Search

Background/Aims Magnetic resonance imaging (MRI) plays an increasingly important role in diagnosing and monitoring patients with inflammatory arthropathies due to its ability to detect early, sometimes subclinical, inflammatory changes, including synovitis. It is a sensitive, accurate and relatively non-operator dependent modality. However, it is typically perceived as expensive and time-consuming, and is used infrequently for evaluation of synovitis in clinical care. MRI is thought to be generally well-tolerated by patients, however, there is a paucity of research on patient experience of MRI, particularly in rheumatology where patients may have complex and/or chronic pain. To improve the acceptability, cost-effectiveness and overall utility of MRI for clinicians and patients, we introduced a short synovitis MRI protocol (MRI-SSP) for rapid assessment of synovitis in the hands and feet. Here, we evaluated the acceptability of MRI-SSP to patients and the perceived utility of the protocol for rheumatologists. Methods Different structured questionnaires were designed for patients and rheumatologists which contained qualitative (free-text) and quantitative (five-point Likert-scale) questions. All patients undergoing MRI-SSP of the hand or wrist at University College London Hospital (UCLH) between 01/02/22 to 01/07/22 were prospectively invited to participate and completed the questionnaire via telephone within four weeks of their scan. All rheumatologists at our centre were invited to respond to an online questionnaire. Likert scores were analysed quantitatively and thematic analysis was performed on free-text comments. Results Patient experience - 30 patients agreed to participate (mean age 48 years, range 21-74; 87% female). Average patient Numerical Pain Rating Scale score was 5.1/10 (range 1-10). We found that: 90% found the scan length acceptable; 90% had no or mild side-effects from intravenous contrast; 40% had no pain during the scan; 57% had no anxiety during the scan; 97% found the scan acceptable overall; 97% would be happy to have the scan again; scan length and comfort were important for patients; good radiographer communication helped to alleviate patient anxiety. Rheumatologist perception - 10 rheumatologists responded. Of these, 40% perform ultrasound to assess for synovitis in clinic. We found that: 90% strongly agreed that the MRI-SSP report was helpful in answering clinical questions; 90% strongly agreed that the MRI-SSP influenced clinical decision making; there was a mixed response regarding which modality rheumatologists preferred for assessing synovitis (40% no preference, 30% MRI, 30% ultrasound) and this was independent of which rheumatologists performed ultrasound in clinic. Conclusion Overall, patients found MRI-SSP to be an acceptable investigation, and rheumatologists felt it helpful in clinical decision-making. Important factors affecting patient acceptability were scan length and comfort. In general, our results suggest that dedicated short MRI scanning protocols have the potential to improve the acceptability and accessibility of MRI for rheumatology patients. Disclosure N. Thorley: None. L. Dwyer-Hemmings: None. S. Singh: None. T.J.P. Bray: None. L. Bida: None. M.A. Hall-Craggs: None.

Imaging, and particularly MRI, plays a crucial role in the assessment of inflammation in rheumatic disease, and forms a core component of the diagnostic pathway in axial spondyloarthritis. However, conventional imaging techniques are limited by image contrast being non-specific to inflammation and a reliance on subjective, qualitative reader interpretation. Quantitative MRI methods offer scope to address these limitations and improve our ability to accurately and precisely detect and characterise inflammation, potentially facilitating a more personalised approach to management. Here, we review quantitative MRI methods and emerging quantitative imaging biomarkers for imaging inflammation in axial spondyloarthritis. We discuss the potential benefits as well as the practical considerations that must be addressed in the movement toward clinical translation of quantitative imaging biomarkers.

Magnitude-based fitting of chemical shift-encoded data enables proton density fat fraction (PDFF) andSimulations of multi-echo gradient-echo signal intensities are used to investigate the performance and behavior of MAGORINO over the space of clinically plausible PDFF,Simulations show that Rician noise-based magnitude fitting outperforms existing Gaussian noise-based fitting and reveals two key mechanisms underpinning the observed improvement. First, the likelihood functions exhibit two local optima; Rician noise modeling increases the chance that the global optimum corresponds to the ground truth. Second, when the global optimum corresponds to ground truth for both noise models, the optimum from Rician noise modeling is closer to ground truth. Multisite phantom experiments show good agreement of MAGORINO PDFF with reference values, and in vivo experiments replicate the performance benefits observed in simulation.The MAGORINO algorithm reduces Rician noise-related bias in PDFF and

Objective To demonstrate proof-of-concept for a quantitative MRI method using histographic analysis to assess bone marrow oedema and fat metaplasia in the sacroiliac joints. Materials and methods Fifty-three adolescents aged 12–23 with known or suspected sacroiliitis were prospectively recruited and underwent quantitative MRI (qMRI) scans, consisting of chemical shift-encoded (at 3 T) and diffusion-weighted imaging (at 1.5 T), plus conventional MRI (at 1.5 T) and clinical assessment. qMRI scans produced proton-density fat fraction (PDFF) and apparent diffusion coefficient (ADC) maps of the sacroiliac joints (SIJs), which were analysed using an in-house software tool enabling partially automated ROI definition and histographic analysis. Logistic regression and receiver operating characteristic (ROC) analyses assessed the predictive performance of ADC- and PDFF-based parameters in identifying active inflammation (oedema) and structural damage (fat metaplasia). Results ADC-based parameters were associated with increased odds of oedema (all p p 0.9). Conclusions ADC-based parameters can differentiate patients with bone marrow oedema from those without, whilst PDFF-based parameters can differentiate patients with fat metaplasia from those without. Histographic analysis might improve performance compared with simple averages such as the mean and median and offers excellent agreement within and between observers. Key Points • Quantitative MRI with histographic analysis can identify bone marrow oedema (an active inflammatory lesion) and fat metaplasia (a ‘chronic’ inflammatory lesion) in patients with spondyloarthritis. • The use of histographic analysis might improve the performance of quantitative MRI for detecting bone marrow oedema and fat metaplasia compared with simple averages such as the mean and median. • Bone marrow oedema and fat metaplasia are known to be of diagnostic and prognostic significance, and the proposed method could support clinical decisions around biologic (and other) therapies in spondyloarthritis.

Background/Aims To assess the potential for whole-body MRI (WBMRI) to modify rheumatologists’ impression of disease activity and treatment management in adolescent patients with JIA. Methods Two rheumatology consultants experienced in managing people with JIA reviewed anonymised clinical data from an opportunistic sample of 30 patients with JIA (aged 15-24), not under their care. The cohort were clinically assessed by a senior rheumatology fellow before undergoing a research WBMRI scan, reported for musculoskeletal inflammation by a radiologist blinded to clinical information. The clinical findings and patient-reported outcomes recorded on that visit, alongside the patients’ present and past treatments, imaging and laboratory results were included in the clinical summaries examined by each rheumatologist. They then independently rated their impression of disease activity (See Table 1) and documented their resulting treatment recommendations per patient, in a two-stage approach. The first stage data analysis did not include the WBMRI reports. In stage two, the rheumatologists re-rated disease activity and treatment suggestions in light of WBMRI findings. The responses without and with the WBMRI findings were compared for each consultant and between them. Results Disease activity ratings were changed after reviewing the WBMRI reports in 16/30 and 17/30 patients by the rheumatologist A and B respectively. The activity category (‘active’ to ‘inactive’ or vice versa) changed in 7/16 and 4/17 cases, respectively. The certainty in the activity status increased for both rating clinicians (from ‘likely’ to ‘definitely’ in the same category or from ‘not sure’ to any other category) in 7/16 and 11/17 cases, respectively, whilst decreased for both in two cases. Disease activity assessments and treatment recommendations with and without WBMRI, are summarised in Table 1. Inter-rater agreement without and with WBMRI regarding disease activity (active/inactive) was 84.00% and 82.1% respectively, and regarding the intention to change treatment (yes/no) was 63.3% and 83.3%, respectively. Conclusion WBMRI scan findings changed the rheumatologists’ impression or level of certainty regarding disease activity in about half the patients and treatment plan in about one-third. Therefore, a larger study involving a greater number of rheumatologists across the country, should be considered to validate these results. Disclosure V. Choida: None. R.S. Tattersall: None. J.J. Manson: None. D. Sen: None. C. Ciurtin: None. M.A. Hall-Craggs: None.

Objectives To develop evidence-based recommendations on the use of MRI in the diagnosis of axial SpA (axSpA). Methods A working group comprising nine rheumatologists and nine musculoskeletal radiologists with an interest in axSpA was established, with support from the British Society of Spondyloarthritis (BRITSpA). Two meetings were held. In the first meeting, research questions were formulated. In the second meeting, the results of a systematic literature review designed to inform the recommendations were reviewed. An anonymized Delphi process was used to formulate the final set of recommendations. For each recommendation, the level of evidence and strength of recommendation was determined. The level of agreement was assessed using a 0–10 numerical rating scale. Results Two overarching principles were formulated, as follows: The diagnosis of axSpA is based on clinical, laboratory and imaging features (overarching principle 1), and patients with axSpA can have isolated inflammation of either the sacroiliac joints or the spine (overarching principle 2). Seven recommendations addressing the use of MRI in the assessment of patients with suspected axSpA were formulated, covering topics including recommended sequences, anatomical coverage, acquisition parameters and interpretation of active and structural MRI lesions. The level of agreement for each recommendation was very high (range 8.8–9.8). Conclusion A joint rheumatology and radiology consensus on the acquisition and interpretation of MRI in axSpA diagnosis was achieved, and a research agenda formulated. This consensus should help standardize practice around MRI and ensure a more informed, consistent approach to the diagnosis of axSpA.

Objectives: To assess body composition in patients with non-small cell lung cancer (NSCLC) and colorectal cancer using whole-body MRI and relate this to clinical outcomes. Methods: 53 patients with NSCLC (28 males, 25 females; mean age 66.9) and 74 patients with colorectal cancer (42 males, 32 females; mean age 62.9) underwent staging whole-body MRI scans, which were post-processed to derive fat mass (FM), fat free mass (FFM) and skeletal muscle (SM) indices and SM fat fraction (FF). These were compared between the two cancer cohorts using two-sided t-tests and the chi-squared test. Measurements of body composition were correlated with outcomes including length of hospital stay, metastatic status and mortality. Results: Patients with NSCLC had significantly lower FFM (p = 0.0071) and SM (p = 0.0084) indices. Mean SM FF was greater in patients with NSCLC (p = 0.0124) and was associated with longer hospital stay (p = 0.035). There was no significant relationship between FM, FFM and SM indices and length of hospital stay, metastatic status or mortality. Conclusions: Patients with NSCLC had lower FFM and SM indices than patients with colorectal cancer and greater SMFF, indicating lower SM mass with fatty infiltration. These findings reflect differences in the phenotype of the two groups and suggest patients with lung cancer are more likely to require additional nutritional support. Advances in knowledge: Body composition differs between NSCLC and colorectal cancer. Patients with NSCLC have both a reduced SM mass and greater SM FF suggesting that they are more nutritionally deplete than patients with colorectal cancer.

Background/Aims Magnetic resonance imaging can facilitate the diagnosis of JIA, but is also increasingly used for monitoring disease activity in individual joints. This prospective study aims to measure the frequency of subclinical synovitis on whole-body MRI, in adolescent patients with JIA. Methods JIA patients were recruited from a tertiary adolescent and young adult rheumatology clinic, between September 2019 and August 2020. All patients were examined by a senior rheumatology registrar, before undergoing a contrast enhanced whole-body MRI scan. Patients were assigned to a clinically active or inactive group, depending on their active joint count (AJC); active patients had AJC≥ 1, while the clinically inactive patients had an AJC =0. The post-contrast, water-only mDixon images were assessed for synovitis by one radiologist, blinded to clinical information. Only joints that were definitely abnormal were counted as synovitic. Eighty-one joints per patient were examined with both methods. The presence of subclinical synovitis in a patient was defined as synovitis in one or more joints on MRI, which were not active clinically. Results Thirty-two patients aged 15 to 24 were included in the analysis. The patient characteristics and the frequency of subclinical synovitis are summarised in the table. Subclinical synovitis was detected in a similar proportion of JIA patients in both active and inactive groups (46.7% vs. 41.2%, P = 0.76). The most frequent region with subclinical synovitis was the hindfoot, detected in 22% (7/32) of JIA patients and 17.2% (11/64) of hindfoot joints assessed by MRI. The second most common joint with clinically unsuspected inflammation was the knee, found in 19% (6/32) of JIA patients and 14% (9/64) knee joints. Similarly, 16% (5/32) of the adolescent patients had active disease in the hip, ankle or midfoot joints. The frequency of elbow involvement was also considerable, with 12% (7/58) of joints with subclinical synovitis in 14% (4/29) of JIA patients. Conclusion In conclusion, 43.8% of JIA patients had subclinical synovitis on whole-body MRI scan with no significant difference between the clinically active vs. inactive JIA patients. Large joints were predominantly affected. Further research is required to validate our findings in a larger cohort of JIA patients. Disclosure V. Choida: None. C. Ciurtin: None. T.J.P. Bray: None. D. Sen: None. C. Fisher: None. M. Leandro: None. M.A. Hall-Craggs: None.

Background:. While perinatal risk factors are widely used to help identify those at risk for developmental dysplasia of the hip (DDH) within the first 6 to 8 weeks of life, limited data exist about their association with radiographic evidence of dysplasia in childhood. The purpose of this study was to determine which perinatal risk factors are associated with acetabular dysplasia in children who are ≥2 years of age. Methods:. Pelvic radiographs were made in 1,053 children (mean age, 4.4 years [range, 2 to 7 years]) who had been assessed prospectively as having at least 1 of 9 widely accepted perinatal risk factors for DDH. Two radiologists who were blinded to patient risk factors, history, and age determined the acetabular index (AI). The primary outcome was defined as an AI >2 standard deviations from the Tönnis reference values (“severe” dysplasia). The secondary outcome was an AI of >20° at >2 years of age. The association between risk factors and outcomes was assessed using logistic regression. The effect of treatment in infancy was adjusted for in 37 hips. Results:. Twenty-seven participants (3%) showed “severe” hip dysplasia; 3 of these had received treatment for DDH in infancy. Girls were more likely to experience this outcome (odds ratio [OR] = 2.59; 95% confidence interval [CI] = 1.04 to 6.46; p = 0.04); no other examined risk factors were significant. The secondary outcome appeared in 146 participants (14%), 12 of whom had received treatment in infancy. We observed the following predictors for this outcome: female sex (OR = 1.77; 95% CI = 1.21 to 2.59; p = 0.003), breech presentation (OR = 1.74; 95% CI = 1.08 to 2.79; p = 0.02), and being a firstborn child, which had a protective effect (OR = 0.67; 95% CI = 0.46 to 0.96; p = 0.03). Conclusions:. We identified a substantial number of cases that will require at least radiographic surveillance for mild and severe hip dysplasia; 92% had no prior diagnosis of DDH. Those who had been born breech were affected by this outcome even if ultrasonography of the hip had been normal at 6 to 8 weeks, suggesting a benefit from additional radiographic testing. Level of Evidence:. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

There is increasing scrutiny from healthcare organizations towards the utility and associated costs of imaging. MRI has traditionally been used as a high-end modality, and although shown extremely important for many types of clinical scenarios, it has been suggested as too expensive by some. This editorial will try and explain how value should be addressed and gives some insights and practical examples of how value of MRI can be increased. It requires a global effort to increase accessibility, value for money, and impact on patient management. We hope this editorial sheds some light and gives some indications of where the field may wish to address some of its research to proactively demonstrate the value of MRI. Level of Evidence: 5. Technical Efficacy: Stage 5. J. Magn. Reson. Imaging 2019;49:e14–e25.

Imaging plays a vital role in the diagnosis and management of rheumatological disorders. Traditionally, plain film radiography was widely used in arthropathies to assess periarticular bony changes; these often reflect established changes in the late stage of disease and thus have limited value in early diagnosis and disease monitoring. Magnetic resonance imaging (MRI) has become an important imaging modality in rheumatological disorders because it can assess both morphological and functional changes. It plays a substantial role in early diagnosis, monitoring of disease evolution, assessment of treatment responses and prognostication. More recently, advances in hardware and novel imaging sequences have aided the development of new MRI techniques: whole-body MRI, for example, is gaining in popularity and allows an assessment of overall inflammatory status in arthritis. Quantitative MRI shows promise in allowing more objective evaluation and standardization of imaging-based assessment of inflammatory arthritis. This article also discusses other emerging imaging techniques. These include high-resolution peripheral quantitative computed tomography in early detection and monitoring of periarticular bone damage, fluorescence optical imaging in visualizing active inflammation, and molecular imaging in investigating pathogenesis and disease evaluation on a cellular level.

To evaluate whole-body MRI (WB-MRI) parameters significantly associated with treatment response in multiple myeloma (MM). Twenty-one MM patients underwent WB-MRI at diagnosis and after two cycles of chemotherapy. Scans acquired at 3.0 T included T2, diffusion-weighted-imaging (DWI) and mDixon pre- and post-contrast. Twenty focal lesions (FLs) matched on DWI and post-contrast mDixon were selected for each time point. Estimated tumour volume (eTV), apparent diffusion coefficient (ADC), enhancement ratio (ER) and signal fat fraction (sFF) were derived. Clinical treatment response to chemotherapy was assessed using conventional criteria. Significance of temporal parameter change was assessed by the paired t test and receiver operating characteristics/area under the curve (AUC) analysis was performed. Parameter repeatability was assessed by interclass correlation (ICC) and Bland–Altman analysis of 10 healthy volunteers scanned at two time points. Fifteen of 21 patients responded to treatment. Of 254 FLs analysed, sFF (p

Purpose To evaluate proton density fat fraction (PDFF) and R2* as markers of bone marrow composition and structure in inflamed bone in patients with spondyloarthritis. Methods Phantoms containing fat, water, and trabecular bone were constructed with proton density fat fraction (PDFF) and bone mineral density (BMD) values matching those expected in healthy bone marrow and disease states, and scanned using chemical shift-encoded MRI (CSE-MRI) at 3T. Measured PDFF and R2* values in phantoms were compared with reference FF and BMD values. Eight spondyloarthritis patients and 10 controls underwent CSE-MRI of the sacroiliac joints. PDFF and R2* in areas of inflamed bone and fat metaplasia in patients were compared with normal bone marrow in controls. Results In phantoms, PDFF measurements were accurate over the full range of PDFF and BMD values. R2* measurements were positively associated with BMD but also were influenced by variations in PDFF. In patients, PDFF was reduced in areas of inflammation and increased in fat metaplasia compared to normal marrow. R2* measurements were significantly reduced in areas of fat metaplasia. Conclusion PDFF measurements reflect changes in marrow composition in areas of active inflammation and structural damage and could be used for disease monitoring in spondyloarthritis. R2* measurements may provide additional information bone mineral density but also are influenced by fat content. Magn Reson Med, 2017.

Objective To identify the whole-body MRI (WB-MRI) image type(s) with the highest value for assessment of multiple myeloma, in order to optimise acquisition protocols and read times. Methods Thirty patients with clinically-suspected MM underwent WB-MRI at 3 Tesla. Unenhanced Dixon images [fat-only (FO) and water-only (WO)], post contrast Dixon [fat-only plus contrast (FOC) and water-only plus contrast (WOC)] and diffusion weighted images (DWI) of the pelvis from all 30 patients were randomised and read by three experienced readers. For each image type, each reader identified and labelled all visible myeloma lesions. Each identified lesion was compared with a composite reference standard achieved by review of a complete imaging dataset by a further experienced consultant radiologist to determine truly positive lesions. Lesion count, true positives, sensitivity, and positive predictive value were determined. Time to read each scan set was recorded. Confidence for a diagnosis of myeloma was scored using a Likert scale. Conspicuity of focal lesions was assessed in terms of percent contrast and contrast to noise ratio (CNR). Results Lesion count, true positives, sensitivity and confidence scores were significantly higher when compared to other image types for DWI (P

The role of conventional qualitative MRI is well established in the management of spondyloarthritis for assessment of inflammation and structural damage. The identification of a ‘positive’ MRI is now an important component of diagnostic pathways in spondyloarthritis.1 The role of q uantitative MRI (QMRI) is less established but offers the potential for direct measurement of disease characteristics. This approach is yielding huge benefits in fields such as oncology and neurology, where quantifiable measurements can be used to identify, stage and monitor disease. Given the influence that radiological assessment of disease burden has on treatment decisions, we argue that a quantitative imaging approach should be rigorously explored as a tool for assessment of inflammation in musculoskeletal imaging. Typically for QMRI, a model is fitted to a series of images to yield maps of a defined physical characteristic of the tissue. Assessment can then take the form of …

BACKGROUND Quantification of fat by proton density fat fraction (PDFF) measurements may be valuable for the quantification and follow-up of pathology in multicenter clinical trials and routine practice. However, many centers do not have access to specialist methods (such as chemical shift imaging) for PDFF measurement. This is a barrier to more widespread trial implementation. PURPOSE/HYPOTHESIS To determine the agreement between fat fraction (FF) measurements derived from 1) basic vendor-supplied sequences, 2) basic sequences with offline correction, and 3) specialist vendor-supplied methods. STUDY TYPE Prospective. POPULATION Two substudies with ten and five healthy volunteers. FIELD STRENGTH/SEQUENCE Site A: mDixon Quant (Philips 3T Ingenia); Site B: IDEAL and FLEX (GE 1.5T Optima MR450W); Site C: DIXON, with additional 5-echo gradient echo acquisition for offline correction (Siemens 3T Skyra); Site D: DIXON, with additional VIBE acquisitions for offline correction (Siemens 1.5T Avanto). The specialist method at site A was used as a standard to compare to the basic methods at sites B, C, and D. ASSESSMENT Regions of interest were placed on areas of subchondral bone on FF maps from the various methods in each volunteer. STATISTICAL TESTS Relationships between FF measurements from the various sites and Dixon methods were assessed using Bland-Altman analysis and linear regression. RESULTS Basic methods consisting of IDEAL, LAVA FLEX, and DIXON produced FF values that were linearly related to reference FF values (P

Background Inflammation is a mediator and primary driver of joint damage in juvenile idiopathic arthritis (JIA). Musculoskeletal pain can be experienced in the presence or absence of inflammation. Enthesitis related arthritis (ERA) is a subtype of JIA characterised by inflammation of the spine, enthesis, and peripheral joints. Cytokines and numerous other regulatory molecules are implicated in pain and inflammation, yet, to date, no reliable biomarkers have been identified. Objectives To assess if cytokine profiles correlate with pain or disease activity in patients with ERA. Methods 42 patients, with either a prior diagnosis of JIA or back pain, agreed to have a standard clinical MRI scan of lumbar spine, sacroiliac joints, and pelvis and to donate serum. Serum was also collected from 12 volunteer age matched healthy controls. Serum was analysed using a bead-based multiplex assay (Luminex) for the concentrations of the following analytes: IL-6, IL-12, IL-17, IL-23, IL-27, TNFα, IFNγ, MIF, OPG, SOST, GM-CSF, VEGF, DKK-1, S100A8, MMP-3 and CRP. To assess pain levels, patients indicated on a scale of 0-10 the amount of back pain experienced at night and separately the amount of back pain experienced at any time during the last week. They also completed a Bath Ankylosing Spondylitis Disease activity Index (BASDAI) questionnaire to assess disease activity. Cytokine concentrations in patients with ERA were compared with those of controls. The levels were also correlated with the two measures of back pain as well as individual questions from the BASDAI questionnaire. Results Of all 54 samples tested, 11 patients and 5 controls cross-reacted with the negative control for the assay and thus were excluded from analysis. Based on MRI scan results, 14 patients had ERA, 8 had biomechanical pain, 7 had other subtypes of JIA, and 2 had non-specific features of spinal inflammation. The median overall back pain and the total BASDAI scores for the ERA group were 2.4 (IQR=1.45-5.55) and 2.5 (IQR= 0.75-6.25) respectively, suggesting well controlled disease on treatment and minimal residual symptoms. There was no statistical difference between cytokine levels in the ERA group compared to controls when corrected for multiple testing, with the exception of IL-12 which was significantly higher in controls (p=0.003). No correlation was found between cytokines and pain scores (at night or overall during the last week) or with the overall BASDAI score or any of the sub-component questions of the BASDAI questionnaire. Conclusion Well-controlled ERA patients on treatment have similar cytokine profiles as healthy controls and they do not correlate with clinical pain scores or disease activity. Disclosure of Interests None declared

Background Magnetic resonance imaging is increasingly used to diagnose, stratify and monitor inflammation in patients with spondyloarthritis, including young patients with enthesitis-related arthritis (ERA). Recently, there has been interest in the use of quantitative magnetic resonance imaging (qMRI) as an objective method of assessing disease. For example, diffusion-weighted imaging (DWI) and fat fraction (FF) mapping have emerged as biomarkers of oedema and structural damage, respectively, in inflamed bone1. However, as yet there are limited data to tie these biomarkers to underlying immunopathology. Objectives To analyse the relationships between quantitative imaging biomarkers (QIBs), axial pain and serum biomarkers – including ‘inflammatory’ biomarkers and those reflecting bone turnover - in a cohort of ERA patients. Methods 28 patients with ERA were prospectively recruited. The hips, sacroiliac joints and lumbar spine were assessed with chemical shift-encoded MRI and diffusion weighted imaging. Quantitative MRI parameters, such as the apparent diffusion coefficient (ADC) and fat fraction (FF) were measured in the sacroiliac joints. Visual scores for inflammation and fat metaplasia were also reported. BASDAI questionnaires were completed. Serum cytokines and bone markers were measured via multiplex bead-based immunoassays (Luminex) and results were available for 14 patients with ERA. Results The mean visual analogue score for spinal and hip pain (BASDAI Q2) was 3.9 (Table 1). There was a correlation between ADCmean and spinal and hip pain (rs=0.393, P=0.043). There was also a negative correlation between FFmean and the above pain score (rs = -0.378, P=0.047). There was a positive correlation between matrix metalloproteinase-3 (MMP-3) levels and FFmean (n=14, rs=0.698, P=0.006). However, the correlation did not reach statistical significance when corrected for multiple testing. Conclusion The correlation of ADCmean, which increases with increased tissue water/inflammation, with spinal and hip pain suggests that BASDAI Q2 relates to pain of active inflammation. Similarly the inverse correlation of FFmean, which increases with bone healing and reduced inflammation, and BASDAI Q2, would also support this relationship. References [1] Bray TJP, Bainbridge A, Punwani S, Ioannou Y, Hall-Craggs MA. Simultaneous Quantification of Bone Edema/Adiposity and Structure in Inflamed Bone using Chemical-Shift Encoded MRI in Spondyloarthritis. Magnetic Resonance in Medicine2018Feb;79(2):1031-1042 Disclosure of Interests None declared

Diffusion-weighted imaging has received attention as a method for characterizing inflammatory exudates in bone marrow in immune-mediated inflammatory diseases and reveals an increase in diffusivity in regions of bone marrow oedema. Various models of diffusion attenuation have been investigated but the model providing the best description of tissue pathophysiology in regions of marrow oedema is unknown. Determining the most appropriate model is an important step towards protocol optimization and the development of a robust and clinically useful method. We aimed to determine which of three candidate models of diffusion attenuation most accurately describes the acquired signal from normal and inflamed bone marrow. 11 subjects with spondyloarthritis and evidence of active inflammation (ie bone marrow oedema) on MRI and 17 patients with no evidence of active inflammation underwent diffusion-weighted imaging of the sacroiliac joints (b-values 0, 50, 100, 300 and 600 s/mm2 ). Monoexponential, intravoxel incoherent motion (IVIM) and kurtosis models were fitted to the acquired signal from regions of interest in areas of bone marrow oedema and normal marrow. The three models were compared in terms of sum of squared error and information content (corrected Akaike information criterion). Model parameters were compared between regions of bone marrow oedema and regions of normal marrow. f the three models investigated, the IVIM model provided the best description of the signal over the 0-600 s/mm2 range across normal and inflamed bone marrow. There was a particular advantage of the IVIM model in normal marrow, where it was best able to capture the pronounced fast diffusion component observed in several cases. However, IVIM and kurtosis effects both became smaller and the signal behaviour became closer to monoexponential in the presence of bone marrow oedema. Our data suggest that increases in Dtissue (in the IVIM framework) might account for the reduced deviation from monoexponential behaviour in oedematous bone.

Objectives To summarize the evidence on the performance of MRI for the diagnosis of axial SpA. Methods This was a systematic literature review of all studies from January 2013 to March 2017 including adult patients with clinically suspected axial SpA undergoing MRI. Studies from a previously published systematic literature review up to January 2013 were also included. Results Thirty-one studies were included. Six studies demonstrated good sensitivity and specificity for SI joint (SIJ) bone marrow oedema (BMO). Specificity was increased by the presence of other structural lesions alongside BMO, particularly erosions or fat infiltration. Four studies addressed the utility of SIJ fat infiltration, finding good sensitivity but poor specificity. SIJ erosions showed good specificity in five studies. Studies addressing high T1 signal in the SIJ, fluid signal in the SIJ, ankylosis, sclerosis, capsulitis, backfill and vacuum phenomenon reported limited diagnostic value. In the spine, four studies reported moderate sensitivity and specificity for corner inflammatory lesions, and four reported poor sensitivity and specificity for spinal fat infiltration. Five studies evaluated the added value of spinal MRI over SIJ MRI alone, with variable results depending on the cohort. Six studies addressed the effect of acquisition parameters on diagnostic accuracy: fat-saturated T2-weighted imaging and short tau inversion recovery (STIR) imaging showed comparable utility in identifying BMO. Three studies showed that gadolinium was of minimal added value in the detection of BMO. Conclusions These results confirmed the diagnostic utility of MRI in axial SpA. Performance varied according to the characteristics of the cohort and the number and combination of MRI lesions considered.

Purpose Accurate delineation of target volume and normal tissue is critical for intensity modulated radiation therapy (IMRT) use in cervical cancer. Phase III Multicentre Trial of Weekly Induction Chemotherapy Followed by Standard Chemoradiation versus Standard Chemoradiation Alone in Patients With Locally Advanced Cervical Cancer (INTERLACE) radiation therapy quality assurance (RTQA) has highlighted significant interobserver delineation variation. Prescriptive guidelines reduce interobserver variation in other cancers. Methods and Materials A literature search using PubMed/Medline database of guidelines for target anatomy delineation in cervical cancer was undertaken. Differences in practice in these publications and INTERLACE trial RTQA were identified. Consensus best practice delineation was derived and a pictorial atlas produced. The proportion of outlines complying with protocol in test and real-time cases was compared before and after atlas implementation within the INTERLACE RTQA pack. Results Seven key papers were reviewed. Eleven areas of variation were identified. These included the definition and editing of bowel, definition of the femur, vagina, parametria, inferior and superior nodal borders, nodal clinical target volume (CTV) editing, para-aortic nodal CTV definition, and the margin to be used around enlarged nodes. The average proportion of outlines (of 4; primary CTV, nodal CTV, bladder, rectum) complying with protocol in test and real-time cases improved from 1.8 to 2.7 (difference, 0.9; 95% confidence interval, 0.3-1.5; P = .003) with atlas use. Conclusion Differences exist in the published literature and clinical practice. This pictorial atlas reflects consensus recommendations and is now available to INTERLACE participating centers. Atlas use has reduced interobserver delineation variation in this trial setting.

Enthesitis‐related arthropathy (ERA) is severe subtype of juvenile idiopathic arthritis (JIA), and carries a substantial burden of morbidity and disability.1 Sacroiliitis is a particular problem in ERA, and up to 80% of patients with low back pain in ERA have sacroiliitis.2 However, monitoring the disease is difficult because clinical symptoms may be nonspecific; clinical assessment has been shown to be an insensitive tool for assessing sacroiliitis as diagnosed using magnetic resonance imaging (MRI).3 An accurate, specific method for diagnosis and quantification of sacroiliitis is therefore an important part of these patients' management. MRI has emerged as a valuable tool for assessing the sacroiliac joints.4 Conventional qualitative techniques rely on visual analysis of short tau inversion recovery (STIR) images,5 but recent research has demonstrated that diffusion‐weighted imaging (DWI) can be used as a fast, objective alternative.6, 7, 8, 9 However, assessment of joint inflammation in adolescence is challenging because the structure and composition of the sacroiliac joint changes substantially during skeletal maturation. Sacral ossification begins in the first two sacral segments in utero.10, 11 As the sacral apophyses ossify during childhood, residual cartilaginous connections that link the SIJs and the neural foramina gradually disappear. The apophyses typically fuse between the ages of 16 and 20, although sometimes the SIJs remain immature well into late adolescence.10, 12 Immature sacroiliac joint morphology may be misinterpreted as inflammation because unossified cartilage causes juxta‐articular areas of high signal on STIR images (Fig. ​(Fig.1).1). To our knowledge, there are no previous studies investigating the influence of joint maturity on apparent diffusion coefficient (ADC) values as measured using DWI. Figure 1 STIR and T 1‐weighted images from an 11‐year‐old female (a,b). In this case, the juxta‐articular bands of high signal on the STIR images were misdiagnosed as inflammation. Further scans (c,d) 2 years later (when the patient ... We hypothesized that ADC values would vary with joint maturity, since unossified bone would be expected to contain a higher proportion of water than fully mineralized bone (the relationship between water content and ADC is well established13. Furthermore, we hypothesized that normalized ADC (nADC) values14 would also be higher in unfused SIJs. nADC values (ie, the mean SIJ ADC value divided by a “reference” ADC obtained from normal sacral bone) are of particular interest because nADC has been investigated as a biomarker of inflammation in sacroiliitis,6 and may be less susceptible to between‐scan variability than uncorrected ADC. In this study we aimed to evaluate the association between SIJ maturity and both ADC and nADC measurements in adolescent and young adult patients with noninflammatory back pain.

Background:Whole body MRI (WBMRI) is an imaging technique that allows the assessment of the spine and peripheral joints in patients with inflammatory arthritis (IA) in a single examination. Depending on the protocol, it can potentially identify synovitis, enthesitis, spondyloarthritis and chronic structural changes.Objectives:To evaluate the performance of WBMRI in patients with IA for detecting inflammation compared with clinical assessments and to show changes in response to treatment.Methods:We conducted a systematic search of the electronic databases MEDLINE, EMBASE and Cochrane Library. Two authors selected independently the eligible studies, extracted the predefined data and assessed the quality using the QUADAS2 tool. Studies that reported a)disease activity scores, b)patient or physician reported outcomes or c)results from other imaging tests in IA patients who underwent WBMRI were included.Results:Fourteen studies out of 471 met our inclusion criteria. The majority of the studies were performed in Spondyloarthritis [SpA] (n=9), followed by Rheumatoid Arthritis [RA] (n=4) and Psoriatic Arthritis [PsA] patients (n=3). Nine studies provided clinical and MRI outcome measures. There was great heterogeneity in the quality of studies, disease specific outcomes reported and methodology used to compare with MRI findings. One study documented low correlation between 28 swollen/tender joint count and MRI bone marrow oedema (BME)/synovitis in RA patients, whereas another reported that 31% of MRI negative joints (other than hand joints) exhibited tenderness. In PsA, one study demonstrated correlation between 28 swollen joint count and BME (r=0.54,p=0.03). Superiority of WBMRI in the detection of synovitis and enthesitis over clinical examination was documented in two studies with SpA patients. A third study in SpA showed a ranging agreement of 49 to 100% between clinical and WBMRI enthesitis.Treatment response to biologics was assessed by WBMRI in 7 studies (5 in SpA, 2 in RA). In RA, one study showed numerical (but not statistically significant) reduction of WBMRI joint count at week 16 and 52 of Adalimumab treatment, whereas the reduction was statistically significant for the subset of patients achieving good EULAR response at week 16. The other study demonstrated a reduction in WBMRI synovitis and bone oedema scores after 1 year of anti-TNF or Tocilizumab treatment (median DAS28 score decreased from 5.1 to 2.1). A multicentre open label study reported a reduction in the number of MRI enthesitis lesions, spinal and sacroiliac joint scores at week 48, year 2 and 3 of Etanercept treatment in SpA patients. The mean BASDAI score decreased from 5.4 at baseline to 1.5 at year 2 and 2.2 at year 3. Improvement in WBMRI scores in SpA was also documented in one Adalimumab and one further Etanercept study.Conclusion:There was a variable level of correlation between clinical and WBMRI outcome measures across the included studies. The clinical significance of inflammation detected by WBMRI in some studies remains unclear. Many of the devised WBMRI scores appear to decrease after biologic treatment. Further studies are needed to determine the accuracy of WBMRI in detecting inflammation and its potential utility for clinical practice.Disclosure of Interests:Varvara Choida: None declared, Anastasia-Vasiliki Madenidou: None declared, Debajit Sen: None declared, Margaret Hall-Craggs: None declared, Coziana Ciurtin Grant/research support from: Pfizer, Consultant of: Roche, Modern Biosciences

Background:The incidence of inflammatory and structural lesions on magnetic resonance imaging of sacroiliac joints (MRI SIJs) in patients with hypermobility related disorders has not been fully investigated. Hypermobile patients are more susceptible to pelvic instability and biomechanical stress of the SIJs, leading to MRI SIJ changes similar to those occurring in spondyloarthritis (SpA). Patients with hypermobility and suspected SpA pose a unique challenge owing to the high prevalence of back pain in the hypermobility cohort and the absence of spinal restriction on clinical examination.Objectives:In this study, we aim to investigate the incidence of MRI SIJ lesions in patients with hypermobility.Methods:We performed a retrospective study of all patients with a confirmed diagnosis of hypermobility related disorders (including hypermobility syndrome, hypermobility spectrum disorders and Ehlers-Danlos Syndromes) referred for an MRI lumbar spine and SIJ between 2011 and 2019 to investigate long-standing back pain. MRIs were examined by a musculoskeletal (MSK) radiologist with more than 25 years of experience, who was blinded to the clinical outcome of the patients. MRI SIJs were assessed for the presence of bone marrow oedema, subchondral sclerosis, erosion, fatty change, enthesitis, ankylosis, joint fluid and capsulitis.Results:51 patients with confirmed hypermobility related disorders were referred for MRI SIJ and lumbar spine between 2011 and 2019. 3 patients demonstrated clinical features in keeping with a diagnosis of SpA and were excluded from the study. 15/48 (31.3%) of patients with hypermobility and back pain (but no clinical picture of SpA) were found to have inflammatory and/or structural lesions on MRI SIJ. The most frequent lesions were small foci of bone marrow oedema (16.6%) followed by subchondral sclerosis (12.5%) and fatty change (10.4%). The incidence of erosions was 4.2%.Conclusion:There is a relatively high incidence of inflammatory and structural lesions on MRI SIJ of patients with hypermobility. The presence of hypermobility should be taken into consideration when interpreting MRI changes in patients with suspected SpA. Further research into long-term outcomes of MRI SIJs in patients with hypermobility and back pain is required to establish the clinical significance of these findings.Disclosure of Interests: :Alexis Jones: None declared, Coziana Ciurtin Grant/research support from: Pfizer, Consultant of: Roche, Modern Biosciences, Hanadi Kazkaz: None declared, Margaret Hall-Craggs: None declared

Background Magnetic resonance imaging (MRI) is an important part of diagnostic pathways in spondyloarthritis (SpA), and can be used to stratify patients and assess severity. However, measurements of the burden of inflammation currently rely on qualitative assessment, which is subjective and time-consuming thus impractical for clinical practice. There is a need for a more objective, faster method for measuring inflammation and damage with potential for automation, and quantitative MRI is a candidate tool. Objectives We aimed to provide proof-of-principle for the BEACH (Bone OEdema and Adiposity quantification with Apparent diffusion coefficient and Chemical shift imaging with histograms) tool, which quantifies bone marrow oedema and fat metaplasia – features of active and chronic inflammation – in the SIJs. Methods Fifty-three patients aged 12–24 years with either SpA or mechanical back pain were recruited prospectively, and underwent quantitative MRI consisting of diffusion weighted imaging (DWI) and fat fraction (FF) mapping, 2,3 and conventional MRI scans. Apparent diffusion coefficient (ADC) and FF maps were assessed using the BEACH tool, which automatically propagates ROIs on subchondral bone after the observer defines the SIJ. Pixel values were analysed to derive the histographic parameters for ADC and FF: median, 10th, 25th, 75th and 90th percentiles (denoted ADC 10 , ADC 25 , FF 10 , FF 25 , etc), and p high and plough (the proportion of high and low value pixels respectively). Conventional MRI scans were assessed using visual scoring. 4 Patients were deemed to have active inflammation if their inflammation score was ≥2, and to have fat metaplasia if this score was ≥3. Quantitative measurements were compared between inflamed and non-inflamed SIJs. Results Use of the BEACH tool is demonstrated in figure 1(a)-(f). Example ADC histograms are shown in (g),(h). ADC 75 , ADC 90 , and p high(ADC) were significantly increased in inflamed SIJs ( P= 0.041, 0.006 and 0.003 respectively), although median ADC values did not differ significantly between inflamed and uninflamed joints ( P= 0.31). Diagnostic performance was superior for histographic parameters (AUC = 0.59, 0.67 and 0.69) than for the median (AUC=0.54) Median FF, FF 75 , FF 90 and p high(FF) were all significantly increased in SIJs with fat metaplasia compared to those without (all p 0.0001). Diagnostic performance was superior for histographic parameters FF 75 , FF 90 and p high(FF) (AUC=0.89, 0.92 and 0.92) than for the median (AUC=0.87). Conclusions ADC and FF measurements can differentiate between inflamed and non-inflamed SIJs, and between joints with and without fat metaplasia. Compared to simple averages such as the median, histographic parameters can increase diagnostic performance for detecting inflammation and fat metaplasia. There is minimal subjectivity associated with ROI placement using the BEACH tool, which can potentially make inflammation scores more reproducible. References [1] Vendhan K, et al. Br J Radiol. 2016. [2] Bray TJP, et al. Rheumatol. 2017. [3] Bray TJP, et al. Magn Reson Med. 2017. [4] Maksymowych WP, et al. Arthr Care Res. 2005. Acknowledgements Funding: TJPB:ARUK grant 21369;MHC, UCLH BRC;CC, CF:ARUK. Disclosure of Interest None declared

Background Magnetic resonance imaging (MRI) is an essential tool in the diagnosis and management of axial spondyloarthritis (axSpA). However, a recent survey showed variable practices in the use of MRI across the UK. 1 To inform a joint rheumatology and radiology consensus exercise aimed at standardising practice, we systematically reviewed the literature regarding the use of MRI in the diagnosis of axSpA. Objectives We aimed to answer three research questions: 1. How does the choice of anatomical region influence diagnostic performance? 2. How do MRI acquisition parameters influence diagnostic performance? 3. Which lesion, or combination of lesions, is most sensitive and specific for the diagnosis of axSpA? Methods MEDLINE (via Pubmed) and EMBASE (via Ovid) databases were searched using previously-reported terms. 2 These terms identified studies including adult patients with clinically suspected axSpA undergoing MRI, where a diagnosis of axSpA was used as an outcome and where patients with a negative test for SpA were used as controls. We included studies performed between January 2013 and March 2017, in addition to those included in a previous systematic literature review, which included all studies up to January 2013. 2 Search results were screened by title and abstract, and the included studies were subject to detailed review and quality assessment using the QUADAS-2 tool. 3 Results The combined search resulted in a total of 8114 studies; 34 of these were finally selected for inclusion. Five studies evaluated the added value of spinal MRI over SIJ MRI alone, with variable results depending on the cohort. Three studies addressed the effect of sequence choice on diagnostic accuracy, demonstrating comparable utility of fat-saturated T2-weighted (T2w) sequences and STIR imaging, and suggesting T2w Dixon imaging as a potential alternative method for fat suppression. Three studies investigated the role of gadolinium in the SIJs, and overall found minimal added value. Bone marrow oedema of the sacroiliac joint (SIJ) was found to be the most sensitive and specific lesion in the diagnosis of axSpA in seven studies. Sensitivity and specificity were increased by including other structural lesions, particularly bone marrow fat or erosions. Four studies addressed the utility of SIJ fat infiltration, demonstrating good sensitivity but relatively poor specificity. A number of studies addressing erosions, high T1 signal in the SIJ, fluid signal in the SIJ, ankylosis, sclerosis, capsulitis, backfill and vacuum phenomenon reported low to moderate diagnostic performance for these features. In the spine, four studies reported moderate sensitivity and specificity for corner inflammatory lesions, and four reported poor sensitivity and specificity for spinal fatty lesions. Three studies evaluated agreement between observers for inflammatory and structural features. Agreement was best for the presence of oedema in the SIJs, but was poor for structural features. Agreement was weak to moderate for global diagnosis. Conclusions These results have informed the recommendations of a consensus group aiming to standardise practice around the use of MRI scans in the UK. References [1] Bennett, et al. J Rheumatol2017. [2] Mandl, et al. Ann Rheum Dis2015. [3] Whiting, et al. Annals Int Medicine2011. Disclosure of Interest None declared

Background The use of magnetic resonance imaging (MRI) has been instrumental in the early recognition and characterisation of axial spondyloarthritis (axSpA). However, a recent survey in the UK showed that there is diverse practice in the use of MRI and limited knowledge of MRI features suggestive of axSpA among radiologists.1 Objectives To develop clinical practice recommendations for the acquisition and interpretation of MRI of the spine and sacroiliac joints (SIJs) in the investigation of axSpA through a collaboration between rheumatologists and radiologists. Methods A working group comprising 9 rheumatologists and 9 musculoskeletal radiologists with an interest in axSpA was established. The EULAR standardised operating procedures were followed.2 Two working group meetings were held, the first to define the scope of the exercise and the second to review the results of the Systematic Literature Review that informed the recommendations. An anonymised Delphi process was used to formulate the final set of recommendations. The level of evidence and strength of recommendation was added to the recommendations. The level of agreement by working group members was assessed using a numerical rating scale. Results A total of 2 overarching principles and 7 recommendations were formulated (figure 1). The first 3 recommendations address the MRI acquisition protocol, namely anatomical areas to be scanned and sequences to be used. The remaining 4 recommendations address the interpretation of active and structural lesions of the spine and SIJs. Conclusions A UK joint rheumatology and radiology consensus on the most appropriate MRI acquisition protocol and interpretation of images in the investigation of axSpA was achieved. This consensus will help standardise practices and ensure prompt and effective patient management in the diagnosis and treatment of axSpA. References [1] Bennett, et al. J Rheumatol2017. [2] van der Heijde, et al. Ann Rheum Dis2015. Acknowledgements This work was financially supported by the British Society for Spondyloarthritis (BRITSpA). Disclosure of Interest None declared

We read with interest the recent paper on diffusion-weighted imaging (DWI) as a means of supporting the diagnosis of ankylosing spondylitis1, and the corresponding editorial questioning the role of DWI2. The paper1 adds to the growing body of evidence supporting the use of DWI to characterize and quantify inflammation in patients with spondyloarthritis (SpA)3,4. The corresponding editorial argues that DWI is of limited clinical use, and the authors’ main criticisms are summarized as follows: 1. Any sequence can be measured numerically, and this is a facility not confined to DWI. 2. The number of steps required for normalizing measurements and choosing regions of interest (ROI) depends on review of the initial qualitative images and is subjective. 3. The variable diffusion of background marrow poses further challenges for DWI. However, if we look in greater detail at the existing literature on quantitative imaging, it is apparent that many of these issues can be addressed, and indeed there are multiple advantages that quantitative techniques … Address correspondence to Prof. M.A. Hall-Craggs, 2nd Floor, Charles Bell House, 43-45 Foley St., London W1W 7TS, UK. E-mail: margaret.hall-craggs{at}nhs.net

The radiology of bone has been transformed by magnetic resonance imaging, which has the ability to interrogate bone's complex architecture and physiology. New techniques provide information about both the macrostructure and microstructure of bone ranging from micrometre detail to the whole skeleton. Furthermore functional information about bone physiology can be used to detect disease early before structural changes occur. The future of bone imaging is in quantifying the anatomical and functional information to diagnose and monitor disease more precisely. This review explores the state of the art in quantitative MRI bone imaging.

A 16 year old boy had a two year history of skin lumps on his legs and progressive muscle weakness. Examination revealed a …