“The first thing you think of when a patient [like this one] walks into your office is medial meniscal tear just because meniscal lesions are so common in a patient in this age group,” said Dr. Hollis G. Potter, chief of magnetic resonance imaging at the Hospital for Special Surgery in New York. “You might also suspect that she might have some early medial osteoarthritis.”
“There wasn't anything glaring in her presentation that directed them to think that she had an inflammatory arthropathy,” said Dr. Potter.
Upon magnetic resonance imaging (MRI), the patient was found to have severe synovial expansion with an inflammatory synovitis. “It was pretty clear that even if her meniscus had been torn—which it wasn't—that wouldn't be the cause of her pain. The cause was really the fact that she had an inflammatory synovitis,” said Dr. Potter.
The synovial proliferation extended into the medial and lateral gutters (see arrows in first image). The patient also had early marginal bony erosion (see arrow in second image) affecting the medial tibial plateau. Together, the synovial proliferation and bony erosion indicated rheumatoid arthritis (RA).
The images were obtained using a cartilage-sensitive sequence used for evaluating articular cartilage.
“We do this for all patients routinely,” said Dr. Potter. The technique allows physicians to noninvasively evaluate the morphologic integrity of the cartilage. “When we find articular lesions, I find it drives patient management more than anything else.”
“It's always been my sense that the purpose of MRI is to find what physicians are not clinically suspecting,” said Dr. Potter, who is also a professor of radiology at Cornell University, New York.
“I find that if the MRI doesn't in fact change the management or affect the management in some way, it's a very expensive test that really hasn't helped anybody at all,” Dr. Potter told RHEUMATOLOGY NEWS in an interview.
Based on the imaging findings, the patient underwent serologic testing and was placed on appropriate clinical management. This patient was identified with RA early in the disease progression when disease-modifying antirheumatic drugs can make a big difference in slowing disease progression.
Dr. Potter and her colleagues have found another use for MRI in rheumatology: They are investigating synovial recruitment patterns in patients with early, clinically suspected, inflammatory RA—patients who meet the American College of Rheumatology criteria for inflammatory arthritis. In an ongoing, prospective pilot study, they are using MR angiography with a contrast agent to assess neovascularity in areas of inflammatory synovium. The hope is that work like this will help better define patients who are good candidates for therapy with biologic agents, said Dr. Potter.
Synovial expansion with an inflam-matory synovitis (arrows) suggests RA.
Marginal bony erosion (arrow) suggests RA. There is no evidence of meniscal tear. Photos courtesy Dr. Hollis G. Potter