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. 1999 Mar;58(3):156–163. doi: 10.1136/ard.58.3.156

Magnetic resonance imaging of the wrist in early rheumatoid arthritis reveals progression of erosions despite clinical improvement

F McQueen 1, N Stewart 1, J Crabbe 1, E Robinson 1, S Yeoman 1, P Tan 1, L McLean 1
PMCID: PMC1752839  PMID: 10364913

Abstract

OBJECTIVES—To investigate the progression of joint damage in early rheumatoid arthritis (RA) using magnetic resonance imaging (MRI) of the wrist and determine whether this technique can be used to predict prognosis.
METHODS—An inception cohort of 42 early patients has been followed up prospectively for one year. Gadolinium enhanced MRI scans of the dominant wrist were obtained at baseline and one year and scored for synovitis, tendonitis, bone marrow oedema, and erosions. Plain radiographs were performed concurrently and scored for erosions. Patients were assessed clinically for disease activity and HLA-DRB1 genotyping was performed.
RESULTS—At one year, MRI erosions were found in 74% of patients (31 of 42) compared with 45% at baseline. Twelve patients (28.6%) had radiographic erosions at one year. The total MRI score and MRI erosion score increased significantly from baseline to one year despite falls in clinical measures of inflammation including erythrocyte sedimentation rate (ESR), C reactive protein (CRP), and swollen joint count (p < 0.01 for all). Baseline findings that predicted carpal MRI erosions at one year included a total MRI score of 6 or greater (sensitivity: 93.3%, specificity 81.8%, positive predictive value 93.3%, p = 0.000007), MRI bone oedema (OR = 6.47, p < 0.001), MRI synovitis (OR = 2.14, p = 0.003), and pain score (p = 0.01). Radiological erosions at one year were predicted by a total MRI score at baseline of greater than 13 (OR = 12.4, p = 0.002), the presence of MRI erosions (OR = 11.6, p = 0.005), and the ESR (p = 0.02). If MRI erosions were absent at baseline and the total MRI score was low, radiological erosions were highly unlikely to develop by one year (negative predictive value 0.91 and 0.92 respectively). No association was found between the shared epitope and erosions on MRI (p = 0.4) or radiography (p = 1.0) at one year.
CONCLUSIONS—MRI scans of the dominant wrist are useful in predicting MRI and radiological erosions in early RA and may indicate the patients that should be managed aggressively. Discordance has been demonstrated between clinical improvement and progression of MRI erosion scores.

 Keywords: magnetic resonance imaging; carpus; rheumatoid arthritis; prognosis

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Figure 1  .

Figure 1  

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MRI erosion score at baseline and one year for observer 1 and observer 2. Box plots show the mean (x), median (-), interquartile range (box) and spread of the data.

Figure 2  .

Figure 2  

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Progression of erosions on MRI and radiography from baseline to one year.

Figure 3  .

Figure 3  

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(A) Coronal T1 weighted MRI scan of the dominant carpus of a study patient at baseline showing bone marrow oedema of the capitate (arrow). (B) Coronal T1 scan of the same patient at one year showing progression of MRI changes with erosions of the hamate, capitate, scaphoid, lunate, triquetrum and distal radius (arrows). (C) Axial T1 scan at baseline showing synovial thickening within the distal radioulnar joint and radiocarpal joint adjacent to the palmar aspect of the distal radius (asterixes). (D) Axial T1 scan of the same patient at one year showing a large erosion that has developed within the palmar aspect of the distal radius (arrow).

Figure 4  .

Figure 4  

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(A) Receiver operating characteristic (ROC) curve for the prediction of MRI erosions at one year by baseline total MRI score. The apex of the curve defines the point at which the optimum sensitivity and specificity for this test are achieved (see text). (B) ROC curve for the prediction of radiological erosions at one year by baseline total MRI.

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Alarcón G. S., López-Méndez A., Walter J., Boerbooms A. M., Russell A. S., Furst D. E., Rau R., Drosos A. A., Bartolucci A. A. Radiographic evidence of disease progression in methotrexate treated and nonmethotrexate disease modifying antirheumatic drug treated rheumatoid arthritis patients: a meta-analysis. J Rheumatol. 1992 Dec;19(12):1868–1873. [PubMed] [Google Scholar]
  2. Arnett F. C., Edworthy S. M., Bloch D. A., McShane D. J., Fries J. F., Cooper N. S., Healey L. A., Kaplan S. R., Liang M. H., Luthra H. S. The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum. 1988 Mar;31(3):315–324. doi: 10.1002/art.1780310302. [DOI] [PubMed] [Google Scholar]
  3. Brook A., Corbett M. Radiographic changes in early rheumatoid disease. Ann Rheum Dis. 1977 Feb;36(1):71–73. doi: 10.1136/ard.36.1.71. [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Eberhardt K., Fex E., Johnson U., Wollheim F. A. Associations of HLA-DRB and -DQB genes with two and five year outcome in rheumatoid arthritis. Ann Rheum Dis. 1996 Jan;55(1):34–39. doi: 10.1136/ard.55.1.34. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Fex E., Jonsson K., Johnson U., Eberhardt K. Development of radiographic damage during the first 5-6 yr of rheumatoid arthritis. A prospective follow-up study of a Swedish cohort. Br J Rheumatol. 1996 Nov;35(11):1106–1115. doi: 10.1093/rheumatology/35.11.1106. [DOI] [PubMed] [Google Scholar]
  6. Foley-Nolan D., Stack J. P., Ryan M., Redmond U., Barry C., Ennis J., Coughlan R. J. Magnetic resonance imaging in the assessment of rheumatoid arthritis--a comparison with plain film radiographs. Br J Rheumatol. 1991 Apr;30(2):101–106. doi: 10.1093/rheumatology/30.2.101. [DOI] [PubMed] [Google Scholar]
  7. Fries J. F., Williams C. A., Morfeld D., Singh G., Sibley J. Reduction in long-term disability in patients with rheumatoid arthritis by disease-modifying antirheumatic drug-based treatment strategies. Arthritis Rheum. 1996 Apr;39(4):616–622. doi: 10.1002/art.1780390412. [DOI] [PubMed] [Google Scholar]
  8. Gilkeson G., Polisson R., Sinclair H., Vogler J., Rice J., Caldwell D., Spritzer C., Martinez S. Early detection of carpal erosions in patients with rheumatoid arthritis: a pilot study of magnetic resonance imaging. J Rheumatol. 1988 Sep;15(9):1361–1366. [PubMed] [Google Scholar]
  9. Gough A., Faint J., Salmon M., Hassell A., Wordsworth P., Pilling D., Birley A., Emery P. Genetic typing of patients with inflammatory arthritis at presentation can be used to predict outcome. Arthritis Rheum. 1994 Aug;37(8):1166–1170. doi: 10.1002/art.1780370809. [DOI] [PubMed] [Google Scholar]
  10. Hameed K., Bowman S., Kondeatis E., Vaughan R., Gibson T. The association of HLA-DRB genes and the shared epitope with rheumatoid arthritis in Pakistan. Br J Rheumatol. 1997 Nov;36(11):1184–1188. doi: 10.1093/rheumatology/36.11.1184. [DOI] [PubMed] [Google Scholar]
  11. Hanley J. A., McNeil B. J. The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology. 1982 Apr;143(1):29–36. doi: 10.1148/radiology.143.1.7063747. [DOI] [PubMed] [Google Scholar]
  12. Hannonen P., Möttönen T., Hakola M., Oka M. Sulfasalazine in early rheumatoid arthritis. A 48-week double-blind, prospective, placebo-controlled study. Arthritis Rheum. 1993 Nov;36(11):1501–1509. doi: 10.1002/art.1780361104. [DOI] [PubMed] [Google Scholar]
  13. Harris E. D., Jr Rheumatoid arthritis. Pathophysiology and implications for therapy. N Engl J Med. 1990 May 3;322(18):1277–1289. doi: 10.1056/NEJM199005033221805. [DOI] [PubMed] [Google Scholar]
  14. Higami K., Hakoda M., Matsuda Y., Ueda H., Kashiwazaki S. Lack of association of HLA-DRB1 genotype with radiologic progression in Japanese patients with early rheumatoid arthritis. Arthritis Rheum. 1997 Dec;40(12):2241–2247. doi: 10.1002/art.1780401220. [DOI] [PubMed] [Google Scholar]
  15. Jevtic V., Watt I., Rozman B., Kos-Golja M., Praprotnik S., Logar D., Presetnik M., Demsar F., Jarh O., Campion G. Contrast enhanced Gd-DTPA magnetic resonance imaging in the evaluation of rheumatoid arthritis during a clinical trial with DMARDs. A prospective two-year follow-up study on hand joints in 31 patients. Clin Exp Rheumatol. 1997 Mar-Apr;15(2):151–156. [PubMed] [Google Scholar]
  16. Jorgensen C., Cyteval C., Anaya J. M., Baron M. P., Lamarque J. L., Sany J. Sensitivity of magnetic resonance imaging of the wrist in very early rheumatoid arthritis. Clin Exp Rheumatol. 1993 Mar-Apr;11(2):163–168. [PubMed] [Google Scholar]
  17. Kirwan J. R. The effect of glucocorticoids on joint destruction in rheumatoid arthritis. The Arthritis and Rheumatism Council Low-Dose Glucocorticoid Study Group. N Engl J Med. 1995 Jul 20;333(3):142–146. doi: 10.1056/NEJM199507203330302. [DOI] [PubMed] [Google Scholar]
  18. Lee J., Lee S. K., Suh J. S., Yoon M., Song J. H., Lee C. H. Magnetic resonance imaging of the wrist in defining remission of rheumatoid arthritis. J Rheumatol. 1997 Jul;24(7):1303–1308. [PubMed] [Google Scholar]
  19. McQueen F. M., Stewart N., Crabbe J., Robinson E., Yeoman S., Tan P. L., McLean L. Magnetic resonance imaging of the wrist in early rheumatoid arthritis reveals a high prevalence of erosions at four months after symptom onset. Ann Rheum Dis. 1998 Jun;57(6):350–356. doi: 10.1136/ard.57.6.350. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Mulherin D., Fitzgerald O., Bresnihan B. Clinical improvement and radiological deterioration in rheumatoid arthritis: evidence that the pathogenesis of synovial inflammation and articular erosion may differ. Br J Rheumatol. 1996 Dec;35(12):1263–1268. doi: 10.1093/rheumatology/35.12.1263. [DOI] [PubMed] [Google Scholar]
  21. Nepom G. T., Gersuk V., Nepom B. S. Prognostic implications of HLA genotyping in the early assessment of patients with rheumatoid arthritis. J Rheumatol Suppl. 1996 Mar;44:5–9. [PubMed] [Google Scholar]
  22. Olerup O., Zetterquist H. HLA-DR typing by PCR amplification with sequence-specific primers (PCR-SSP) in 2 hours: an alternative to serological DR typing in clinical practice including donor-recipient matching in cadaveric transplantation. Tissue Antigens. 1992 May;39(5):225–235. doi: 10.1111/j.1399-0039.1992.tb01940.x. [DOI] [PubMed] [Google Scholar]
  23. Reiser M. F., Bongartz G. P., Erlemann R., Schneider M., Pauly T., Sittek H., Peters P. E. Gadolinium-DTPA in rheumatoid arthritis and related diseases: first results with dynamic magnetic resonance imaging. Skeletal Radiol. 1989;18(8):591–597. doi: 10.1007/BF00355334. [DOI] [PubMed] [Google Scholar]
  24. Sharp J. T., Young D. Y., Bluhm G. B., Brook A., Brower A. C., Corbett M., Decker J. L., Genant H. K., Gofton J. P., Goodman N. How many joints in the hands and wrists should be included in a score of radiologic abnormalities used to assess rheumatoid arthritis? Arthritis Rheum. 1985 Dec;28(12):1326–1335. doi: 10.1002/art.1780281203. [DOI] [PubMed] [Google Scholar]
  25. Tan P. L., Farmiloe S., Roberts M., Geursen A., Skinner M. A. HLA-DR4 subtypes in New Zealand Polynesians. Predominance of Dw13 in the healthy population and association of Dw15 with rheumatoid arthritis. Arthritis Rheum. 1993 Jan;36(1):15–19. doi: 10.1002/art.1780360104. [DOI] [PubMed] [Google Scholar]
  26. Van Jaarsveld C. H., Otten H. G., Jacobs J. W., Kruize A. A., Brus H. L., Bijlsma J. W. Association of HLA-DR with susceptibility to and clinical expression of rheumatoid arthritis: re-evaluation by means of genomic tissue typing. Br J Rheumatol. 1998 Apr;37(4):411–416. doi: 10.1093/rheumatology/37.4.411. [DOI] [PubMed] [Google Scholar]
  27. Voorter C. E., Rozemuller E. H., de Bruyn-Geraets D., van der Zwan A. W., Tilanus M. G., van den Berg-Loonen E. M. Comparison of DRB sequence-based typing using different strategies. Tissue Antigens. 1997 May;49(5):471–476. doi: 10.1111/j.1399-0039.1997.tb02781.x. [DOI] [PubMed] [Google Scholar]
  28. Wolfe F., Ross K., Hawley D. J., Roberts F. K., Cathey M. A. The prognosis of rheumatoid arthritis and undifferentiated polyarthritis syndrome in the clinic: a study of 1141 patients. J Rheumatol. 1993 Dec;20(12):2005–2009. [PubMed] [Google Scholar]
  29. van de Loo F. A., Joosten L. A., van Lent P. L., Arntz O. J., van den Berg W. B. Role of interleukin-1, tumor necrosis factor alpha, and interleukin-6 in cartilage proteoglycan metabolism and destruction. Effect of in situ blocking in murine antigen- and zymosan-induced arthritis. Arthritis Rheum. 1995 Feb;38(2):164–172. doi: 10.1002/art.1780380204. [DOI] [PubMed] [Google Scholar]
  30. van der Heijde D. M., van Leeuwen M. A., van Riel P. L., Koster A. M., van 't Hof M. A., van Rijswijk M. H., van de Putte L. B. Biannual radiographic assessments of hands and feet in a three-year prospective followup of patients with early rheumatoid arthritis. Arthritis Rheum. 1992 Jan;35(1):26–34. doi: 10.1002/art.1780350105. [DOI] [PubMed] [Google Scholar]

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