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Ann Rheum Dis. 2001 Sep; 60(9): 859–868.
PMCID: PMC1753833

What is the fate of erosions in early rheumatoid arthritis? Tracking individual lesions using x rays and magnetic resonance imaging over the first two years of disease

Abstract

OBJECTIVES—To investigate the progression of erosions at sites within the carpus, in patients with early rheumatoid arthritis (RA), using magnetic resonance imaging (MRI) and plain radiology over a two year period.
METHODS—Gadolinium enhanced MRI scans of the dominant wrist were performed in 42 patients with RA at baseline (within six months of symptom onset) and one year. Plain wrist radiographs (x rays) and clinical data were obtained at baseline, one year, and two years. Erosions were scored by two musculoskeletal radiologists on MRI and x ray at 15 sites in the wrist. A patient centred analysis was used to evaluate the prognostic value of a baseline MRI scan. A lesion centred analysis was used to track the progression of individual erosions over two years.
RESULTS—The baseline MRI erosion score was predictive of x ray erosion score at two years (p=0.004). Patients with a "total MRI score" (erosion, bone oedema, synovitis, and tendonitis) [gt-or-equal, slanted]13 at baseline were significantly more likely to develop erosions on x ray at two years (odds ratio 13.4, 95% CI 2.65 to 60.5, p=0.002). Baseline wrist MRI has a sensitivity of 80%, a specificity of 76%, a positive predictive value of 67%, and a high negative predictive value of 86% for the prediction of wrist x ray erosions at two years. A lesion centred analysis, which included erosions scored by one or both radiologists, showed that 84% of baseline MRI erosions were still present at one year. When a more stringent analysis was used which required complete concordance between radiologists, all baseline lesions persisted at one year. The number of MRI erosion sites in each patient increased from 2.1 (SD 2.7) to 5.0 (4.6) (p<0.0001) over the first year of disease. When MRI erosion sites were tracked, 21% and 26% were observed on x ray, one and two years later. A high baseline MRI synovitis score, Ritchie score, and erythrocyte sedimentation rate were predictive of progression of MRI erosions to x ray erosions over one year (p=0.005, 0.01, and 0.03 respectively), but there was no association with the shared epitope. Progression of MRI erosions to x ray erosions was not seen in those with transient polyarthritis.
CONCLUSIONS—MRI scans of the wrist, taken when patients first present with RA, can predict radiographic erosions at two years. MRI may have a role in the assessment of disease prognosis and selection of patients for more or less aggressive treatment. However, only one in four MRI erosions progresses to an x ray erosion over one year, possibly owing to healing, observer error, or technical limitations of radiography at the carpus. Progression of MRI erosions to x ray erosions is greatest in those with high baseline disease activity.

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Selected References

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Figures and Tables

Figure 1
Diagram of the carpus to show sites at which erosions were scored on MRI and x ray. (1) distal ulna; (2) distal radius; (3) triquetrum; (4) pisiform; (5) lunate; (6) scaphoid; (7) hamate; (8) capitate; (9) trapezoid; (10) trapezium; (11) 5th metacarpal ...
Figure 2
The receiver operating characteristic curve used to investigate the ability of the baseline total MRI score to predict x ray erosions at the dominant carpus at two years. A cut off of 13 provides the maximum sensitivity (80%) and specificity ...
Figure 3
Serial MRI scans from patient No 16. (A) Baseline MRI scan (coronal T1 image) shows a large area of bone marrow oedema in the distal pole of the triquetrum. The cortex in this region is indistinct (white arrow). Another area of oedema is also ...
Figure 4
Serial MRI scans and x rays from patient No 4. (A) Baseline MRI scan (coronal T1 image) showing no erosions. (B) MRI scan at one year (coronal T1 image) shows erosions which have developed at the distal pole of the scaphoid and the adjacent margin ...
Figure 5
Serial MRI scans and x rays for patient No 40. (A) Baseline MRI (coronal T1 image) shows no erosions. (B) One year MRI (coronal T1 image) shows small erosion at the base of the 5th metacarpal joint (white arrow). (C) Baseline posteroanterior ...
Figure 6
Serial MRI scans and x rays for patient No 24 whose diagnosis was revised at two years from RA to transient undifferentiated polyarthritis. (A) Baseline MRI (coronal T1 image) shows bone marrow oedema within the hamate (black arrow). (B) One ...

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