dual energy ct for gout - apma 2017 gout lecture .pdfgout dual energy ct - limitations • artifacts...
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Dual Energy CT for Gout
Benjamin D. Levine, MDAssociate Professor of Radiology
Dept. of Radiological SciencesMusculoskeletal Section
UCLA Health
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Gout
• Deposition of monosodium urate crystals (MSU) in joints and soft tissues
• Body’s reaction to MSU leads to inflammation and symptoms
• Hallmark is hyperuricemiawww.pathologyoutlines.com
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GoutDiagnosis
• Clinical Findings
• Reference standard
ID of MSU crystals in joint fluid aspirate or soft tissue biopsy (thin, needle, negative birefringence on polarized microscopy)
www.pathologyoutlines.com
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Gout Diagnosis (Difficult/Elusive)
• Reliability of polarizing microscopy is poor
• Unusual manifestations, mimics, and disease coexistence
• Hyperuricemia may not be present in acute gout (42%)
• Joint aspiration and/or needle biopsy may not be feasible:
Physician experience/skill
Busy office setting/blind aspiration
Small joints, periarticular soft tissues
• Joint aspiration/biopsy complications
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GoutIdeal Imaging
Accurate, non-invasive, early diagnosis Differentiate disease mimics
Detect unusual manifestations
Detect subclinical disease
Evaluate severity and sequelae of disease
Distinguish acute vs. chronic
Quantify urate burden
Monitor response to uratelowering therapy Outcome measures for clinical trials
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GoutImaging
• Radiography (X-Ray)
• Advanced Imaging
Magnetic Resonance Imaging (MRI)
High Resolution Ultrasound
Computed Tomography (CT) Dual Energy CT
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Gout Radiography
Marginal erosions with overhanging edges and sclerosis
Preserved joint spaces until late
Soft tissue nodules (tophi)
Normal xrays in early gout
45-70% negative
Latent period between first clinical symptoms and specific x-ray signs (5-10 yrs)
Rettenbacher T, et al. Eur Radiol 2008; 18:621-630
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GoutMRI
Comprehensive (soft tissue, bone, joint)
Not specific, variable MR features Tophi intermediate to low
signal
Variable enhancement and marrow edema
Location is key
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GoutHigh-Resolution Ultrasound
Joint features:
Joint effusion US more sensitive than
clinical exam
Synovitis
Erosions
Hyperechoic floating MSU crystals (“snowstorm”)
Filippucci E, et al. Clin Exp Rheumatol 2011; 29:901–905
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GoutHigh-Resolution Ultrasound
Double Contour Sign
MSU crystals on hyaline cartilage
Specific (99%) for gout and asymptomatic hyperuricemia
Not sensitive (44%)
Sign can resolve with therapy
Girish G,et al. AJR 2013; 201:515-525
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GoutHigh-Resolution Ultrasound
Synovitis
Heterogenous, hyperechoic foci, hypoechoic rim
Increased vascularity
Nodular, mass-like
Synovitis in RA:• Hypoechoic, arborizing,
fingerlike
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GoutHigh-Resolution Ultrasound
Erosions
Intraarticular discontinuity of the bone surface seen in 2 perpendicular planes (Outcome Measures in Rheumatology Group)
Caution:
Normal cortical variation
Degenerative changes
Post traumatic changes
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GoutHigh-Resolution Ultrasound
Tophi
• Hyperechoic, anechoic rim, nodular, infiltrative
• Posterior shadowing
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GoutHigh-Resolution Ultrasound
Tendons/Ligaments
Most commonly envelops (45%) rather than occurs intratendinous
Achilles Tendon
Peroneal tendons
Popliteus tendon
Cruciate ligaments
Patellar Tendon
de Ávila Fernandes E, et al. Insights Imaging 2010; 1:143–148
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GoutCT
Tophi
Discrete, hyperdense masses (160-170 HU)
Within bone, around joints, in tendons, in soft tissues
Erosions
Associated with tophi (82%)
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GoutDual Energy CT
• Two x-ray sources (80 and 140 kVp)
• Simultaneously acquires two data sets
• X-ray absorption is energy dependent
• Materials act differently at different energies depending on their chemical composition
• Creates a difference in attenuation (DEI)
• Each unique DEI makes classification of chemical composition of different tissues possible
• Computer algorithm software color codes different tissues based their unique DEI, and fuses with CT image
Desai MA, et al. Radiographics 2011; 31:1365-1375
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GoutDual Energy CT
Urate-Positive
Green, globular, focal, and confluent
Adjacent to an erosion
Ligaments, tendons, cartilage, menisci
Minimum diameter 3 mm
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GoutDual Energy CT
• Sensitivity 78-100%
• Specificity 89-100%
• Good overall accuracy
Bongartz T, et al. Ann Rheum Dis 2015; 74:1072–1077
Mallinson PI, et al. Skel Radiol 2014; 43(3):277-81
Glazebrook KN, et al. Radiology 2011; 261:516–524
Choi HK, et al. Ann Rheum Dis 2012; 71:1466–1471
Bongartz T, et al. Arthritis Rheum 2011; 63 (suppl 10): 1617
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Gout Dual Energy CT - Clinical Utility
Establish/confirm diagnosis
Unusual Clinical manifestations
Distinguish gout from disease mimics
Discordant Serum Urate
Evaluate acute vs. chronic changes
Detect subclinical disease
Volumetric quantification of urate burden
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GoutDual Energy CT - Clinical Utility
• DECT enables diagnosis of gout when the standard diagnostic approach fails (30%)
False negative synovial fluid analysis
Inability to aspirate fluid (synovitis, small joints)
Unable to biopsy suspected tophus Tendons, ligaments, entheses
Bongartz T, et al. Ann Rheum Dis 2015; 74:1072–1077
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Gout Dual Energy CT - Clinical Utility
• DECT can measure MSU volume
• Changes in actual MSU volume burden following treatment
• Prediction of gout flare risk
• Correlation with cardiac risk factors
• Research implications• Outcome measures
• Gout score/biomarker
• Gout distribution
Fitzgerald J, Levine BD, Raymond J, McMahon MA. Impact of Plasma
Urate and Tophaceous Burden on Inflammatory Biomarkers of
Cardiovascular Disease. Arthritis Rheumatol. 2016; 68 (suppl 10)
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GoutDual Energy CT - Limitations
• Artifacts Skin (calluses) and nailbeds
Motion and metal
Edges of cortical bone, linear
Subcutaneous tissue
Muscle
• Ionizing radiation
• May have more limited sensitivity in acute gout
• May have limited specificity in advanced knee osteoarthritis
Girish G,et al. AJR 2013; 201:515-525
Bongartz T, et al. Ann Rheum Dis 2015; 74:1072–1077
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GoutDual Energy CT
Ideal Imaging Technique
Highly specific• Confirms diagnosis of gout
• Distinguishes disease mimics/unusual manifestations
• Detects subclinical disease
Non-invasive • Alternative to joint aspiration/biopsy
Early disease detection • To reduce morbidity
Quantifies urate volume burden
Monitors response to treatment
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GoutDo We Really Have to Aspirate the Joint?
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GoutDo We Really Have to Biopsy?
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Dual Energy CT for Gout
Benjamin D. Levine, MDAssociate Professor of Radiology
Dept. of Radiological SciencesMusculoskeletal Section
UCLA Health