Recent Trends and Technology Advances in Rheumatoid Arthritis Clinical Ultrasonography and Power Doppler Imaging
Abstract
AbstractNew technological advances and sonographic techniques generally remain poorly used in routine clinical rheumatological practice, and do not encompass the benefits of recent advances in early diagnosis, follow-up and prognosis of rheumatoid arthritis (RA) disease management. Sonography today plays a key role in early diagnosis of RA through its capacity to document synovitis, tendon involvement, cartilage damage and bone erosion in disease management where conventional X-ray can be normal. Visualisation of synovial microvascular blood flow as a sign of inflammation has become one of the most important tools to monitor disease progression in RA patients and the power Doppler ultrasound (PDUS) predictive value remains useful in evaluating clinical disease. Furthermore, new improved probes are now available that allow standardised measurements. In addition, the inexpensive 3D PDUS (compared with magnetic resonance imaging) deserves better recognition based on new advances in power Doppler quantification which provide ratios of user defined regions of interest of vascularity. Standardisation of these procedures can increase the value and use of power Doppler over the next few years.
Keywords
Rheumatoid arthritis, musculoskeletal imaging, ultrasonography, power Doppler, 3D imaging, fusion imaging, synovitis
Disclosure: Walter Grassi has received consultancy fees and payment for writing or reviewing the manuscript from GE Healthcare. Alan Davies is employed by GE Healthcare, which includes stock, stock options, salary and pension. Olivier Boumendil has received financial support from GE Healthcare in respect of this paper.
Received: 20 May 2011 Accepted: 19 July 2011 Citation: European Musculoskeletal Review, 2011;6(3):148–52
Correspondence: Walter Grassi, Clinica Reumatologica, Scuola di Specializzazione in Reumatologia, Università Politecnica delle Marche, c/o Ospedale ‘A Murri’, ASL 5, Via dei Colli, 52 60035 Jesi, Ancona, Italy. E: walter.grassi@univpm.it
Ultrasonography plays an important role in the management of rheumatoid arthritis (RA).1,2 In a 2003 paper, the Ancona group of rheumatologists, headed by Walter Grassi, described the monitoring of therapeutic response in rheumatic diseases by using the unfulfilled potential of power Doppler ultrasound (PDUS).3 Three studies reported in 2003 described the use of PDUS as an imaging tool for the evaluation of RA treatment.4,5 Since 2002, many studies have used PDUS for therapy monitoring, diagnosis, clinical and pathophysiological research.6 The methodology has been confirmed for the measurement of disease activity of RA.7 Structural imaging and some proof of concept studies still prefer to use magnetic resonance imaging (MRI), but ultrasound today is suited for widespread clinical practice. Further, evaluation of PDUS as a biomarker of disease activity is an active area of research1,8 including synovitis follow-up as a marker of disease activity, and improved accuracy (especially cartilage and bone erosion imaging) as well as providing excellent prognostic information as the technology improves. In 2011, PDUS still requires further evaluation before a general usage of PDUS for individual clinical guidance or as an outcome measurement.9,10 This is principally due to the reported difficulties in standardisation and reproducibility of quantification of PDUS for primary imaging and disease monitoring, particularly in comparison with MRI and with conventional X-rays.6
Ultrasound is Increasingly Used in the Management of Rheumatoid Arthritis
In 2007, the European League Against Rheumatism (EULAR) recommended that, “Clinical examination is the method of choice for detecting synovitis. In doubtful cases, ultrasound, power Doppler, and MRI might be helpful to detect synovitis”.11 The examination is clinically focused around an anatomical and radiological approach compared to the disease-based rheumatologist approach. Different equipment offers differences in grey scale definition, precision and power Doppler accuracy. Most conventional US machinery suffices for the diagnosis of synovitis, but the evaluation of disease activity encompasses Doppler image resolution (see Figures 1 to 3). Doppler sensitivity should be not less than 12MHz for RA follow-up monitoring, particularly when managing early disease (7.5MHz probe has been demonstrated to be unable to monitor early disease and prognosticate).
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