures on knee (5), hip (2), elbow (1), wrist (3), shoulder (1) and thumb (1). Histological specimens were scored for hyperplasia of synovial lining and synovial stroma, inflammation, lymphoid follicles and vascularity on a scale of 04 (absent, minimal, mild, moderate and severe) and a total score calculated by adding the individual scores (020). The total scores were classified as minimal (05), mild (610), moderate (1115) or severe (1620) disease activity. Nine of 13 joints also had US and/or MRI done prior to surgery. US was assessed for effusion, tenosynovitis, synovitis on grey scale and Doppler signal. MRIs were evaluated for bone marrow edema (BME), synovial proliferation, effusion and erosion. The biopsy specimens were scored by a pathologist and the imaging studies scored by 2 radiologists and a rheumatologist who were blinded to other results.
The 12 patients comprised 10 females and 2 males with median disease duration of 2 years (range 120). Four of 12 patients were on anti-TNF therapy, 5 on methotrexate (MTX) alone, 3 on MTX and hydroxychloroquine (HCQ) and 1 on HCQ and sulfasalazine. The median histology score for the 13 specimens was 12 (moderate disease activity). Three specimens had severe, 6 moderate, 2 mild and 2 minimal disease activity on histology. Thickening of the synovial lining and stroma was seen in all patients. Inflammatory tissue was comprised mainly of lymphoplasmacytic cells in all specimens and neutrophils were noted in 6. Vascularity was also noted in all specimens (median score of 3). Interestingly, the 3 of 4 specimens with minimal and mild disease were subjects on anti-TNF therapy while the other was on methotrexate. Synovitis on US (grey scale)was seen in all 9 joints. Doppler signal was present in 5 of 6, effusion in 7 of 9 and tenosynovitis in 2 of 3 joints examined. All 4 joints that had MR images revealed synovitis, erosion and BME and one was also with effusion
Despite clinical remission, histology and imaging studies documented a persistently active disease state that may benefit from more aggressive therapy. Anti-TNF therapy may be more effective at suppression of disease activity than traditional DMARDs. Future studies will determine if this state is associated with disease progression.
To cite this abstract, please use the following information:
Anandarajah, Allen P., Thiele, Ralf G., Monu, Johnny, Seo, Gwy-Suk, Bokhari, Aqiba, Ritchlin, Christopher T.; Rheumatoid Arthritis Patients in Clinical Remission Manifest Persistent Joint Inflammation on Histology and Imaging. [abstract]. Arthritis Rheum 2010;62 Suppl 10 :1051