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The Role of Ultrasonography in the Assessment of Skeletal Hand Involvement in Systemic Sclerosis
Journal of Medical Ultrasound (2011) 19, 141e142
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journal homepage: www.jmu-online.com
LETTER TO THE EDITOR
The Role of Ultrasonography in the Assessment of Skeletal Hand Involvement in Systemic Sclerosis Francesca Ingegnoli 1*, Patrizia Boracchi 2, Amedeo Soldi 1, Anna Ingegnoli 3, Roberta Gualtierotti 1, Valentina Galbiati 1, Pier Luigi Meroni 4 1 Division of Rheumatology, Istituto Gaetano Pini, University of Milan, 2 Medical Statistics and Biometry, Department of Occupational and Environmental Health L. Devoto, Section of Medical Statistics and Biometry, University of Milan, 3 Department of Clinical Sciences, Section of Radiological Sciences, University of Parma, and 4 Laboratory of Immunorheumatology Research, Istituto Auxologico IRCCS, Milano, Italy
Received 5 October, 2011; accepted 17 October, 2011 During the course of systemic sclerosis (SSc), patients often experience hand involvement as the first clinical manifestation, and the broad spectrum of hand conditions leads to a loss of manual dexterity and interferes with daily and working life [1,2]. The diagnosis of hand involvement is primarily based on clinical signs and symptoms, and radiographic abnormalities [1e6]. Nevertheless, a recent study has emphasized the role of ultrasonography (US) in identifying subclinical synovitis or tenosynovitis that cannot be detected by means of radiography [7]. We investigated the complementary role of US in the detection of hand abnormalities, and the correlations between hand abnormalities and disease subsets, disease activity, and autoantibody profiles. This cross-sectional study involved 55 patients with SSc [8] consecutively referred to our clinic: they had a mean age of 58.5 years, 83.6% were women, and 74% had limited cutaneous (lc)-SSc. Disease activity was assessed as described by the European Scleroderma Study Group [9,10]. Musculoskeletal hand involvement was characterized by arthralgia in 25 cases, flexion contractures in 15, and arthritis in six, thus confirming that hand involvement is frequent in SSc [1e7]. The hands of each patient were assessed by means * Correspondence to: Dr Francesca Ingegnoli MD, Division of Rheumatology, Istituto Gaetano Pini, University of Milan, Piazza Cardinal Ferrari 1, 20122 Milano, Italy. E-mail address: [email protected] (F. Ingegnoli).
of US (GE LOGIQ 9 unit, Milwaukee, USA; 9e14 MHz) and radiography in 30 joints: 2 wrists, 10 metacarpophalangeal (MCP) joints, 10 proximal interphalangeal (PIP) joints, and eight distal interphalangeal (DIP) joints. The radiographs were classified as normal (i.e., the absence of juxta-articular osteoporosis, joint space narrowing, erosions, subchondral sclerosis, osteophytes, bone resorption, and calcinosis), degenerative (i.e., joint space narrowing, subchondral sclerosis, osteophytes at the PIP and/or DIP joints), inflammatory (i.e., juxta-articular osteoporosis, joint space narrowing, erosive changes at the PIP, MCP and/or carpal joints), or periarticular (i.e., bone resorption and/or calcinosis). The US imaging patterns were classified as normal (i.e., the absence of joint space narrowing, erosions, osteophytes, synovitis, bone resorption, calcinosis, and tenosynovitis), degenerative (i.e., joint space narrowing and osteophytes at the PIP and/or DIP joints), inflammatory (i.e., joint space narrowing, erosive changes and/or synovitis at the PIP, MCP and/or carpal joints), periarticular (i.e., bone resorption and/or calcinosis), or tendinous (i.e., the presence of tenosynovitis). In the case of the coexistence of two or more imaging patterns, the prominent one was chosen. The relations between these variables were explored using multiple correspondence analysis, an extension of simple correspondence analysis in which the original variables are represented in a space defined by factorial axes characterized by a percentage of inertia (i.e., the amount of total variability explained by the axis itself). The distance
0929-6441/$36 ª 2011, Elsevier Taiwan LLC and the Chinese Taipei Society of Ultrasound in Medicine. All rights reserved. doi:10.1016/j.jmu.2011.10.007
142
F. Ingegnoli et al.
Fig. 1 Concordance between conventional radiography and ultrasonography. (A) The soft tissue calcium deposits on the 2nd metacarpophalangeal joint in the radiograph; (B) appear as a hyperechoic image with posterior acoustic shadowing on a longitudinal ultrasonography scan.
between points, defined on the basis of a c2 metric, indicates the dissimilarities between categories [11,12]. Simple correspondence analysis showed an overall concordance between the radiographic and US patterns of 69%, with a confidence interval of 0.56e0.79, thus providing further evidence of the close concordance between the two imaging techniques in documenting the most frequent hand musculoskeletal abnormalities (Fig. 1). However, US revealed a tendinous pattern in 16% of the patients, who were otherwise misdiagnosed by means of radiography. The normal pattern found in 38.2% of the radiographs was confirmed by US in 27.3% of the patients. The degenerative radiographic pattern observed in 38.2% of patients was confirmed by US in 18 cases. Inflammatory radiographic changes were observed in two patients and confirmed by US, which also revealed tenosynovitis in both cases. A periarticular radiographic pattern was shown in 11 cases and US revealed that two also had tenosynovitis. US identifies a broad spectrum of hand conditions in a higher percentage of patients than radiography (72.7% vs. 61.8%), possibly because synovitis and tenosynovitis can only be visualized by US. Multiple correspondence analysis revealed two major clusters: the first grouping, anticentromere (ACA)-negative patients with diffuse cutaneous-SSc and a high degree of disease activity; the second grouping, ACA-positive patients with lcSSc and a low degree of disease activity. Cluster analysis showed a correlation between more severe disease (i.e., diffuse cutaneous-SSc with a high degree of disease activity) and the coexistence of two or more imaging patterns, whereas a single well-defined imaging pattern was more frequently observed in the cluster with less severe SSc (i.e., ACA-positive patients with lcSSc and a low degree of disease activity). In conclusion, our findings show the complementary role of US in assessing hand involvement in SSc, and that patients with severe disease more frequently have multiple coexisting hand abnormalities.
References [1] Baron M, Lee P, Keystone EC. The articular manifestations of progressive systemic sclerosis (scleroderma). Ann Rheum Dis 1982;41:147e52. [2] Lovell CR, Jayson MIV. Joint involvement in systemic sclerosis. Scand J Rheumatol 1979;8:154e60. [3] Blocka KLN, Basset LW, Furst DE, et al. The arthropathy of advanced progressive systemic sclerosis. A radiographic survey. Arthritis Rheum 1981;24:874e84. [4] La Montagna G, Sodano A, Capurro V, et al. The arthropathy of systemic sclerosis: a 12 month prospective clinical and imaging study. Skeletal Radiol 2005;34:35e41. [5] Avouac J, Guerini H, Wipff J, et al. Radiological hand involvement in systemic sclerosis. Ann Rheum Dis 2006;65: 1088e92. [6] La Montagna G, Baruffo A, Tirri R, et al. Foot involvement in systemic sclerosis: a longitudinal study of 100 patients. Semin Arthritis Rheum 2002;31:248e55. [7] Cuomo G, Zappia M, Abignano G, et al. Ultrasonographic features of the hand and wrist in systemic sclerosis. Rheumatology 2009;48:1414e7. [8] Preliminary criteria for the classification of systemic sclerosis (scleroderma). Subcommittee for scleroderma criteria of the american rheumatism association diagnostic and therapeutic criteria committee. Arthritis Rheum 1980;23:581e90. [9] Valentini G, Della Rossa A, Bombardieri S, et al. European multicentre study to define disease activity criteria for systemic sclerosis. II. Identification of disease activity variables and development of preliminary activity indexes. Ann Rheum Dis 2001;6:592e8. [10] Valentini G, Bencivelli W, Bombardieri S, et al. European Scleroderma Study Group to define disease activity criteria for systemic sclerosis. III. Assessment of the construct validity of the preliminary activity criteria. Ann Rheum Dis 2003;62: 901e3. [11] Greenacre M. Theory and application of correspondence analysis. London: Academic Press; 1984. [12] Lebart L, Piron M, Morineau A. Statistique explorative Multidimensionale. Paris: Dunod; 1995.
Available online at www.sciencedirect.com
journal homepage: www.jmu-online.com
LETTER TO THE EDITOR
The Role of Ultrasonography in the Assessment of Skeletal Hand Involvement in Systemic Sclerosis Francesca Ingegnoli 1*, Patrizia Boracchi 2, Amedeo Soldi 1, Anna Ingegnoli 3, Roberta Gualtierotti 1, Valentina Galbiati 1, Pier Luigi Meroni 4 1 Division of Rheumatology, Istituto Gaetano Pini, University of Milan, 2 Medical Statistics and Biometry, Department of Occupational and Environmental Health L. Devoto, Section of Medical Statistics and Biometry, University of Milan, 3 Department of Clinical Sciences, Section of Radiological Sciences, University of Parma, and 4 Laboratory of Immunorheumatology Research, Istituto Auxologico IRCCS, Milano, Italy
Received 5 October, 2011; accepted 17 October, 2011 During the course of systemic sclerosis (SSc), patients often experience hand involvement as the first clinical manifestation, and the broad spectrum of hand conditions leads to a loss of manual dexterity and interferes with daily and working life [1,2]. The diagnosis of hand involvement is primarily based on clinical signs and symptoms, and radiographic abnormalities [1e6]. Nevertheless, a recent study has emphasized the role of ultrasonography (US) in identifying subclinical synovitis or tenosynovitis that cannot be detected by means of radiography [7]. We investigated the complementary role of US in the detection of hand abnormalities, and the correlations between hand abnormalities and disease subsets, disease activity, and autoantibody profiles. This cross-sectional study involved 55 patients with SSc [8] consecutively referred to our clinic: they had a mean age of 58.5 years, 83.6% were women, and 74% had limited cutaneous (lc)-SSc. Disease activity was assessed as described by the European Scleroderma Study Group [9,10]. Musculoskeletal hand involvement was characterized by arthralgia in 25 cases, flexion contractures in 15, and arthritis in six, thus confirming that hand involvement is frequent in SSc [1e7]. The hands of each patient were assessed by means * Correspondence to: Dr Francesca Ingegnoli MD, Division of Rheumatology, Istituto Gaetano Pini, University of Milan, Piazza Cardinal Ferrari 1, 20122 Milano, Italy. E-mail address: [email protected] (F. Ingegnoli).
of US (GE LOGIQ 9 unit, Milwaukee, USA; 9e14 MHz) and radiography in 30 joints: 2 wrists, 10 metacarpophalangeal (MCP) joints, 10 proximal interphalangeal (PIP) joints, and eight distal interphalangeal (DIP) joints. The radiographs were classified as normal (i.e., the absence of juxta-articular osteoporosis, joint space narrowing, erosions, subchondral sclerosis, osteophytes, bone resorption, and calcinosis), degenerative (i.e., joint space narrowing, subchondral sclerosis, osteophytes at the PIP and/or DIP joints), inflammatory (i.e., juxta-articular osteoporosis, joint space narrowing, erosive changes at the PIP, MCP and/or carpal joints), or periarticular (i.e., bone resorption and/or calcinosis). The US imaging patterns were classified as normal (i.e., the absence of joint space narrowing, erosions, osteophytes, synovitis, bone resorption, calcinosis, and tenosynovitis), degenerative (i.e., joint space narrowing and osteophytes at the PIP and/or DIP joints), inflammatory (i.e., joint space narrowing, erosive changes and/or synovitis at the PIP, MCP and/or carpal joints), periarticular (i.e., bone resorption and/or calcinosis), or tendinous (i.e., the presence of tenosynovitis). In the case of the coexistence of two or more imaging patterns, the prominent one was chosen. The relations between these variables were explored using multiple correspondence analysis, an extension of simple correspondence analysis in which the original variables are represented in a space defined by factorial axes characterized by a percentage of inertia (i.e., the amount of total variability explained by the axis itself). The distance
0929-6441/$36 ª 2011, Elsevier Taiwan LLC and the Chinese Taipei Society of Ultrasound in Medicine. All rights reserved. doi:10.1016/j.jmu.2011.10.007
142
F. Ingegnoli et al.
Fig. 1 Concordance between conventional radiography and ultrasonography. (A) The soft tissue calcium deposits on the 2nd metacarpophalangeal joint in the radiograph; (B) appear as a hyperechoic image with posterior acoustic shadowing on a longitudinal ultrasonography scan.
between points, defined on the basis of a c2 metric, indicates the dissimilarities between categories [11,12]. Simple correspondence analysis showed an overall concordance between the radiographic and US patterns of 69%, with a confidence interval of 0.56e0.79, thus providing further evidence of the close concordance between the two imaging techniques in documenting the most frequent hand musculoskeletal abnormalities (Fig. 1). However, US revealed a tendinous pattern in 16% of the patients, who were otherwise misdiagnosed by means of radiography. The normal pattern found in 38.2% of the radiographs was confirmed by US in 27.3% of the patients. The degenerative radiographic pattern observed in 38.2% of patients was confirmed by US in 18 cases. Inflammatory radiographic changes were observed in two patients and confirmed by US, which also revealed tenosynovitis in both cases. A periarticular radiographic pattern was shown in 11 cases and US revealed that two also had tenosynovitis. US identifies a broad spectrum of hand conditions in a higher percentage of patients than radiography (72.7% vs. 61.8%), possibly because synovitis and tenosynovitis can only be visualized by US. Multiple correspondence analysis revealed two major clusters: the first grouping, anticentromere (ACA)-negative patients with diffuse cutaneous-SSc and a high degree of disease activity; the second grouping, ACA-positive patients with lcSSc and a low degree of disease activity. Cluster analysis showed a correlation between more severe disease (i.e., diffuse cutaneous-SSc with a high degree of disease activity) and the coexistence of two or more imaging patterns, whereas a single well-defined imaging pattern was more frequently observed in the cluster with less severe SSc (i.e., ACA-positive patients with lcSSc and a low degree of disease activity). In conclusion, our findings show the complementary role of US in assessing hand involvement in SSc, and that patients with severe disease more frequently have multiple coexisting hand abnormalities.
References [1] Baron M, Lee P, Keystone EC. The articular manifestations of progressive systemic sclerosis (scleroderma). Ann Rheum Dis 1982;41:147e52. [2] Lovell CR, Jayson MIV. Joint involvement in systemic sclerosis. Scand J Rheumatol 1979;8:154e60. [3] Blocka KLN, Basset LW, Furst DE, et al. The arthropathy of advanced progressive systemic sclerosis. A radiographic survey. Arthritis Rheum 1981;24:874e84. [4] La Montagna G, Sodano A, Capurro V, et al. The arthropathy of systemic sclerosis: a 12 month prospective clinical and imaging study. Skeletal Radiol 2005;34:35e41. [5] Avouac J, Guerini H, Wipff J, et al. Radiological hand involvement in systemic sclerosis. Ann Rheum Dis 2006;65: 1088e92. [6] La Montagna G, Baruffo A, Tirri R, et al. Foot involvement in systemic sclerosis: a longitudinal study of 100 patients. Semin Arthritis Rheum 2002;31:248e55. [7] Cuomo G, Zappia M, Abignano G, et al. Ultrasonographic features of the hand and wrist in systemic sclerosis. Rheumatology 2009;48:1414e7. [8] Preliminary criteria for the classification of systemic sclerosis (scleroderma). Subcommittee for scleroderma criteria of the american rheumatism association diagnostic and therapeutic criteria committee. Arthritis Rheum 1980;23:581e90. [9] Valentini G, Della Rossa A, Bombardieri S, et al. European multicentre study to define disease activity criteria for systemic sclerosis. II. Identification of disease activity variables and development of preliminary activity indexes. Ann Rheum Dis 2001;6:592e8. [10] Valentini G, Bencivelli W, Bombardieri S, et al. European Scleroderma Study Group to define disease activity criteria for systemic sclerosis. III. Assessment of the construct validity of the preliminary activity criteria. Ann Rheum Dis 2003;62: 901e3. [11] Greenacre M. Theory and application of correspondence analysis. London: Academic Press; 1984. [12] Lebart L, Piron M, Morineau A. Statistique explorative Multidimensionale. Paris: Dunod; 1995.