Radiation synovectomy with (90)Yttrium, (186)Rhenium and (169)Erbium: a systematic literature review with meta-analyses.

OBJECTIVE: To perform a systemic review and meta-analysis on the effectiveness of radiosynoviorthesis (RSO). METHODS: A search of medical databases was conducted. Criteria for inclusion: articles in English, minimum follow-up of 6 months, specification of joint disease, reported outcome of at least 5 RSOs. The studies were scored for quality by the Oxford Centre of Evidenced-based Medicine Levels of Evidence, from 1 to 4. RESULTS: Twenty-one (21) studies were included (3 quality 1b, 5 2b and 13 4), analysing 169Erbium/186Rhenium-RSO used predominantly in small joints and 49 (1 quality 1b, 10 2b and 38 4) on 90Yttrium-RSO used predominantly in knee joints. The reported success rates of 169Erbium/186Rhenium-RSO ranged from 69-100% at 6 months, and from 54-100% at > or =12 months; for 90Yttrium they were 24-100% and 29-94%, res-pectively. Studies comparing the effect of RSO with that of glucocorticoid (GC) or saline injection alone were pooled. At 6 months, the pooled odds ratio favouring RSO of the knee with Yttrium over control is 4 (confidence interval (CI) 95% 1.2-14), p=0.02, but at 12 months the ratio was 1.7 (CI95% 0.69-4), p=0.26. For RSO of small joints with Erbium/Rhenium compared to controls, the pooled odds ratio at 6 months is 2 (CI95% 0.66-6), p=0.22 and at 12 months 2 (CI95% 1.09-3.5), p=0.03. CONCLUSION: Reported success rates of RSO are high, but differences in effect with GC injection are less evident, although there is marked heterogeneity in study design of the (small number of) comparative studies.

Radiation synovectomy of the upper extremity joints: does leakage from the joint to non-target organs impair its therapeutic effect?

Does leakage impair the therapeutic effect of radiosynoviorthesis (RSO)? Are there differences in leakage between (169)Erbium and (186)Rhenium? At baseline and at 6 and 12 months after RSO, six clinical parameters were scored. Changes in clinical variables over time were summed to a change composite index (CCI), ranging from 0 (no effect) to 12 (maximal effect). CCI >or= 6 was considered successful treatment. Differences in leakage between responders and non-responders, and between (169)Erbium and (186)Rhenium were examined. Regression analyses were performed to explore whether baseline variables predicted leakage. Both at 6 and 12 months response rates were 25 of 36 (69%). Five of 11 (45%) non-responders showed leakage versus 20 of 25 (80%) responders (P=0.06). Mean leakage to lymph nodes was 0.4+/-0.7% versus 2.4+/-0.8% (P=0.04). Median leakage to liver/spleen was 0% versus 0.3% (P=0.4). Only age at the time of injection correlated significantly with leakage to lymph nodes. The (169)Erbium group showed leakage in 1 of 7 (14%) versus 24 of 30 (80%) for the (186)Rhenium group (P=0.002). Mean leakage to lymph nodes was 0.11+/-0.3% versus 2.1+/-2.8% (P=0.001). Median leakage to liver/spleen was 0% versus 0.5% (P=0.006). Leakage to non-target organs does not impair the clinical effect of RSO. Only age predicted leakage to lymph nodes significantly. Other baseline characteristics did not predict leakage. (169)Erbium shows significantly lower leakage to non-target organs than (186)Rhenium in RSO.

Clinical effect of radiation synovectomy of the upper extremity joints: a randomised, double-blind, placebo-controlled study.

PURPOSE: To compare the clinical efficacy of radiosynoviorthesis (RSO) with intra-articular radionuclide plus glucocorticoid (GC) injection (group A) with that of placebo plus GC injection (group B) for the treatment of persistent synovitis in joints of the upper extremity. METHODS: At baseline and at 6 and 12 months after intra-articular injection, six clinical parameters were scored. Changes in clinical values over time were summed to provide a change composite index (CCI), ranging from 0 (no effect) to 12 (maximal effect). A CCI > or =6 was considered to indicate successful treatment. Differences in response rate and CCI between groups A and B were examined. Regression analyses were performed to explore whether baseline variables could predict therapeutic effect. RESULTS: Sixty-eight joints in 44 patients were treated. Six months after intra-articular injection, response rates (CCI > or =6) were 69% (25/36) in group A and 29% (9/31) in group B (p=0.001). The mean CCIs +/- standard deviation at 6 months were 6.7+/-3.2 for group A and 3.3+/-3.8 for group B (p=0.001). At 12 months the response rates were 69% (25/36) in group A and 32% (8/25) in group B (p=0.004). The mean CCIs at 12 months were 6.8+/-3.3 for group A and 4.2+/-4.7 for group B (p= 0.046). None of the baseline variables predicted the therapeutic effect. CONCLUSION: RSO (radionuclide plus GC) of upper extremity joints with immobilisation for 72 h shows a significantly better response rate than placebo plus GC in patients with persistent synovitis after at least one failed outpatient intra-articular GC injection.

Rasburicase treatment in severe tophaceous gout: a novel therapeutic option.

We recently encountered a destructive case of tophaceous gout in a 57-year-old patient. Despite perfect therapy compliance, the patient failed in the conventional urate-lowering treatment, accounting for the ongoing urate retention and accumulation with progressive tophaceous bulky disease. Application of an experimental scheme of uricolytical therapy on this patient was able to reduce bulky disease significantly. In modern medicine, potent urate-debulking medication with urate oxidase (uricase) derivatives is at our disposal, and it is a challenge for rheumatologists to install the right strategy including innovative approaches with potent uricolytic therapy on the right patient at the right time.

High dose chemotherapy and syngeneic stem cell transplantation in a patient with refractory rheumatoid arthritis: poor response associated with persistence of host autoantibodies and synovial abnormalities.

BACKGROUND: Immunoablative therapy combined with haematopoietic stem cell transplantation (SCT) is a possible treatment for patients with severe rheumatoid arthritis (RA). CASE REPORT: A patient with rheumatoid factor positive, progressively erosive RA, refractive to treatment, was treated with high dose cyclophosphamide, followed by reinfusion of an unmanipulated peripheral blood graft derived from her identical twin sister. The clinical response was unsatisfactory, necessitating reinstitution of treatment with disease modifying antirheumatic drugs, which was associated with persistence of host serum autoantibodies and a cellular infiltrate in synovium, notably of plasma cells. DISCUSSION: The effectiveness of syngeneic SCT may be critically dependent on the degree of immunoablation achieved or on the composition of the graft.

The effect of radiation synovectomy in patients with persistent arthritis: a prospective study.

OBJECTIVE: To investigate and compare the effects of radiation synovectomy of various joints in a rheumatological practice. METHODS: Consecutive patients referredfor radiation synovectomy to Medical Center Alkmaarfrom 1993 till 1996 were analyzed (n = 138). Patients had to have persistent arthritis despite at least two intra-articular glucocorticoid injections with 20 mg triamcinolone hexacetonide. The knees were treated with 185 MBq Yttrium-90; shoulders, elbows, wrists, hips and talocrural joints received 185 MBq Rhenium-186 and meta-carpophalangeal joints and proximal interphalangeal joints 37 MBq Erbium-169. The radionuclide injection was followed by injection of 20 mg triamcinolone in order to prevent flare-up of synovitis (due to chemical irritation) and needle-track burn. The clinical effect was assessed by evaluating VAS pain (0-10 point scale), functional disability, tenderness and swelling of the treated joint and patient's and physician's global assessments of the effect of therapy (each on a 4-point scale). RESULTS: The overall success rate for radiation synovectomy one year after treatment was 70% with a significant improvement in the variables VAS pain, functional disability and joint tenderness and swelling, when compared to baseline values (p < 0.000001). Moderate to considerable satisfaction of patients and physicians one year after treatment was found for > 50% of cases. Wrists and shoulders were the joints with highest success rate of treatment, followed by the elbows. Lowest success rates were found for hips and ankles. In RA treatment was effective in 76% of cases whereas patients with OA exhibited a success rate of 50%. In RA all treated joints, except the ankles, exhibited a success rate of > or = 75%. No short-term clinical adverse side effects were noted. CONCLUSION: Radiation synovectomy seems to be a successful treatment for persistent arthritis when other therapeutic modalities have failed.

Comparison of cyclosporine and D-penicillamine for rheumatoid arthritis: a randomized, double blind, multicenter study.

Ninety-two patients with active rheumatoid arthritis (RA) were entered in a randomized double blind study of 24 weeks comparing cyclosporine (initial daily dose 5 mg/kg) with D-penicillamine (initial daily dose 250 mg). The groups were well balanced in baseline characteristics. In the cyclosporine group, 10 patients stopped prematurely, one because of inefficacy. In the D-penicillamine group, 9 patients stopped prematurely, 3 because of inefficacy. The 2 antirheumatic drugs were equally effective in reducing disease activity, except for a significant (p = 0.005) decrease in erythrocyte sedimentation rate with D-penicillamine treatment. We conclude that under the conditions of this trial, cyclosporine can serve as an alternative to D-penicillamine for the treatment of patients with RA.

A population study on rheumatoid arthritis in Lesotho, southern Africa.

Motivated by the results of a hospital study on rheumatoid arthritis (RA) in Lesotho (southern Africa) a survey of inflammatory polyarthritis (IP) and RA was undertaken in a sample of the rural population of that country. Contrary to expectations the prevalence of IP grades 2-4 (definite disease) was low (0.4%) and equal in both sexes, while probable and definite RA combined (American Rheumatism Association (ARA) criteria) occurred in 1.8% of both males and females. RA was slightly more severe than in other rural African Negro studies but less so when compared with the disease condition of the patients observed in the hospital study. Rheumatoid factor and particularly that directed against heterologous antigen occurred in 41% of the RA patients and in 16% of the controls. Two thirds of the definite cases and 29% of the combined probable and definite group showed radiological abnormalities.

Rheumatoid arthritis in Lesotho.

Thirty-nine black African patients were seen with probable, definite or classical rheumatoid arthritis (RA); 32 of these were seen in a prospective study out of a total of 15 834 new patients 15 years and older at presentation seen in a 12-month period. The diagnosis was based on the American Rheumatism Association criteria for RA or the Rome criteria for inactive RA. The high incidence of severe disease as well as the occurrence of advanced disease in young patients is notable. 80% of the patients came from rural areas. Radiological lesions were found in 74% and serological abnormalities in 92%. Rheumatoid factor (RF) was found to be positive in 12% of an age and sex matched control group and in 19% of a group of patients suffering from tuberculosis.