Potential Adjunctive Role of Radiosynovectomy in Primary Synovial Osteochondromatosis of the Knee: A Case Report / 대한핵의학회잡지

Primary synovial osteochondromatosis (PSOC) is a rare but clinically significant cause of morbidity especially in the male population. Surgery is the primary treatment of choice, but the recurrence rate is reported to be high. Moreover, the presence of widespread loose bodies makes it a cumbersome procedure. The complete removal of the disease is tough at times and results in early recurrence. Radiosynovectomy is an established technique for treating various joint arthropathies. The role of radiosynovectomy in case of PSOC has not yet been explored. This case report described the case of a young male with PSOC of the knee joint who was treated with radiosynovectomy for pain relief. The patient reported complete relief from the pain along with significant improvement in joint mobility. The post-therapy three-phase bone scan also validated the reduction in joint inflammation. The patient was taken for surgical removal of the redundant loose bodies after a significant improvement in the pain and reduction in inflammation. Post-therapy radiation fibrosis of the synovium also helped in the en bloc removal of the disease. The role of radiosynovectomy in PSOC needs to be further explored concerning its potential role as an adjuvant to surgical procedures.

Effectiveness of radiation synovectomy with samarium-153 particulate hydroxyapatite in rheumatoid arthritis patients with knee synovitis: a controlled randomized double-blind trial

OBJECTIVES: The aim of the present study was to investigate the effectiveness of Samarium153-particulate hydroxyapatite radiation synovectomy in rheumatoid arthritis patients with chronic knee synovitis. METHODS: Fifty-eight rheumatoid arthritis patients (60 knees) with chronic knee synovitis participated in a controlled double-blinded trial. Patients were randomized to receive either an intra-articular injection with 40 mg triamcinolone hexacetonide alone (TH group) or 40 mg triamcinolone hexacetonide combined with 15 mCi Samarium153-particulate hydroxyapatite (Sm/TH group). Blinded examination at baseline (T0) and at 1 (T1), 4 (T4), 12 (T12), 32 (T32), and 48 (T48) weeks post-intervention were performed on all patients and included a visual analog scale for joint pain and swelling as well as data on morning stiffness, flexion, extension, knee circumference, Likert scale of improvement, percentage of improvement, SF-36 generic quality of life questionnaire, Stanford Health Assessment Questionnaire (HAQ), Lequesne index, use of non-steroidal anti-inflammatory drugs or oral corticosteroids, events and adverse effects, calls to the physician, and hospital visits. RESULTS: The sample was homogeneous at baseline, and there were no withdrawals. Improvement was observed in both groups in relation to T0, but no statistically significant differences between groups were observed regarding all variables at the time points studied. The Sm/TH group exhibited more adverse effects at T1 (p<0.05), but these were mild and transitory. No severe adverse effects were reported during follow-up. CONCLUSION: Intra-articular injection of Samarium153-particulate hydroxyapatite (15 mCi) with 40 mg of triamcinolone hexacetonide is not superior to triamcinolone hexacetonide alone for the treatment of knee synovitis in patients with rheumatoid arthritis at 1 y of follow-up.

MR Evaluation of Radiation Synovectomy of the Knee by Means of Intra-articular Injection of Holmium-166-Chitosan Complex in Patients with Rheumatoid Arthritis: Results at 4-month Follow-up

OBJECTIVE: To determine whether MRI is able to demonstrate the effect of radiation synovectomy after the intra-articular injection of holmium-166-chitosan complex for the treatment of rheumatoid arthritis of the knee. MATERIALS AND METHODS: Fourteen patients aged 36-59 years were treated with 10-20 mCi of holmium-166-chitosan complex. A criterion for inclusion in this study was the absence of observable improvement after 3- or more months of treatment of the knee with disease-modifying anti-rheumatic drugs. MR images were acquired both prior to and 4-months after treatment. Clinical evaluation included the use of visual analog scales to assess pain, and the circumference of the knee and its range of motion were also determined. MR evaluation included measurement of the volume of synovial enhancement and wall thickness, the amount of joint effusion, and quantifiable scoring of bone erosion, bone edema and lymph nodes. RESULTS: Visual analog scale readings decreased significantly after radiation synovectomy (p < 0.05). MRI showed that joint effusion decreased significantly (p < 0.05), and that the volume of synovial enhancement tended to decrease, but to an insignificant extent (p = 0.107). CONCLUSION: The decreased joint effusion noted at 4-month follow-up resulted from radiation synovectomy of the rheumatoid knee by means of intra-articular injection of holmium-166-chitosan complex.

Radiation Synovectomy by 166Holmium-Chitosan complex in Collagenase Induced Arthritis of the Knee in the Rabbit / 대한정형외과학회잡지

PURPOSE: To evaluate the histological changes of the synovial membrane treated by 166Ho-Chitosan complex in collagenase induced arthritis of the knee in the rabbit. MATERIAL AND METHOD: Arthritis was induced in sixteen rabbits by intra-articular injection of 1mg collagenase II and then treated by intra-articular injection of 0.4mCi 166Ho-Chitosan complex 2weeks later. The radioisotope scan was checked in each rabbit for the distribution and extra-articular leakage of the 166Ho-Chitosan complex. The synovial tissues from the femorotibial joints were evaluated for serial histological changes 2, 4, 8, 12 weeks after the 166Ho-Chitosan complex injetion. RESULTS: Two weeks after 166Ho-Chitosan complex administration, inflammatory cells such as giant cells, lymphocytes, histiocyte, and fibroblasts appeared in the subsynovial stroma. The most synovial cells were necrotized. Four weeks after 166Ho-Chitosan complex administration, the inflammatory cells were decreased and many fibroblasts appeared on the subsynovial stroma. There was neovasculization in the synovial membrane 4 weeks after administration. The fibers of collagen were noticed in the synovial membrane and subsynovial stroma at 8 weeks. There was no synoviocyte in the synovium and the thickness of fibrosis was increased at 12weeks. There were fragmentation of the nucleoli of synoviocyte and endothelial cell on the transmission electron microscope (TEM) . CONCLUSION: This study suggests that the synovial membranes treated by 166Ho-Chitosan complex in the collagenase induced arthritis of the knee in the rabbit show early radiation damage and then subsequently develop the fibrosis, and no synovial cell regeneration was observed until 12 weeks.

Radiation Synovectomy: when, which disease, and which joint / 대한핵의학회잡지

Radiation synovetomy with various radiopharmaceuticals has been used to alleviate pain and swelling of rheumatoid arthritis and related joint diseases for more than 40 years. It is an attractive alternative to the surgical synovectomy for the management of the various joint diseases. Recently, the development of new radiopharmaceuticals labeled with 90Y, 32P, 186Re, 188Re, 153Sm, 165DY and 166Ho, for the effective management of synovial inflammation and related arthritic problems are gaining attention. In this article the general concepts and the clinical application of radiation synovectomy are reviewed.

Preparation and Biodistribution of Re-188 Sulfru Colloid / 대한핵의학회잡지

PURPOSE: We evaluated the usefulness of Re-188 sulfur colloid for radiation synovectomy and therapy of intraperitoneal metastasis. MATERIALS AND METHODS: We investigated the labeling efficiency of Re-188 sulfur colloid on various conditions. The stability of Re-188 sulfur colloid was observed at room temperature for 24 h and in human serum and synovial fluid for 72 h. The particle size distribution of Re-188 sulfur colloid was rneasured by filtering with various pore size filters. Animal experiment was performed in mice and rabbits. RESULTS: The labeling efficiency of Re-188 sulfur colloid was 64,5+/-5.8% (n=5) at the conditions of sodium thiosulfate 40 mg, EDTA Na2.2H2O 0,8 mg, KReO4 0.8 mg at pH l. After purification, the radiochemical purity was higher than 99%. The stability of Re-188 sulfur colloid was high (>99%) at room temperature for 24 h and in human serum and synovial fluid for 72 h. The particle size distribution of Re-188 sulfur colloid was 0.3% (10 micrometer). In mice, 1 h postinjection of Re-188 sulfur colloid into tail vein, uptakes in lung, liver and muscle were 37.30+/-5.36, 32.33+/-5.79, 6.60+/-0.02% 1D/organ respectively. After I.p. injection in rnice, the uptakes of extraperitonial organs of Re-188 sulfur colloid at 1 and 24 h were 0.1+/-0.1, 0.4+/-0.1% ID/organ, and the excretions through urine and feces (~70 h) were low (2.68+/-0.80, 0.95+/-0.17%). When Re-188 sulfur colloid was injected to synovial space of rabbit, the uptake in other organs except knee was very low. CONCLUSION: Re-188 sulfur colloid showed high labeling efficiency, stability and potency for clinical use.

166Ho - chitosan as a radiation synovectomy agent - Biocompatibility study of 166Ho - chitosan in rabbits / 대한정형외과학회잡지

We developed the 166Ho-chitosan, the new radiation synovectomy agent. Holmium is the more practical isotope based on its longer half-life. And chitosan, is ideal and suitable particles based on its soluble and biodegradable characteristics. We investigated the biocompatibility of the 166Ho-chitosan complex to evaluate the suitability as a radiation synovectomy agent. In vitro stability test, the 166Ho-chitosan complex suspension in saline was stored at room temperture and 37degrees C for 25 days and decay rate was of determined by ITLC(Instant Thin Layer Chromatography). In vivo stability test, the 166Ho-chitosan complex was injected into rabbit joints and followed by gamma camera imaging to quantify extra-articular leakage. Biodistribution study, the 166Ho-chitosan complex was injected into rabbit joints. After 48 hours heart, liver, urinary bladder, spleen, lung, brain, kidney, blood were extracted and radioactivities were measured. In vitro stability test, there was no significant change of radioactivity and no leakage problem indicating the prepared 166Ho-chitosan complex is sufficiently stable. In vivo stability tests revealed that more than 98% of the 166Ho-chitosan remained in joint over a 2 days period. The mean retention percentage of 166Ho-chitosan in knee were 99.9%, 99.9%, 99.8%, 99.7% at 2 h, 6 h, 1 day and 2 days, respectively. A biodistribution study of the rabbits revealed that leakage to heart, liver, urinary bladder, spleen, lung, brain, kidney, blood is 0.71, 1.5, 0.50, 1.5, 0.25, 0.26, 0.81, 0.065(% Injected Dose x 10-3/gram), respectively. The 166Ho-chitosan complex shows less leakge than any other radiation synovectomy agents. Our results indicate that 166Ho-chitosan have the biocompatibility and the suitability as a radiation synovectomy agent.

Synovectomy of the Rheumatoid Knee Using Intra-articular Injection of 165Dy Hydroxide Macroaggregates / 대한정형외과학회잡지

165Dy Hydroxide Macroaggregates(165Dy HMA) has a short half life(2.3 hours) and a size range of 3-5µm that give the advantage of reduced leakage and a shorter hospital stay. This report will show the results of a prospective open study on the efficacy and safety of 165Dy HMA in 178 knees of 141 patients with chronic synovitis refractory to conventional antirheumatic therapy. The final global assessment was classified as good, fair or poor. Extra-articular leakage of 165Dy HMA was determined by the scintigraphic evaluation of liver, groin and knee joints. The optimum radiation dose was 250 mCi. The mean follow up periods were 32.4(14-112) weeks. Thirty seven percent of the knees showed good results, 48% fair results and 15% poor results. In the knees with stage I radiographic changes, 82% showed improvement including 32% of the patients with good results. In the knees with stage II radiographic changes, 90% showed improvement including 42% of the patients with good results. The mean period of improvement for the 158 knees that responded to treatment was 41.4(24-106) weeks. Leakage of radioactivity from the injected joint was minimal. Adverse reactions were rare(radiation burn : 4 cases, transient postinjection swelling : 14 cases). In conclusion, 165Dy HMA radiation synovectomy is a safe and useful therapy for chromic synovitis of the rheumatoid knees.

Clinical Trial of Dysprosium-165 HMA in the Treatment of Rheumatoid Knee Synovitis / 대한류마티스학회지

OBJECTIVES: To evaluate the efficacy and safety of radiation synovectomy with Dy-165 HMA in chronic rheumatoid synovitis of the knee METHODS: Two hundred thirty six knees of 212 patients with rheumatoid arthritis and persistent synovitis of the knee were treated with the intraarticular injection of 250~300 mCi of Dy-165 HMA which was prepared by KAERI. Efficacy was assessed by the following parameters: visual analog scale of the knee pain while walking and resting, circumference of the knee, range of motion of the knee. The final global assessment was classified as good, fair or poor. Estra-articular leakage of Dy-165 HMA was determined by blood pool and urine radioactivity and scintigraphic evaluation of liver, groin, and knee joints. RESULTS: l) The optimum radiation dose was 260mCi. 2) The mean follow up periods were 50.4(24-112) weeks. 3) Forty four percent of the knees showed good results, 32% fair results, and 24% shwoed good results. 4) In knees with stage I radiographic changes, 81% showed improvement, of which 54% showed good results. In knees with stage II changes, 78% showed improvement including 39% of the patients with good results. There was a direct correlation between the radiographic stage and response to treatment. 5) The mean period of improvement for the 180 knees that reponded to treatment was 41.4(24-106) weeks. Ten of the 180 knees with improvement relapsed after the mean period of 64(28-80) weeks. 6) Leakage of radioactivity from the injected joint was minimal. 7) Adverse reactions were rare(radiation burn : 4, transient postinjection "flare" : 14). CONCLUSIONS: The optimum radiation dose in Korean was somewhat less than of other foreign reports. Dy-165 HMA radiation synovectomy is a safe and useful therapy for chronic synovitis of the knee joint.

THE PRELIMINARY APPLICATION OF RADIATION SYNOVECTOMY WITH ~(32)P-CHROMIC PHOSPHATE / 重庆医科大学学报

Twenty-three joints in 14 cases of chronic synovitis were treated with intra-articular injection of 32 p-chromic phosphate, including 19 knee joints, one elbow joint with rheumatoid arthritis and 3 knee joints with degenerative arthritis that was recractory to medical treatment. Results of 23 joints evaluated at end of one year were excellent in 43.5$, good in 30.5%, .fair in 13% and poor in 13%. There was a good correlation between the radiographic stage of the joints and the response to treatment. Patients in stage 1 and 2 were more likely to have good to excellent response. Cur study shows that radiation synovectomy is a simple, safe and effective treatment than other managements for chronic synovitis