AJR 2004; 183:1453-1463
© American Roentgen Ray Society
MRI of Large Intraosseous Lesions in Patients with Inflammatory Arthritis
Jamshid Tehranzadeh1,
Oganes Ashikyan1,
Jane Dascalos2 and
Carolyn Dennehey3
1 Department of Radiological Sciences, University of California, Irvine, 101 The
City Dr. S, Route 140, Orange, CA 92868
2 Department of Radiology, Santa Barbara Cottage Hospital, Santa Barbara, CA
93102.
3 Department of Internal Medicine, University of California, Irvine, Orange, CA
92868.
Received September 26, 2003;
accepted after revision March 16, 2004.
Address correspondence to J. Tehranzadeh.
Abstract
OBJECTIVE. The purpose of our study was to evaluate on MRI the
occurrence of large cystlike intraosseous lesions in patients with
inflammatory arthritis.
SUBJECTS AND METHODS. We prospectively reviewed contrast-enhanced MR
images of 128 hands and wrists in 44 patients with clinical presentation of
inflammatory arthritis. Large lesions (
1 cm) found on MR images were
further evaluated for the presence of a cortical break and intraarticular
extension. These data were correlated with clinical and laboratory findings
and the duration of arthritis.
RESULTS. We found 26 patients with rheumatoid arthritis, seven with
psoriatic arthritis, two with systemic lupus erythematosus, one with
HIV-associated arthritis, one with mixed connective tissue disorder, one with
paraneoplastic-associated arthritis, one with inflammatory bowel disease
arthritis, and five patients with early unclassified inflammatory arthritis.
Twelve patients had 16 large intraosseous lesions, none of which were detected
on available radiographs (availability of radiographs for large erosions was
75%). A cortical break with intraarticular extension of the large lesions was
seen in 12 cases. Four lesions were not intraarticular.
CONCLUSION. Even large intraosseous lesions may be occult on
radiography. MRI is a superior technique for detecting these lesions in the
small joints of the hand and wrist in inflammatory arthritis. Although large
intraosseous erosions often communicate with joints, we observed four large
purely intraosseous enhancing lesions without intraarticular connection.
Patients with large erosions have a longer duration of inflammatory
arthritis.
Introduction
MRI is considered the gold standard in imaging of early rheumatoid
arthritis
[1–5].
The high resolution of MRI allows accurate measurement of large intraosseous
lesions. Enhancement by contrast material confirms the inflammatory nature of
these lesions and separates them from fluid-filled cysts. With the emergence
of new disease-modifying therapies, MRI is becoming an important technique
used not only to detect but also to quantify, follow, and evaluate response to
therapy in inflammatory arthritis. The purpose of this study was to evaluate
the MR images of patients with inflammatory arthritis for the presence of
large intraosseous lesions greater than 1 cm in any dimension, to evaluate
their intraarticular extension, and to describe their appearance.
Subjects and Methods
We obtained institutional review board approval to prospectively obtain and
review MR images and medical records of 44 patients (37 women and seven men)
with hand and wrist pain or clinical presentation suggesting inflammatory
arthritis. Twenty-eight patients underwent bilateral contrast-enhanced MRI
examinations of the wrist and hand from January 2000 to July 2002 at our
medical center. The age range of the patients was 22–78 years with an
average age of 44.8 years. The patients were identified after a review of the
appointment logs at our imaging center. All 44 patients with diagnoses of
inflammatory arthritis and pain or swelling in the wrists and hands were
examined and referred for MRI study by the same rheumatologist. Patients who
were referred for evaluation of traumatic injuries were excluded from the
study. Medical records were reviewed for age and sex of the patient,
presenting symptoms and physical examination findings, and laboratory data
including the following values: C-reactive protein, erythrocyte sedimentation
rate, hemoglobin, rheumatoid factor, and complement levels
(Table 1). Antinuclear antibody
and cryoglobulin levels were not included in the data analyses because of a
lack of data. We included the laboratory results obtained closest to the date
of MRI examination and determined if the patient was receiving any
pharmacologic therapy at any time before the MRI studies. The duration of the
disease was determined from the examination of medical records. When
available, the disease duration was calculated from onset of symptoms to MRI
date; otherwise, the date of the first diagnosis was used. The diagnosis was
determined from medical records, and in unclear cases, the rheumatologist
reexamined the records for clarification. The exact type of inflammatory
arthritis could not be determined from review of medical records in five
patients. The Student's t test was used for data analysis on Tables
1 and
2.
We examined a total of 68 wrists and 60 hands in 44 patients. MRI data were
obtained using 1.5-T superconductive magnets (Eclipse model, Picker
International). Patients were positioned supine with the arm placed next to
the body. A dedicated receive-only wrist coil was used. Imaging studies
included spin-echo T1-weighted images (TR/TE, 400/10) without fat saturation,
spin-echo T1-weighted images (400/9.3) with fat saturation, and
gadolinium-enhanced spin-echo T2-weighted images (2,500/80) with fat
saturation. All these sequences were acquired in three orthogonal planes
(sagittal, coronal, and axial). In addition, a coronal T2-weighted spin-echo
sequence without fat saturation was acquired for wrist examination. The field
of view was 10 cm, the number of excitations was 2, slice thickness was 3 mm
with 0.5-mm intervals, and the matrix was 192 x 256. Contrast agent
included IV gadolinium complex of diethylenetriamine pentaacetic acid
bismethylamide ([0.2 mL/kg = 0.1 mmol/kg, 
20 mL] gadodiamide, Omniscan,
Amersham Health). Acquisitions of enhanced images started immediately after IV
administration of the contrast agent and were all completed within 20 min
after the injection.
Erosions were defined as distinct focal areas with loss of normal signal
intensity on T1-weighted images, which changed to increased signal on
T2-weighted images and enhanced immediately after gadolinium contrast
administration. Two board-certified radiologists (one experienced
musculoskeletal radiologist and one MRI radiologist) evaluated all images by
consensus for the presence of erosions. Large erosions were defined as
erosions measuring 1 cm or greater in any single dimension (Figs.
1A,
1B,
1C,
1D,
1E,
1F,
1G,
1H,
2A,
2B,
2C,
2D,
2E,
2F,
3A,
3B,
3C,
3D,
3E,
3F,
4A,
4B,
4C,
4D,
4E,
4F,
4G,
4H,
5A,
5B,
5C,
5D,
5E,
5F,
5G,
5H,
6A,
6B). The MR images of large
erosions were also reviewed to determine the presence of intraarticular
extension. We also reviewed radiographs of patients with large erosions on MRI
to detect any osseous erosion. Radiographs of the hands and wrists in
anteroposterior, lateral, and oblique views were available and reviewed
independently from MR images without knowledge of the clinical data or MRI
findings. A routine conventional technique was used for radiography in this
study. Radiographs were available in nine (75%) of 12 patients with large
erosions on MR images. High-resolution films, xeroradiography, magnification
techniques, and follow-up MRI were not used.
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Fig. 1A. —48-year-old woman with rheumatoid arthritis since childhood
and intraosseous lesion of distal radius. Radiographs failed to show
intraosseous lesion of distal radius even 25 months after MRI. Lateral
(A), oblique (B), and anteroposterior (C) radiographs of
right wrist show normal findings.
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Fig. 1B. —48-year-old woman with rheumatoid arthritis since childhood
and intraosseous lesion of distal radius. Radiographs failed to show
intraosseous lesion of distal radius even 25 months after MRI. Lateral
(A), oblique (B), and anteroposterior (C) radiographs of
right wrist show normal findings.
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Fig. 1C. —48-year-old woman with rheumatoid arthritis since childhood
and intraosseous lesion of distal radius. Radiographs failed to show
intraosseous lesion of distal radius even 25 months after MRI. Lateral
(A), oblique (B), and anteroposterior (C) radiographs of
right wrist show normal findings.
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Fig. 1D. —48-year-old woman with rheumatoid arthritis since childhood
and intraosseous lesion of distal radius. Radiographs failed to show
intraosseous lesion of distal radius even 25 months after MRI. Sagittal
spin-echo T1-weighted (TR/TE, 400/10) (D), sagittal spin-echo
fat-saturated gadolinium-enhanced T1-weighted (400/9.3, obtained 9 min after
injection) (E), and sagittal spin-echo T2-weighted with fat saturation
(2,500/80) (F) images show 1.0 x 0.5 x 0.4 cm lesion in
distal radius with low signal intensity on T1-weighted images (D).
Lesion enhances with contrast administration on T1-weighted fat-saturated
image (E) and has bright signal on T2-weighted image (F). There
is no cortical break, and lesion is remote from nearest joint. Note bone
marrow edema of lunate bone.
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Fig. 1E. —48-year-old woman with rheumatoid arthritis since childhood
and intraosseous lesion of distal radius. Radiographs failed to show
intraosseous lesion of distal radius even 25 months after MRI. Sagittal
spin-echo T1-weighted (TR/TE, 400/10) (D), sagittal spin-echo
fat-saturated gadolinium-enhanced T1-weighted (400/9.3, obtained 9 min after
injection) (E), and sagittal spin-echo T2-weighted with fat saturation
(2,500/80) (F) images show 1.0 x 0.5 x 0.4 cm lesion in
distal radius with low signal intensity on T1-weighted images (D).
Lesion enhances with contrast administration on T1-weighted fat-saturated
image (E) and has bright signal on T2-weighted image (F). There
is no cortical break, and lesion is remote from nearest joint. Note bone
marrow edema of lunate bone.
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Fig. 1F. —48-year-old woman with rheumatoid arthritis since childhood
and intraosseous lesion of distal radius. Radiographs failed to show
intraosseous lesion of distal radius even 25 months after MRI. Sagittal
spin-echo T1-weighted (TR/TE, 400/10) (D), sagittal spin-echo
fat-saturated gadolinium-enhanced T1-weighted (400/9.3, obtained 9 min after
injection) (E), and sagittal spin-echo T2-weighted with fat saturation
(2,500/80) (F) images show 1.0 x 0.5 x 0.4 cm lesion in
distal radius with low signal intensity on T1-weighted images (D).
Lesion enhances with contrast administration on T1-weighted fat-saturated
image (E) and has bright signal on T2-weighted image (F). There
is no cortical break, and lesion is remote from nearest joint. Note bone
marrow edema of lunate bone.
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Fig. 1G. —48-year-old woman with rheumatoid arthritis since childhood
and intraosseous lesion of distal radius. Radiographs failed to show
intraosseous lesion of distal radius even 25 months after MRI. Coronal
spin-echo T1-weighted (400/10) (G) and coronal spin-echo
gadolinium-enhanced fat-saturated T1-weighted (584/9.3, obtained immediately
after injection) (H) images show lesion (arrow) in proximal
corner in distal radius. Lesion has low signal intensity on T1-weighted image
(G) and enhances with gadolinium contrast material (H).
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Fig. 1H. —48-year-old woman with rheumatoid arthritis since childhood
and intraosseous lesion of distal radius. Radiographs failed to show
intraosseous lesion of distal radius even 25 months after MRI. Coronal
spin-echo T1-weighted (400/10) (G) and coronal spin-echo
gadolinium-enhanced fat-saturated T1-weighted (584/9.3, obtained immediately
after injection) (H) images show lesion (arrow) in proximal
corner in distal radius. Lesion has low signal intensity on T1-weighted image
(G) and enhances with gadolinium contrast material (H).
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Fig. 2B. —47-year-old man with psoriatic arthritis for 6 months and
intraosseous erosion of distal radius. Anteroposterior radiograph of right
wrist shows juxtaarticular osteopenia with small cystic changes of carpal
bones. Large lesion of distal radius was not visualized.
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Fig. 2C. —47-year-old man with psoriatic arthritis for 6 months and
intraosseous erosion of distal radius. Sagittal spin-echo T1-weighted (TR/TE,
400/10) (C), sagittal spin-echo gadolinium-enhanced fat-saturated
T1-weighted (400/9.3, obtained 5 min after injection) (D), and sagittal
spin-echo fat-saturated T2-weighted (2,000/80) (E) images show
punched-out erosion of anterior articular cortex of distal radius, which has
low signal intensity on T1-weighted image (arrow) (C). Lesion
enhances with contrast administration on T1-weighted fat-saturated image
(D), has high signal on T2-weighted image (E), measures 1.0
x 0.3 x 0.7 cm, and is breaking through cortex into distal
radiocarpal joint.
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Fig. 2D. —47-year-old man with psoriatic arthritis for 6 months and
intraosseous erosion of distal radius. Sagittal spin-echo T1-weighted (TR/TE,
400/10) (C), sagittal spin-echo gadolinium-enhanced fat-saturated
T1-weighted (400/9.3, obtained 5 min after injection) (D), and sagittal
spin-echo fat-saturated T2-weighted (2,000/80) (E) images show
punched-out erosion of anterior articular cortex of distal radius, which has
low signal intensity on T1-weighted image (arrow) (C). Lesion
enhances with contrast administration on T1-weighted fat-saturated image
(D), has high signal on T2-weighted image (E), measures 1.0
x 0.3 x 0.7 cm, and is breaking through cortex into distal
radiocarpal joint.
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Fig. 2E. —47-year-old man with psoriatic arthritis for 6 months and
intraosseous erosion of distal radius. Sagittal spin-echo T1-weighted (TR/TE,
400/10) (C), sagittal spin-echo gadolinium-enhanced fat-saturated
T1-weighted (400/9.3, obtained 5 min after injection) (D), and sagittal
spin-echo fat-saturated T2-weighted (2,000/80) (E) images show
punched-out erosion of anterior articular cortex of distal radius, which has
low signal intensity on T1-weighted image (arrow) (C). Lesion
enhances with contrast administration on T1-weighted fat-saturated image
(D), has high signal on T2-weighted image (E), measures 1.0
x 0.3 x 0.7 cm, and is breaking through cortex into distal
radiocarpal joint.
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Fig. 2F. —47-year-old man with psoriatic arthritis for 6 months and
intraosseous erosion of distal radius. Coronal spin-echo gadolinium-enhanced
fat-saturated T1-weighted image (384/9.3, obtained immediately after
injection) shows intraosseous lesion (arrow) at distal epiphysis of
radius. Note marked synovial enhancement of wrist joint.
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Fig. 3A. —51-year-old woman with inflammatory arthritis for 8 months
and intraosseous lesion of capitate bone. Sagittal spin-echo T1-weighted
(TR/TE, 400/10) (A), sagittal spin-echo gadolinium-enhanced
fat-saturated T1-weighted (525/9.3, obtained 5 min after injection)
(B), and sagittal spin-echo T2-weighted (2,500/80) (C) images
show 1.3 x 0.7 x 1.2 cm lesion in capitate bone. Lesion has low
signal on T1-weighted image (A), enhances with contrast administration
(B), and has high signal on T2-weighted image (C).
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Fig. 3B. —51-year-old woman with inflammatory arthritis for 8 months
and intraosseous lesion of capitate bone. Sagittal spin-echo T1-weighted
(TR/TE, 400/10) (A), sagittal spin-echo gadolinium-enhanced
fat-saturated T1-weighted (525/9.3, obtained 5 min after injection)
(B), and sagittal spin-echo T2-weighted (2,500/80) (C) images
show 1.3 x 0.7 x 1.2 cm lesion in capitate bone. Lesion has low
signal on T1-weighted image (A), enhances with contrast administration
(B), and has high signal on T2-weighted image (C).
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Fig. 3C. —51-year-old woman with inflammatory arthritis for 8 months
and intraosseous lesion of capitate bone. Sagittal spin-echo T1-weighted
(TR/TE, 400/10) (A), sagittal spin-echo gadolinium-enhanced
fat-saturated T1-weighted (525/9.3, obtained 5 min after injection)
(B), and sagittal spin-echo T2-weighted (2,500/80) (C) images
show 1.3 x 0.7 x 1.2 cm lesion in capitate bone. Lesion has low
signal on T1-weighted image (A), enhances with contrast administration
(B), and has high signal on T2-weighted image (C).
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Fig. 3D. —51-year-old woman with inflammatory arthritis for 8 months
and intraosseous lesion of capitate bone. Coronal spin-echo T1-weighted
(400/10) (D), coronal spin-echo gadolinium-enhanced fat-saturated
T1-weighted (578/9, obtained immediately after injection) (E), and
coronal spin-echo fat-saturated T2-weighted (2,200/80) (F) images show
same lesion as seen in A–C. Lesion has low signal on T1-weighted
image (D), enhances with contrast administration (E), has high
signal on T2-weighted image (F), and shows break in cortex with
intraarticular extension. Note tenosynovitis of extensor carpi ulnaris
muscle.
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Fig. 3E. —51-year-old woman with inflammatory arthritis for 8 months
and intraosseous lesion of capitate bone. Coronal spin-echo T1-weighted
(400/10) (D), coronal spin-echo gadolinium-enhanced fat-saturated
T1-weighted (578/9, obtained immediately after injection) (E), and
coronal spin-echo fat-saturated T2-weighted (2,200/80) (F) images show
same lesion as seen in A–C. Lesion has low signal on T1-weighted
image (D), enhances with contrast administration (E), has high
signal on T2-weighted image (F), and shows break in cortex with
intraarticular extension. Note tenosynovitis of extensor carpi ulnaris
muscle.
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Fig. 3F. —51-year-old woman with inflammatory arthritis for 8 months
and intraosseous lesion of capitate bone. Coronal spin-echo T1-weighted
(400/10) (D), coronal spin-echo gadolinium-enhanced fat-saturated
T1-weighted (578/9, obtained immediately after injection) (E), and
coronal spin-echo fat-saturated T2-weighted (2,200/80) (F) images show
same lesion as seen in A–C. Lesion has low signal on T1-weighted
image (D), enhances with contrast administration (E), has high
signal on T2-weighted image (F), and shows break in cortex with
intraarticular extension. Note tenosynovitis of extensor carpi ulnaris
muscle.
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Fig. 4A. —41-year-old man with seronegative rheumatoid arthritis and
intraosseous lesion of distal phalanx of fifth finger. Lateral oblique
radiograph of right hand shows findings negative for erosion. Note deformity
of fifth metacarpal bone due to old healed fracture.
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Fig. 4B. —41-year-old man with seronegative rheumatoid arthritis and
intraosseous lesion of distal phalanx of fifth finger. Anteroposterior
radiograph of right hand was unremarkable for erosion.
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Fig. 4C. —41-year-old man with seronegative rheumatoid arthritis and
intraosseous lesion of distal phalanx of fifth finger. Sagittal spin-echo
T1-weighted (TR/TE, 414/10) (C), sagittal spin-echo gadolinium-enhanced
fat-saturated T1-weighted (630/9.3, obtained 5 min after injection)
(D), and sagittal spin-echo fat-saturated T2-weighted (2,799/80)
(E) images show 1.0 x 0.5 x 0.7 cm lesion in proximal
aspect of distal phalanx of fifth digit. Lesion has low signal intensity on
T1-weighted image (C), enhances with contrast administration
(D), and has high signal intensity on T2-weighted image (E).
Note synovitis of proximal interphalangeal joint.
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Fig. 4D. —41-year-old man with seronegative rheumatoid arthritis and
intraosseous lesion of distal phalanx of fifth finger. Sagittal spin-echo
T1-weighted (TR/TE, 414/10) (C), sagittal spin-echo gadolinium-enhanced
fat-saturated T1-weighted (630/9.3, obtained 5 min after injection)
(D), and sagittal spin-echo fat-saturated T2-weighted (2,799/80)
(E) images show 1.0 x 0.5 x 0.7 cm lesion in proximal
aspect of distal phalanx of fifth digit. Lesion has low signal intensity on
T1-weighted image (C), enhances with contrast administration
(D), and has high signal intensity on T2-weighted image (E).
Note synovitis of proximal interphalangeal joint.
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Fig. 4E. —41-year-old man with seronegative rheumatoid arthritis and
intraosseous lesion of distal phalanx of fifth finger. Sagittal spin-echo
T1-weighted (TR/TE, 414/10) (C), sagittal spin-echo gadolinium-enhanced
fat-saturated T1-weighted (630/9.3, obtained 5 min after injection)
(D), and sagittal spin-echo fat-saturated T2-weighted (2,799/80)
(E) images show 1.0 x 0.5 x 0.7 cm lesion in proximal
aspect of distal phalanx of fifth digit. Lesion has low signal intensity on
T1-weighted image (C), enhances with contrast administration
(D), and has high signal intensity on T2-weighted image (E).
Note synovitis of proximal interphalangeal joint.
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Fig. 4F. —41-year-old man with seronegative rheumatoid arthritis and
intraosseous lesion of distal phalanx of fifth finger. Coronal spin-echo
T1-weighted (400/10) image shows lesion in proximal aspect of distal phalanx
of fifth digit. Note absence of synovitis at distal interphalangeal joint of
fifth digit and presence of synovitis in proximal interphalangeal joints of
third and fourth fingers.
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Fig. 4G. —41-year-old man with seronegative rheumatoid arthritis and
intraosseous lesion of distal phalanx of fifth finger. Coronal spin-echo
gadolinium-enhanced fat-saturated T1-weighted image (735/9.3, obtained
immediately after injection) (G) and coronal spin-echo fat saturated
T2-weighted (2,500/80) (H) image show lesion in proximal aspect of
distal phalanx of fifth digit. Note absence of synovitis at distal
interphalangeal joint of fifth digit and presence of synovitis in proximal
interphalangeal joints of third and fourth fingers.
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Fig. 4H. —41-year-old man with seronegative rheumatoid arthritis and
intraosseous lesion of distal phalanx of fifth finger. Coronal spin-echo
gadolinium-enhanced fat-saturated T1-weighted image (735/9.3, obtained
immediately after injection) (G) and coronal spin-echo fat saturated
T2-weighted (2,500/80) (H) image show lesion in proximal aspect of
distal phalanx of fifth digit. Note absence of synovitis at distal
interphalangeal joint of fifth digit and presence of synovitis in proximal
interphalangeal joints of third and fourth fingers.
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Fig. 5A. —46-year-old woman with systemic lupus erythematosus of 7
months' duration and intraosseous lesions at base of second metacarpal and
trapezoid bones. Lateral radiograph of left wrist was unremarkable for
erosion.
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Fig. 5B. —46-year-old woman with systemic lupus erythematosus of 7
months' duration and intraosseous lesions at base of second metacarpal and
trapezoid bones. Anteroposterior slightly oblique radiograph of left wrist
shows juxtaarticular osteopenia and no large erosion. Note possible small
cystic change of ulnar styloid and distal first metacarpal bone.
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Fig. 5C. —46-year-old woman with systemic lupus erythematosus of 7
months' duration and intraosseous lesions at base of second metacarpal and
trapezoid bones. Sagittal spin-echo T1-weighted (TR/TE, 414/10) (C),
sagittal spin-echo gadolinium-enhanced fat-saturated T1-weighted (400/9.3,
obtained 5 min after injection) (D), and sagittal spin-echo
fat-saturated T2-weighted (2,500/80) (E) images show 1.6 x 1.2
x 1.4 cm lesion in proximal second metacarpal bone with cortical
disruption into carpometacarpal joint. Lesion has low signal intensity on
T1-weighted image (C), enhances with contrast administration
(D), and has high signal intensity on T2-weighted image (E).
Note smaller lesion in trapezoid bone and adjacent soft-tissue inflammation
and synovitis.
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Fig. 5D. —46-year-old woman with systemic lupus erythematosus of 7
months' duration and intraosseous lesions at base of second metacarpal and
trapezoid bones. Sagittal spin-echo T1-weighted (TR/TE, 414/10) (C),
sagittal spin-echo gadolinium-enhanced fat-saturated T1-weighted (400/9.3,
obtained 5 min after injection) (D), and sagittal spin-echo
fat-saturated T2-weighted (2,500/80) (E) images show 1.6 x 1.2
x 1.4 cm lesion in proximal second metacarpal bone with cortical
disruption into carpometacarpal joint. Lesion has low signal intensity on
T1-weighted image (C), enhances with contrast administration
(D), and has high signal intensity on T2-weighted image (E).
Note smaller lesion in trapezoid bone and adjacent soft-tissue inflammation
and synovitis.
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Fig. 5E. —46-year-old woman with systemic lupus erythematosus of 7
months' duration and intraosseous lesions at base of second metacarpal and
trapezoid bones. Sagittal spin-echo T1-weighted (TR/TE, 414/10) (C),
sagittal spin-echo gadolinium-enhanced fat-saturated T1-weighted (400/9.3,
obtained 5 min after injection) (D), and sagittal spin-echo
fat-saturated T2-weighted (2,500/80) (E) images show 1.6 x 1.2
x 1.4 cm lesion in proximal second metacarpal bone with cortical
disruption into carpometacarpal joint. Lesion has low signal intensity on
T1-weighted image (C), enhances with contrast administration
(D), and has high signal intensity on T2-weighted image (E).
Note smaller lesion in trapezoid bone and adjacent soft-tissue inflammation
and synovitis.
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Fig. 5F. —46-year-old woman with systemic lupus erythematosus of 7
months' duration and intraosseous lesions at base of second metacarpal and
trapezoid bones. Coronal spin-echo T1-weighted (400/10) (F), coronal
spin-echo gadolinium-enhanced fat-saturated T1-weighted (584/9, obtained
immediately after injection) (G), and coronal spin-echo fat saturated
T2-weighted (2,500/80) (H) images show same lesions as in
A–E with low signal intensity on T1-weighted image (F),
enhancement with contrast administration (G), and high signal intensity
on T2-weighted image (H). Note edema of capitate and hamate bones and
bases of third and fourth metacarpal bones with marked synovitis of wrist
joint.
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Fig. 5G. —46-year-old woman with systemic lupus erythematosus of 7
months' duration and intraosseous lesions at base of second metacarpal and
trapezoid bones. Coronal spin-echo T1-weighted (400/10) (F), coronal
spin-echo gadolinium-enhanced fat-saturated T1-weighted (584/9, obtained
immediately after injection) (G), and coronal spin-echo fat saturated
T2-weighted (2,500/80) (H) images show same lesions as in
A–E with low signal intensity on T1-weighted image (F),
enhancement with contrast administration (G), and high signal intensity
on T2-weighted image (H). Note edema of capitate and hamate bones and
bases of third and fourth metacarpal bones with marked synovitis of wrist
joint.
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Fig. 5H. —46-year-old woman with systemic lupus erythematosus of 7
months' duration and intraosseous lesions at base of second metacarpal and
trapezoid bones. Coronal spin-echo T1-weighted (400/10) (F), coronal
spin-echo gadolinium-enhanced fat-saturated T1-weighted (584/9, obtained
immediately after injection) (G), and coronal spin-echo fat saturated
T2-weighted (2,500/80) (H) images show same lesions as in
A–E with low signal intensity on T1-weighted image (F),
enhancement with contrast administration (G), and high signal intensity
on T2-weighted image (H). Note edema of capitate and hamate bones and
bases of third and fourth metacarpal bones with marked synovitis of wrist
joint.
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Fig. 6A. —41-year-old woman with seronegative rheumatoid arthritis with
large erosion of third metacarpal head. Coronal spin-echo T1-weighted (TR/TE,
400/10) (A) and coronal spin-echo gadolinium-enhanced fat-saturated
T1-weighted (578/9.3, obtained immediately after injection) (B) images
show large erosion (arrow, A) of third metacarpal head
measuring 1.3 cm.
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Fig. 6B. —41-year-old woman with seronegative rheumatoid arthritis with
large erosion of third metacarpal head. Coronal spin-echo T1-weighted (TR/TE,
400/10) (A) and coronal spin-echo gadolinium-enhanced fat-saturated
T1-weighted (578/9.3, obtained immediately after injection) (B) images
show large erosion (arrow, A) of third metacarpal head
measuring 1.3 cm.
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Results
Review of medical records revealed the following diagnoses in our patient
population: seropositive and seronegative rheumatoid arthritis (n =
26), psoriatic arthritis (n = 7), systemic lupus erythematosus
(n = 2), HIV-associated arthritis (n = 1), mixed connective
tissue disorder (n = 1), paraneoplastic-associated arthritis
(n = 1), cryoglobulin and inflammatory bowel disease–associated
arthritis (n = 1), and early unclassified inflammatory arthritis
(n = 5). A total of 291 small and large erosions (215 in wrists and
76 in hands) were identified. The wrist erosions included the following:
capitate bone (n = 53), lunate bone (n = 44), triquetrum
bone (n = 27), ulnar and radial styloid (n = 22), scaphoid
bone (n = 20), hamate bone (n = 20), trapezium bone
(n = 16), trapezoid bone (n = 12), and pisiform bone
(n = 1). The erosions in hands consisted of 68 in the metacarpal
bones and eight in phalanges. Among these 291 erosions, 275 were small (< 1
cm) and the rest were large erosions. The capitate bone followed by the lunate
bone were the two most common sites of erosion. Six MRI examinations (four
hands and two wrists) in four patients did not depict any erosions; these
served as controls in our study. Thirty-nine patients (89%) were treated with
nonsteroidal antiinflammatory drugs, disease-modifying drugs, or steroids
before undergoing imaging.
We found 16 large erosions in 12 patients (nine women; three men) after
review of 128 studies in 44 patients. The age range of these 12 patients was
27–78 years with an average age of 47.3 years. The large erosions ranged
from 1 to 2 cm with average diameter of 1.2 cm. We found six large erosions in
the metacarpal bones, four in the capitate bones, two in the distal radius,
two in the phalanges, and one each in the lunate bone and ulnar styloid
process. All large lesions showed marked enhancement on gadolinium-enhanced
studies. Fifteen of these lesions (94%) were subchondral. A cortical break
with intraarticular extension was seen in 12 large lesions. In four cases, we
could not detect a cortical break or articular connections in any of three
orthogonal planes. Eleven patients with large erosions had concurrent small
erosions in the hand and wrist joints. One patient with psoriatic arthritis
and a large lesion in the fourth proximal phalanx had no other small or large
erosions on MRI of the hand. Another patient with rheumatoid arthritis had
multiple hand and wrist erosions including a large lesion in the third
metacarpal head on the right side and only a single large lesion on the left
side at the base of the first metacarpal bone. No large intraosseous lesions
were revealed in any of the nine patients who underwent radiography.
The average age of patients with large erosions was 47.3 years; the average
age of patients with small erosions was 43.8 years. The mean duration of the
disease for patients with large lesions was 80.8 months and with small
lesions, 41.5 months. The disease duration in patients with large erosions
ranged from 2 to 360 months. Large erosions were present in 43% of male
patients and 24% of female patients. There was no statistically significant
difference between sexes (relative risk, 1.8; 95% confidence interval,
0.4–4.4) for the presence of large erosions.
Rheumatoid arthritis (26 patients) and psoriatic arthritis (seven patients)
were the most common diagnoses in our series. Rheumatoid factor data were
available in 10 patients with large lesions and in 27 patients without large
lesions. Rheumatoid factor was positive in two patients (20%) with large
lesions and in six patients (22%) without large lesions. No statistically
significant differences in other laboratory findings were found between the
two groups (Table 2).
Discussion
Erosions are surface lesions in bone and cartilage caused by inflammation
in joints due to infiltration of lymphocytes, macrophages, and neutrophils. A
thickened synovial tissue (pannus) is formed as a result of proliferation of
highly vascular connective tissue in the synovium. Synovial lymphocytes
synthesize immunoglobulin, including anti-IgG immunoglobulin (the rheumatoid
factor). Lymphokines secreted by synovial T cells attack and activate monocyte
macrophages. Proteases and collagenases secreted by these cells destroy the
articular cartilage. Other mediators of rheumatoid arthritis include
leukotrienes, superoxides, and prostaglandins.
The synovium eventually invades bone to produce erosions that are initially
seen at the margins of the joint where cartilage is absent (bare areas). This
process progresses to destroy cartilage and bone. The joint capsule,
ligaments, and tendons are all damaged by this process
[6]. Bone erosions are seen on
MRI in many cases in which findings on radiography are unremarkable
[1–5].
MRI may not be as sensitive in detecting cortical destruction and
endosteal–periosteal reaction compared with high-resolution film or
xeroradiography, magnification techniques, or CT
[7]; however, MRI delineates
erosions and subchondral cysts with greater sensitivity than conventional
radiography or CT [8]. This
advantage is attributable to the multiplanar tomographic capability and high
sensitivity of MRI for subchondral marrow imaging. Intraosseous lesions that
destroy cortical bone become more detectable on conventional radiography. In
contrast, purely intraosseous lesions without a cortical break (marrow
lesions) are harder to detect radiographically. In a recent study, the median
time that MRI detection preceded new radiographic erosions was 2 years.
Erosion on MRI is defined as a focal loss of the normal signal intensity of
bone on T1-weighted images, which changes to high signal on T2-weighted
sequence [2].
Some confusion exists in the literature about the nomenclature of large
intraosseous lesions and their etiology. The terms "cyst" and
"erosion" have been used interchangeably in the description of
radiographic findings in arthritis. The use of the term "cyst" by
radiologists in the context of arthritis, however, is a misnomer in most
instances because the radiologist is unable to determine whether a radiolucent
lesion is filled with solid material or indeed does represent a fluid-filled
cyst [9]. Some authors have
reported that cysts contain rheumatoid granulation tissue, which may be an
extension of the pannus through an articular surface defect, and in certain
instances, cysts may be caused by an intramedullary rheumatoid nodule
[10]. Other authors believe a
cyst starts as an isolated structure beneath the subchondral bone
[11].
Enhanced T1-weighted images can differentiate fluid-filled cysts from
pannus-filled spaces. The latter are highly vascularized and enhance greatly
on gadolinium-enhanced T1-weighted images, whereas a "cyst" by
definition is a fluid-containing structure with homogeneous low signal on
T1-weighted images and homogeneous high signal on T2-weighted images. The cyst
may enhance only at peripheral margins if images are acquired immediately
after contrast injection. Delayed gadolinium-enhanced images show contrast
diffusion in fluid-filled spaces causing the bright signal of cystic fluid on
T1-weighted sequences. In this article, "intraosseous lesions"
refer to focal marrow space lesions, which are highly vascularized and enhance
greatly with gadolinium administration on T1-weighted images.
Large intraosseous lesions have been described in the cystic form of
arthritis and in the bones of the large joints. The identification of large
cystic areas, especially in the hands and wrists of physically active men, has
been termed "rheumatoid arthritis of the robust reaction type"
[12]. Robust rheumatoid
arthritis is a form encountered in people who characteristically remain active
despite the presence of severe arthritis. This relatively uncommon finding is
more often seen in men than in women and is characteristically not complicated
by osteoporosis [10]. Although
large lesions are often considered a continuum of small lesions, the
prevalence of large lesions in the hands and wrists of male patients with
rheumatoid arthritis deserves its own recognition.
One study examined intraosseous lesions in cystic rheumatoid arthritis.
After gadolinium contrast injection, no cysts showed enhancement on MRI of the
feet and hands, suggesting that these large lesions did not contain hyperemic
synovial tissue [13]. An
earlier study also described the cystic form of arthritis with the exclusive
presence of cystic intraosseous lesions in patients with no radiographic or
MRI evidence of erosions [14].
Large synovial cysts have been described in the hip
[15] and the knee joints
[16]. To our knowledge, no
previous reports specifically address large enhancing lesions on MRI of the
hands and wrists in patients with rheumatoid or other inflammatory
arthritis.
In this study, we describe the presence of large enhancing lesions on MRI
of the wrists and hands of patients with inflammatory arthritis. The large
enhancing lesions are commonly seen in the metacarpal bones, radius, and
carpal bones. In our study, no statistically significant difference in age,
disease duration, or laboratory data was found between the patients with large
erosions and those without them. Robust inflammatory arthritis that leads to
the development of large cysts is more common among men. In comparison to the
group with small erosions, our study containing large erosions comprised more
men. A larger study is needed to evaluate whether a statistically significant
difference in the prevalence of large erosions is present in men.
In this study, all the large erosions showed contrast enhancement in
patients with various inflammatory arthritides. This finding suggests that
large intraosseous lesions in various inflammatory arthritis states may
contain synovial tissue.
Konig et al. [17]
quantitatively evaluated hypervascular and fibrous pannus on dynamic MRI
enhanced with gadopentetate dimeglumine (diethylenetriamine pentaacetic acid)
in the knees of the 20 patients with rheumatoid arthritis and of two healthy
volunteers. These researchers observed and described three types of pannus
formation in patients with rheumatoid arthritis. These included hypervascular
pannus with remarkable enhancement on images after the administration of
gadopentetate dimeglumine, slightly vascular pannus that showed partial
enhancement, and fibrous pannus that lacked visible vascularity and did not
enhance after gadopentetate dimeglumine administration. Hypervascular pannus
was seen in the early stages of disease, whereas fibrous pannus was noted in
later or burnt-out stages of the disease.
The finding of enhancing large intraosseous lesions in our study contrasts
with the findings of Gubler et al.
[14], who describe cystic
intraosseous lesions that did not enhance. This difference suggests that large
intraosseous lesions found on MRI may represent different processes in
inflammatory arthritis. Because no large intraosseous process was seen on
radiographs in our study, we suggest that this vascularized intraosseous
lesion may represent an early erosion that is depicted only on MRI and can be
differentiated from cysts on the basis of contrast enhancement. Large
intraosseous lesions seen on MRI should be differentiated from marrow space
edema. The latter has no distinct margin and has less significant contrast
enhancement.
To our knowledge, the exact definition of the term "early rheumatoid
arthritis" has not yet been agreed upon. This study clearly shows that
large erosions can be present in both new-onset and late inflammatory
arthritis. Large erosions were present in patients with disease duration as
short as 2 months and as young as 27 years. These findings suggest that the
presence or absence of large erosions is not entirely dependent on disease
duration but rather on other factors such as degree of inflammatory
activity.
New dynamic MRI techniques might prove useful in estimating the
inflammatory activity in single joints. For example, enhancement rates on
dynamic MRI correlate with inflammation observed on biopsy specimens
[18]. Care should be taken
when evaluating MR images that show large erosions because their presence or
absence might not necessarily indicate the length of time that inflammation
was present.
This study did not reveal statistically significant differences in
inflammatory markers between patients with and without large erosions. This
finding suggests that global inflammatory markers do not reflect the amount of
inflammatory activity in the small joints of the hand and wrist. The
percentage of patients with and without the rheumatoid factor was also similar
in both groups in our series, suggesting that rheumatoid factor activity is
not a significant contributor to the development of large erosions.
We examined our erosions in three orthogonal planes, yet four of our 16
large lesions did not show a cortical break and were not connected to the
joint. Osseous erosions often result from intraarticular synovial
proliferation. The concept of purely intraosseous tophi has been established
in gout [19,
20]. Intraosseous rheumatoid
nodules are rare; however, they have been described in patients with
rheumatoid nodulosis
[21–23].
Brantley et al. [21] even
described an intraosseous rheumatoid nodule with avidity for gallium-67
citrate in the rib of a 9-year-old boy with rheumatoid nodulosis. Although
none of our large intraosseous lesions have been biopsied for pathologic
diagnosis, their distinct margin, MRI signal characteristic on T1- and
T2-weighted images, and intense enhancement with contrast material in the
context of inflammatory arthritis are highly suggestive of their vascularized
nature. Further investigation of cadaveric specimens is necessary to discover
the true nature of these lesions.
The limitation of this study is that only nine of 12 patients with large
intraosseous lesions had radiographic correlation; however, the erosions and
their pattern of enhancement on MRI were unequivocal. Another limitation of
this study is the lack of histologic proof for these lesions. However, we
relied on our clinical data, the great body of literature on this subject, and
intuitive reasoning to explain the results. Correlation between MRI findings
and clinical data should be interpreted with caution in this study because
laboratory values were obtained from retrospective review of the records.
In conclusion, even large intraosseous lesions may be occult on
radiography. MRI is an effective technique for detecting these large lesions
in the small joints of the hand and wrist. These large intraosseous erosions
often communicate with joints; however, we encountered four purely
intraosseous vascularized enhancing lesions that did not connect with the
joint. Patients with large erosions have a longer duration of inflammatory
arthritis.
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Abstract
Introduction
