Imaging

DETROIT – Patients with proximal pancreatic cancer should be reimaged before surgery if more than 3 weeks have passed since their most recent cross-sectional imaging study.

The recommendation is based on a retrospective analysis involving 487 patients that identified a significant, roughly twofold increase in unanticipated metastasis encountered at surgery if the interval between imaging and operation was more than 3 weeks.

Among 293 patients with proximal pancreatic cancer and precise imaging data, the frequency of occult metastasis was 12% when the imaging-to-operation interval (IOI) was 20 days or fewer, compared with 20% at an IOI of 21-27 days, 25% at 28-34 days, 35% at 35-41 days, 29% at 42-48 days, and 30% at 49-86 days.

There were no significant differences between patients in the various 1-week intervals in terms of sex, age, tumor size, percentage of poor grade tumors, lymph node positivity, vascular invasion, or perineural invasion, Dr. Jeffrey Glant said at the annual meeting of the Central Surgical Association.

In linear regression analysis, the relationship between frequency of unanticipated metastases and weekly IOI was statistically significant (P = .006) and had a correlation coefficient R² value of 0.99.

A similar relationship was not observed among 36 patients with distal pancreatic cancer and precise imaging data. The frequency of unanticipated metastasis among these patients was 0% at 0-6 days, 33% at 7-13 days, 38% at 14-20 days, 0% at 21-27 days, 0% at 28-34 days, 20% at 35-41 days, 33% at 42-48 days, and 25% at 49-87 days, said Dr. Glant of the department of surgery at Indiana University in Indianapolis.

Cross-sectional imaging is the primary preoperative staging modality in pancreatic cancer, which is the fourth most common cause of cancer death in the United States. The rate of encountering metastasis at operation is typically 10%-30%, he noted. The reasons for the delay in surgery could not be ascertained from the retrospective data.

Dr. Glant reported on 487 patients undergoing planned pancreatic resection for pancreatic ductal adenocarcinoma between January 2004 and December 2009 at the university’s high-volume pancreatic surgery center. Patients were excluded if they had received neoadjuvant therapy, prior pancreatic resection, or exploratory surgery for suspected metastatic disease.

Precise imaging data were available for 329 patients. Cross-sectional imaging was defined as dual-phase, contrast-enhanced CT, or MRI if CT was contraindicated.

Of the 285 patients (59%) who had their most recent imaging study performed at the university, 202 underwent resection and 83 were not resected. Metastasis was discovered at time of operation in 39 patients, he said.

Of the 202 (41%) patients whose most recent imaging study was performed at an outside institution, 139 underwent resection and 63 were not resected. Among the 202 patients, 35 had metastasis discovered at time of operation.

The overall frequency of unanticipated metastasis was statistically similar between patients who were imaged at the university and those who were imaged at an outside institution (14% vs. 17%), Dr. Glant said. This was true whether the patients had proximal (14% vs. 17%) or distal (15% vs. 25%) disease. Patients imaged at an outside venue, however, had significantly larger tumors than did those imaged at the university (3.4 cm vs. 3.1 cm; P = .05) and a higher rate of vascular invasion (73% vs. 61%; P = .03).

"It is appropriate and advisable to obtain more current imaging if the delay [in surgery] will exceed 3 weeks," Dr. Glant said.

Invited discussant Dr. Carl R. Schmidt of the Ohio State University, Columbus, said the size of the series, the robustness of the analysis, and the time period evaluated left no doubt in his mind about the use of modern imaging and the validity of the main finding. He asked what proportion of patients at the university undergoes staging laparoscopy, and what the distribution of metastasis was.

Coauthor Dr. Joshua A. Waters, also of Indiana University, replied that with just 16 patients undergoing staging laparoscopy in the entire series, the procedure is not routinely performed at the university in the setting of proximal pancreatic cancer. He also cited a recent study reporting a decrease in yield of staging laparoscopy from 1995 to 2005, particularly in those with proximal pancreatic cancers (J. Am. Coll. Surg. 2008;206:445-50). Regarding the distribution of the metastases, 80% were on the liver and 20% were at another location, primarily peritoneal implants, he said.

When asked whether any patients had undergone endobiliary stenting prior to resection, Dr. Waters said that a significant proportion of patients were stented prior to arrival at the hospital, and that stenting is known to affect the sensitivity of staging in terms of cross-sectional imaging.

Finally, audience member Dr. Fabrizio Michelassi, professor of surgery at Cornell University in New York City, asked how surgeons should use the data. Should they rush to operate on all patients within 2 weeks to avoid the discovery of more occult metastasis, or wait until 6 weeks for the metastases to declare themselves, since the incidence of occult metastasis appeared to stabilize by then at about 35%?

"One could suggest that if you really wait for 6 weeks, you could probably spare the morbidity of a large operation in 25% of patients who really don’t benefit from it," Dr. Michelassi said.

Dr. Waters said that for patients who are rescanned within 2-3 weeks of cross-sectional imaging and are subsequently found to have a metastatic focus or some evidence of progression, this may be evidence of a more aggressive biology. "This may be a subgroup of patients [whom you] would want to capture by rescanning and potentially not expose to a less than therapeutic laparotomy."

The authors reported no conflicts of interest.

DETROIT – Patients with proximal pancreatic cancer should be reimaged before surgery if more than 3 weeks have passed since their most recent cross-sectional imaging study.

The recommendation is based on a retrospective analysis involving 487 patients that identified a significant, roughly twofold increase in unanticipated metastasis encountered at surgery if the interval between imaging and operation was more than 3 weeks.

Among 293 patients with proximal pancreatic cancer and precise imaging data, the frequency of occult metastasis was 12% when the imaging-to-operation interval (IOI) was 20 days or fewer, compared with 20% at an IOI of 21-27 days, 25% at 28-34 days, 35% at 35-41 days, 29% at 42-48 days, and 30% at 49-86 days.

There were no significant differences between patients in the various 1-week intervals in terms of sex, age, tumor size, percentage of poor grade tumors, lymph node positivity, vascular invasion, or perineural invasion, Dr. Jeffrey Glant said at the annual meeting of the Central Surgical Association.

In linear regression analysis, the relationship between frequency of unanticipated metastases and weekly IOI was statistically significant (P = .006) and had a correlation coefficient R² value of 0.99.

A similar relationship was not observed among 36 patients with distal pancreatic cancer and precise imaging data. The frequency of unanticipated metastasis among these patients was 0% at 0-6 days, 33% at 7-13 days, 38% at 14-20 days, 0% at 21-27 days, 0% at 28-34 days, 20% at 35-41 days, 33% at 42-48 days, and 25% at 49-87 days, said Dr. Glant of the department of surgery at Indiana University in Indianapolis.

Cross-sectional imaging is the primary preoperative staging modality in pancreatic cancer, which is the fourth most common cause of cancer death in the United States. The rate of encountering metastasis at operation is typically 10%-30%, he noted. The reasons for the delay in surgery could not be ascertained from the retrospective data.

Dr. Glant reported on 487 patients undergoing planned pancreatic resection for pancreatic ductal adenocarcinoma between January 2004 and December 2009 at the university’s high-volume pancreatic surgery center. Patients were excluded if they had received neoadjuvant therapy, prior pancreatic resection, or exploratory surgery for suspected metastatic disease.

Precise imaging data were available for 329 patients. Cross-sectional imaging was defined as dual-phase, contrast-enhanced CT, or MRI if CT was contraindicated.

Of the 285 patients (59%) who had their most recent imaging study performed at the university, 202 underwent resection and 83 were not resected. Metastasis was discovered at time of operation in 39 patients, he said.

Of the 202 (41%) patients whose most recent imaging study was performed at an outside institution, 139 underwent resection and 63 were not resected. Among the 202 patients, 35 had metastasis discovered at time of operation.

The overall frequency of unanticipated metastasis was statistically similar between patients who were imaged at the university and those who were imaged at an outside institution (14% vs. 17%), Dr. Glant said. This was true whether the patients had proximal (14% vs. 17%) or distal (15% vs. 25%) disease. Patients imaged at an outside venue, however, had significantly larger tumors than did those imaged at the university (3.4 cm vs. 3.1 cm; P = .05) and a higher rate of vascular invasion (73% vs. 61%; P = .03).

"It is appropriate and advisable to obtain more current imaging if the delay [in surgery] will exceed 3 weeks," Dr. Glant said.

Invited discussant Dr. Carl R. Schmidt of the Ohio State University, Columbus, said the size of the series, the robustness of the analysis, and the time period evaluated left no doubt in his mind about the use of modern imaging and the validity of the main finding. He asked what proportion of patients at the university undergoes staging laparoscopy, and what the distribution of metastasis was.

Coauthor Dr. Joshua A. Waters, also of Indiana University, replied that with just 16 patients undergoing staging laparoscopy in the entire series, the procedure is not routinely performed at the university in the setting of proximal pancreatic cancer. He also cited a recent study reporting a decrease in yield of staging laparoscopy from 1995 to 2005, particularly in those with proximal pancreatic cancers (J. Am. Coll. Surg. 2008;206:445-50). Regarding the distribution of the metastases, 80% were on the liver and 20% were at another location, primarily peritoneal implants, he said.

When asked whether any patients had undergone endobiliary stenting prior to resection, Dr. Waters said that a significant proportion of patients were stented prior to arrival at the hospital, and that stenting is known to affect the sensitivity of staging in terms of cross-sectional imaging.

Finally, audience member Dr. Fabrizio Michelassi, professor of surgery at Cornell University in New York City, asked how surgeons should use the data. Should they rush to operate on all patients within 2 weeks to avoid the discovery of more occult metastasis, or wait until 6 weeks for the metastases to declare themselves, since the incidence of occult metastasis appeared to stabilize by then at about 35%?

"One could suggest that if you really wait for 6 weeks, you could probably spare the morbidity of a large operation in 25% of patients who really don’t benefit from it," Dr. Michelassi said.

Dr. Waters said that for patients who are rescanned within 2-3 weeks of cross-sectional imaging and are subsequently found to have a metastatic focus or some evidence of progression, this may be evidence of a more aggressive biology. "This may be a subgroup of patients [whom you] would want to capture by rescanning and potentially not expose to a less than therapeutic laparotomy."

The authors reported no conflicts of interest.

DETROIT – Patients with proximal pancreatic cancer should be reimaged before surgery if more than 3 weeks have passed since their most recent cross-sectional imaging study.

The recommendation is based on a retrospective analysis involving 487 patients that identified a significant, roughly twofold increase in unanticipated metastasis encountered at surgery if the interval between imaging and operation was more than 3 weeks.

Among 293 patients with proximal pancreatic cancer and precise imaging data, the frequency of occult metastasis was 12% when the imaging-to-operation interval (IOI) was 20 days or fewer, compared with 20% at an IOI of 21-27 days, 25% at 28-34 days, 35% at 35-41 days, 29% at 42-48 days, and 30% at 49-86 days.

There were no significant differences between patients in the various 1-week intervals in terms of sex, age, tumor size, percentage of poor grade tumors, lymph node positivity, vascular invasion, or perineural invasion, Dr. Jeffrey Glant said at the annual meeting of the Central Surgical Association.

In linear regression analysis, the relationship between frequency of unanticipated metastases and weekly IOI was statistically significant (P = .006) and had a correlation coefficient R² value of 0.99.

A similar relationship was not observed among 36 patients with distal pancreatic cancer and precise imaging data. The frequency of unanticipated metastasis among these patients was 0% at 0-6 days, 33% at 7-13 days, 38% at 14-20 days, 0% at 21-27 days, 0% at 28-34 days, 20% at 35-41 days, 33% at 42-48 days, and 25% at 49-87 days, said Dr. Glant of the department of surgery at Indiana University in Indianapolis.

Cross-sectional imaging is the primary preoperative staging modality in pancreatic cancer, which is the fourth most common cause of cancer death in the United States. The rate of encountering metastasis at operation is typically 10%-30%, he noted. The reasons for the delay in surgery could not be ascertained from the retrospective data.

Dr. Glant reported on 487 patients undergoing planned pancreatic resection for pancreatic ductal adenocarcinoma between January 2004 and December 2009 at the university’s high-volume pancreatic surgery center. Patients were excluded if they had received neoadjuvant therapy, prior pancreatic resection, or exploratory surgery for suspected metastatic disease.

Precise imaging data were available for 329 patients. Cross-sectional imaging was defined as dual-phase, contrast-enhanced CT, or MRI if CT was contraindicated.

Of the 285 patients (59%) who had their most recent imaging study performed at the university, 202 underwent resection and 83 were not resected. Metastasis was discovered at time of operation in 39 patients, he said.

Of the 202 (41%) patients whose most recent imaging study was performed at an outside institution, 139 underwent resection and 63 were not resected. Among the 202 patients, 35 had metastasis discovered at time of operation.

The overall frequency of unanticipated metastasis was statistically similar between patients who were imaged at the university and those who were imaged at an outside institution (14% vs. 17%), Dr. Glant said. This was true whether the patients had proximal (14% vs. 17%) or distal (15% vs. 25%) disease. Patients imaged at an outside venue, however, had significantly larger tumors than did those imaged at the university (3.4 cm vs. 3.1 cm; P = .05) and a higher rate of vascular invasion (73% vs. 61%; P = .03).

"It is appropriate and advisable to obtain more current imaging if the delay [in surgery] will exceed 3 weeks," Dr. Glant said.

Invited discussant Dr. Carl R. Schmidt of the Ohio State University, Columbus, said the size of the series, the robustness of the analysis, and the time period evaluated left no doubt in his mind about the use of modern imaging and the validity of the main finding. He asked what proportion of patients at the university undergoes staging laparoscopy, and what the distribution of metastasis was.

Coauthor Dr. Joshua A. Waters, also of Indiana University, replied that with just 16 patients undergoing staging laparoscopy in the entire series, the procedure is not routinely performed at the university in the setting of proximal pancreatic cancer. He also cited a recent study reporting a decrease in yield of staging laparoscopy from 1995 to 2005, particularly in those with proximal pancreatic cancers (J. Am. Coll. Surg. 2008;206:445-50). Regarding the distribution of the metastases, 80% were on the liver and 20% were at another location, primarily peritoneal implants, he said.

When asked whether any patients had undergone endobiliary stenting prior to resection, Dr. Waters said that a significant proportion of patients were stented prior to arrival at the hospital, and that stenting is known to affect the sensitivity of staging in terms of cross-sectional imaging.

Finally, audience member Dr. Fabrizio Michelassi, professor of surgery at Cornell University in New York City, asked how surgeons should use the data. Should they rush to operate on all patients within 2 weeks to avoid the discovery of more occult metastasis, or wait until 6 weeks for the metastases to declare themselves, since the incidence of occult metastasis appeared to stabilize by then at about 35%?

"One could suggest that if you really wait for 6 weeks, you could probably spare the morbidity of a large operation in 25% of patients who really don’t benefit from it," Dr. Michelassi said.

Dr. Waters said that for patients who are rescanned within 2-3 weeks of cross-sectional imaging and are subsequently found to have a metastatic focus or some evidence of progression, this may be evidence of a more aggressive biology. "This may be a subgroup of patients [whom you] would want to capture by rescanning and potentially not expose to a less than therapeutic laparotomy."

The authors reported no conflicts of interest.

CANCUN, MEXICO – Most patients with early rheumatoid arthritis do not have radiographic progression within the first 2 years of the disease, a study has shown.

Additionally, the risk of continuous radiographic progression during this period can be predicted using certain baseline indicators of disease activity, Maggie Hong Chen reported at the meeting.

An analysis of data from the Study of New-Onset Rheumatoid Arthritis (SONORA) cohort using the original Sharp method to score radiographic progression over 2 years identified the following four patterns among the 529 early arthritis patients included in the investigation: never progressed, progressed at year 1 only; progressed at year 2 only, and progressed at both year 1 and year 2, said Ms. Chen, a research fellow in the University Health Network Research Institute of the University of Toronto. For the analysis, radiographic progression was defined as a change in total Sharp score of at least 3.5 within a year, she noted.

Of the 529 patients – all of whom were diagnosed with early rheumatoid arthritis based on symptom duration of 3-12 months and who had hand radiographs obtained at baseline, 1 year, and 2 years – 457 patients (86%) had no progression, Ms. Chen reported. Progression at year 1, year 2, and both years 1 and 2 was observed in 18 patients (3.4%), 40 patients (7.6%), and 14 (2.6%), respectively, she said.

The investigators evaluated multiple potential clinical indicators of progression, including baseline Sharp score, baseline levels of C-reactive protein (CRP), answers to the Health Assessment Questionnaire (HAQ), swollen joint count, disease duration, anticyclic citrullinated peptide (anti-CCP) antibody status, gender, rheumatoid factor (RF) status, and smoking history. Of these, "baseline Sharp score was a statistically significant indicator of whether the subject would progress within the 2-year period," Ms. Chen stated, noting that, in the no-progression group, the mean baseline Sharp score was 4.06, compared with 9.33 in the 1-year progression group, 8.28 in the 2-year progression group, and 14.0 among the patients with progression both years.

Significant differences were also observed between the patterns for CRP score, baseline HAQ, swollen joint count, and anti-CCP positive status, said Ms. Chen. "Subjects who had no radiographic progression within the 2-year period were younger with a lower swollen joint count, a lower disease activity score [DAS], and lower CRP. They were also negative for anti-CCP and RF at baseline," she said.

The findings provide insight into the patterns and characteristics of radiographic damage in early rheumatoid arthritis, "and they may also contribute to clinical decision making," said Ms. Chen. The identified indicators can help rheumatologists identify patients at highest risk of continuous radiographic progression and manage them accordingly, potentially with more aggressive therapy if warranted, she said.

Ms. Chen had no financial conflicts of interest to disclose.

CANCUN, MEXICO – Most patients with early rheumatoid arthritis do not have radiographic progression within the first 2 years of the disease, a study has shown.

Additionally, the risk of continuous radiographic progression during this period can be predicted using certain baseline indicators of disease activity, Maggie Hong Chen reported at the meeting.

An analysis of data from the Study of New-Onset Rheumatoid Arthritis (SONORA) cohort using the original Sharp method to score radiographic progression over 2 years identified the following four patterns among the 529 early arthritis patients included in the investigation: never progressed, progressed at year 1 only; progressed at year 2 only, and progressed at both year 1 and year 2, said Ms. Chen, a research fellow in the University Health Network Research Institute of the University of Toronto. For the analysis, radiographic progression was defined as a change in total Sharp score of at least 3.5 within a year, she noted.

Of the 529 patients – all of whom were diagnosed with early rheumatoid arthritis based on symptom duration of 3-12 months and who had hand radiographs obtained at baseline, 1 year, and 2 years – 457 patients (86%) had no progression, Ms. Chen reported. Progression at year 1, year 2, and both years 1 and 2 was observed in 18 patients (3.4%), 40 patients (7.6%), and 14 (2.6%), respectively, she said.

The investigators evaluated multiple potential clinical indicators of progression, including baseline Sharp score, baseline levels of C-reactive protein (CRP), answers to the Health Assessment Questionnaire (HAQ), swollen joint count, disease duration, anticyclic citrullinated peptide (anti-CCP) antibody status, gender, rheumatoid factor (RF) status, and smoking history. Of these, "baseline Sharp score was a statistically significant indicator of whether the subject would progress within the 2-year period," Ms. Chen stated, noting that, in the no-progression group, the mean baseline Sharp score was 4.06, compared with 9.33 in the 1-year progression group, 8.28 in the 2-year progression group, and 14.0 among the patients with progression both years.

Significant differences were also observed between the patterns for CRP score, baseline HAQ, swollen joint count, and anti-CCP positive status, said Ms. Chen. "Subjects who had no radiographic progression within the 2-year period were younger with a lower swollen joint count, a lower disease activity score [DAS], and lower CRP. They were also negative for anti-CCP and RF at baseline," she said.

The findings provide insight into the patterns and characteristics of radiographic damage in early rheumatoid arthritis, "and they may also contribute to clinical decision making," said Ms. Chen. The identified indicators can help rheumatologists identify patients at highest risk of continuous radiographic progression and manage them accordingly, potentially with more aggressive therapy if warranted, she said.

Ms. Chen had no financial conflicts of interest to disclose.

CANCUN, MEXICO – Most patients with early rheumatoid arthritis do not have radiographic progression within the first 2 years of the disease, a study has shown.

Additionally, the risk of continuous radiographic progression during this period can be predicted using certain baseline indicators of disease activity, Maggie Hong Chen reported at the meeting.

An analysis of data from the Study of New-Onset Rheumatoid Arthritis (SONORA) cohort using the original Sharp method to score radiographic progression over 2 years identified the following four patterns among the 529 early arthritis patients included in the investigation: never progressed, progressed at year 1 only; progressed at year 2 only, and progressed at both year 1 and year 2, said Ms. Chen, a research fellow in the University Health Network Research Institute of the University of Toronto. For the analysis, radiographic progression was defined as a change in total Sharp score of at least 3.5 within a year, she noted.

Of the 529 patients – all of whom were diagnosed with early rheumatoid arthritis based on symptom duration of 3-12 months and who had hand radiographs obtained at baseline, 1 year, and 2 years – 457 patients (86%) had no progression, Ms. Chen reported. Progression at year 1, year 2, and both years 1 and 2 was observed in 18 patients (3.4%), 40 patients (7.6%), and 14 (2.6%), respectively, she said.

The investigators evaluated multiple potential clinical indicators of progression, including baseline Sharp score, baseline levels of C-reactive protein (CRP), answers to the Health Assessment Questionnaire (HAQ), swollen joint count, disease duration, anticyclic citrullinated peptide (anti-CCP) antibody status, gender, rheumatoid factor (RF) status, and smoking history. Of these, "baseline Sharp score was a statistically significant indicator of whether the subject would progress within the 2-year period," Ms. Chen stated, noting that, in the no-progression group, the mean baseline Sharp score was 4.06, compared with 9.33 in the 1-year progression group, 8.28 in the 2-year progression group, and 14.0 among the patients with progression both years.

Significant differences were also observed between the patterns for CRP score, baseline HAQ, swollen joint count, and anti-CCP positive status, said Ms. Chen. "Subjects who had no radiographic progression within the 2-year period were younger with a lower swollen joint count, a lower disease activity score [DAS], and lower CRP. They were also negative for anti-CCP and RF at baseline," she said.

The findings provide insight into the patterns and characteristics of radiographic damage in early rheumatoid arthritis, "and they may also contribute to clinical decision making," said Ms. Chen. The identified indicators can help rheumatologists identify patients at highest risk of continuous radiographic progression and manage them accordingly, potentially with more aggressive therapy if warranted, she said.

Ms. Chen had no financial conflicts of interest to disclose.

SNOWMASS, COLO. – Cardiac abnormalities were detected by magnetic resonance imaging in three-quarters of an unselected consecutive series of systemic sclerosis patients, underscoring the impressive frequency of heart involvement in this collagen vascular disease.

"The heart is something we often forget in scleroderma. The heart disease is underestimated," Dr. Fredrick M. Wigley said at the symposium sponsored by the American College of Rheumatology.

The hallmark of cardiac involvement in systemic sclerosis (SSc) is fibrosis and inflammation. Cardiac MRI is unequalled at visualizing these features, he said.

"You can see fibrosis of the myocardium, pericardium, coronary circulation, and conduction system. Arrhythmias are common. Coronary vasospasm is thought to occur, particularly with cold conduction – the so-called Raynaud’s of the heart – leading to ischemic reperfusion injury and fibrosis of the heart," said Dr. Wigley, professor of medicine and director of the scleroderma center at Johns Hopkins University, Baltimore.

A resting tachycardia in patients with systemic sclerosis is a common clinical manifestation of cardiac involvement. Clinically evident heart disease carries an unfavorable prognosis, as do cardiac abnormalities detected via right heart catheterization or other invasive methods. The prognostic significance of asymptomatic abnormalities that are detected only on cardiac MRI and that are not evident at the bedside remains to be established. The noninvasive imaging technique has only recently been applied in systemic sclerosis.

Scleroderma patients at greatest risk for clinically severe cardiac involvement are those with myopathy and rapidly progressing skin disease, according to the rheumatologist.

Dr. Wigley highlighted a recent study by investigators at Lille 2 (France) University that effectively demonstrated the power of cardiac MRI in detecting heart involvement in SSc. The French investigators examined 52 consecutive unselected scleroderma patients with both Doppler echocardiography and cardiac MRI. One or more cardiac abnormalities were found on cardiac MRI in 75% of the patients, while Doppler detected the abnormalities in only 48% of the patients.

Moreover, only cardiac MRI permitted precise analysis of the patterns of cardiac involvement in SSc, as it was able to distinguish between the fibrotic, inflammatory, and microvascular components. Interestingly, patients with limited cutaneous SSc had cardiac MRI abnormalities that were similar to those with diffuse cutaneous disease.

Seven of the 40 patients without pulmonary arterial hypertension were found to have right ventricular dilation on cardiac MRI, underscoring the point that right ventricular dilation is not specific for this common respiratory manifestation of SSc.

Study participants had a mean 11.2-year disease history since developing Raynaud’s phenomenon. The longer a patient’s disease duration, the greater the number of cardiac segments with kinetic abnormalities and delayed contrast enhancement on MRI (Ann. Rheum. Dis. 2009;68:1878-84).

Dr. Wigley said that while to date no therapy has been shown to alter the natural course of cardiac disease in patients with scleroderma, French investigators strongly believe calcium channel blockers are cardioprotective, and they have documented increased myocardial perfusion in nifedipine-treated SSc patients.

He said that he receives consulting fees and/or research grants from Actelion, Amira, Kinemed, Medimmune, Novartis, Orion, Pfizer, and United Therapeutics.

SNOWMASS, COLO. – Cardiac abnormalities were detected by magnetic resonance imaging in three-quarters of an unselected consecutive series of systemic sclerosis patients, underscoring the impressive frequency of heart involvement in this collagen vascular disease.

"The heart is something we often forget in scleroderma. The heart disease is underestimated," Dr. Fredrick M. Wigley said at the symposium sponsored by the American College of Rheumatology.

The hallmark of cardiac involvement in systemic sclerosis (SSc) is fibrosis and inflammation. Cardiac MRI is unequalled at visualizing these features, he said.

"You can see fibrosis of the myocardium, pericardium, coronary circulation, and conduction system. Arrhythmias are common. Coronary vasospasm is thought to occur, particularly with cold conduction – the so-called Raynaud’s of the heart – leading to ischemic reperfusion injury and fibrosis of the heart," said Dr. Wigley, professor of medicine and director of the scleroderma center at Johns Hopkins University, Baltimore.

A resting tachycardia in patients with systemic sclerosis is a common clinical manifestation of cardiac involvement. Clinically evident heart disease carries an unfavorable prognosis, as do cardiac abnormalities detected via right heart catheterization or other invasive methods. The prognostic significance of asymptomatic abnormalities that are detected only on cardiac MRI and that are not evident at the bedside remains to be established. The noninvasive imaging technique has only recently been applied in systemic sclerosis.

Scleroderma patients at greatest risk for clinically severe cardiac involvement are those with myopathy and rapidly progressing skin disease, according to the rheumatologist.

Dr. Wigley highlighted a recent study by investigators at Lille 2 (France) University that effectively demonstrated the power of cardiac MRI in detecting heart involvement in SSc. The French investigators examined 52 consecutive unselected scleroderma patients with both Doppler echocardiography and cardiac MRI. One or more cardiac abnormalities were found on cardiac MRI in 75% of the patients, while Doppler detected the abnormalities in only 48% of the patients.

Moreover, only cardiac MRI permitted precise analysis of the patterns of cardiac involvement in SSc, as it was able to distinguish between the fibrotic, inflammatory, and microvascular components. Interestingly, patients with limited cutaneous SSc had cardiac MRI abnormalities that were similar to those with diffuse cutaneous disease.

Seven of the 40 patients without pulmonary arterial hypertension were found to have right ventricular dilation on cardiac MRI, underscoring the point that right ventricular dilation is not specific for this common respiratory manifestation of SSc.

Study participants had a mean 11.2-year disease history since developing Raynaud’s phenomenon. The longer a patient’s disease duration, the greater the number of cardiac segments with kinetic abnormalities and delayed contrast enhancement on MRI (Ann. Rheum. Dis. 2009;68:1878-84).

Dr. Wigley said that while to date no therapy has been shown to alter the natural course of cardiac disease in patients with scleroderma, French investigators strongly believe calcium channel blockers are cardioprotective, and they have documented increased myocardial perfusion in nifedipine-treated SSc patients.

He said that he receives consulting fees and/or research grants from Actelion, Amira, Kinemed, Medimmune, Novartis, Orion, Pfizer, and United Therapeutics.

SNOWMASS, COLO. – Cardiac abnormalities were detected by magnetic resonance imaging in three-quarters of an unselected consecutive series of systemic sclerosis patients, underscoring the impressive frequency of heart involvement in this collagen vascular disease.

"The heart is something we often forget in scleroderma. The heart disease is underestimated," Dr. Fredrick M. Wigley said at the symposium sponsored by the American College of Rheumatology.

The hallmark of cardiac involvement in systemic sclerosis (SSc) is fibrosis and inflammation. Cardiac MRI is unequalled at visualizing these features, he said.

"You can see fibrosis of the myocardium, pericardium, coronary circulation, and conduction system. Arrhythmias are common. Coronary vasospasm is thought to occur, particularly with cold conduction – the so-called Raynaud’s of the heart – leading to ischemic reperfusion injury and fibrosis of the heart," said Dr. Wigley, professor of medicine and director of the scleroderma center at Johns Hopkins University, Baltimore.

A resting tachycardia in patients with systemic sclerosis is a common clinical manifestation of cardiac involvement. Clinically evident heart disease carries an unfavorable prognosis, as do cardiac abnormalities detected via right heart catheterization or other invasive methods. The prognostic significance of asymptomatic abnormalities that are detected only on cardiac MRI and that are not evident at the bedside remains to be established. The noninvasive imaging technique has only recently been applied in systemic sclerosis.

Scleroderma patients at greatest risk for clinically severe cardiac involvement are those with myopathy and rapidly progressing skin disease, according to the rheumatologist.

Dr. Wigley highlighted a recent study by investigators at Lille 2 (France) University that effectively demonstrated the power of cardiac MRI in detecting heart involvement in SSc. The French investigators examined 52 consecutive unselected scleroderma patients with both Doppler echocardiography and cardiac MRI. One or more cardiac abnormalities were found on cardiac MRI in 75% of the patients, while Doppler detected the abnormalities in only 48% of the patients.

Moreover, only cardiac MRI permitted precise analysis of the patterns of cardiac involvement in SSc, as it was able to distinguish between the fibrotic, inflammatory, and microvascular components. Interestingly, patients with limited cutaneous SSc had cardiac MRI abnormalities that were similar to those with diffuse cutaneous disease.

Seven of the 40 patients without pulmonary arterial hypertension were found to have right ventricular dilation on cardiac MRI, underscoring the point that right ventricular dilation is not specific for this common respiratory manifestation of SSc.

Study participants had a mean 11.2-year disease history since developing Raynaud’s phenomenon. The longer a patient’s disease duration, the greater the number of cardiac segments with kinetic abnormalities and delayed contrast enhancement on MRI (Ann. Rheum. Dis. 2009;68:1878-84).

Dr. Wigley said that while to date no therapy has been shown to alter the natural course of cardiac disease in patients with scleroderma, French investigators strongly believe calcium channel blockers are cardioprotective, and they have documented increased myocardial perfusion in nifedipine-treated SSc patients.

He said that he receives consulting fees and/or research grants from Actelion, Amira, Kinemed, Medimmune, Novartis, Orion, Pfizer, and United Therapeutics.

Erosive progression is arrested in rheumatoid arthritis patients who are treated with adalimumab and methotrexate combination therapy, judging from results of a novel longitudinal study comparing MRI, ultrasonography, CT, and radiography.

However, only MRI was sensitive enough to document repair of individual erosions. Both MRI and ultrasound could detect changes in bone edema, which "was predictive of subsequent erosive progression on CT, both at the individual bone/joint level and also for MRI bone edema at the patient level," reported lead author Dr. Uffe Møller Døhn of the department of rheumatology at the University of Copenhagen in the February 2011 edition of the Annals of the Rheumatic Diseases. "These data emphasize the predictive value of modern imaging, and especially highlight the importance of MRI bone edema for predicting erosive progression."

The findings also offer a different way of thinking about RA’s pathology. In an accompanying editorial, Dr. Fiona McQueen and Dr. Esperanza Naredo said that the study’s findings add to existing evidence suggesting that osteitis is more strongly predictive of bone erosion than is synovitis, which supports "the notion that there is a more direct connection between bone inflammation and bone damage than between synovial inflammation and bone damage" (Ann. Rheum. Dis. 2011;70:241-4). They described synovitis and osteitis as "cousins with a common ancestor, the process that ultimately drives both remaining obscure but possibly sited in the bone marrow."

Dr. Døhn and his associates used MRI, ultrasound, standard radiography, and high-resolution CT images of the wrist and metacarpophalangeal joints 2-5 to study response to adalimumab/methotrexate therapy in 52 RA patients naive to biological agents. All images were obtained before the first dose of adalimumab injection and were repeated after 6 and 12 months of treatment (Ann. Rheum. Dis. 2011;70:252-8).

The median age of patients was 61 years, and 67% were women. From baseline, the researchers did not observe any statistically significant changes in overall bone destruction or repair at 6 or 12 months, but differences were seen when researchers used the smallest-detectable-change cutoff. For example, after 6 and 12 months, the scores of MRI synovitis, grey-scale synovitis, and power Doppler ultrasonography decreased. So did scores as assessed by DAS28 (disease activity score in 28 joints), a health assessment questionnaire, and tender and swollen joint counts.

Study participants with disease progression on CT had higher baseline MRI bone edema scores. In fact, when baseline MRI bone edema was present, the risk ratio for erosive progression in the same bone on CT at 12 months was 3.8. In addition, time-integrated MRI bone edema, power Doppler, and grey-scale synovitis scores were higher in bones and joints with CT progression.

With CT as the reference method, the researchers determined that the sensitivity and specificity for the other imaging modalities were 68% and 92%, respectively, on MRI; 44% and 95% on ultrasonography; and 26% and 98% on radiography.

In their concluding remarks in the editorial, Dr. McQueen and Dr. Naredo emphasized that the reduction of both synovitis and osteitis "is clearly an important therapeutic goal" in treating RA. "The detection and monitoring of synovitis is often more feasible in clinical practice using [ultrasound] than MRI scanning, but the latter does afford the opportunity to detect and monitor bone edema at the same time."

Dr. McQueen is with the department of molecular medicine and pathology at the University of Auckland (New Zealand). Dr. Naredo is with the department of rheumatology at the Hospital Universitario Severo Ochoa in Madrid.

Funding for the study was provided by Abbott Denmark, the Danish Rheumatism Association, and the Aase and Ejner Danielsen Foundation. Dr. Døhn reported no relevant financial conflicts, but many of the study’s coauthors disclosed that they have received consulting fees, speaking fees, or research grants from Abbott, Centocor, Roche, Schering-Plough, UCB-Nordic, and Wyeth. Dr. McQueen and Dr. Naredo stated that they have no conflicts of interest.

Erosive progression is arrested in rheumatoid arthritis patients who are treated with adalimumab and methotrexate combination therapy, judging from results of a novel longitudinal study comparing MRI, ultrasonography, CT, and radiography.

However, only MRI was sensitive enough to document repair of individual erosions. Both MRI and ultrasound could detect changes in bone edema, which "was predictive of subsequent erosive progression on CT, both at the individual bone/joint level and also for MRI bone edema at the patient level," reported lead author Dr. Uffe Møller Døhn of the department of rheumatology at the University of Copenhagen in the February 2011 edition of the Annals of the Rheumatic Diseases. "These data emphasize the predictive value of modern imaging, and especially highlight the importance of MRI bone edema for predicting erosive progression."

The findings also offer a different way of thinking about RA’s pathology. In an accompanying editorial, Dr. Fiona McQueen and Dr. Esperanza Naredo said that the study’s findings add to existing evidence suggesting that osteitis is more strongly predictive of bone erosion than is synovitis, which supports "the notion that there is a more direct connection between bone inflammation and bone damage than between synovial inflammation and bone damage" (Ann. Rheum. Dis. 2011;70:241-4). They described synovitis and osteitis as "cousins with a common ancestor, the process that ultimately drives both remaining obscure but possibly sited in the bone marrow."

Dr. Døhn and his associates used MRI, ultrasound, standard radiography, and high-resolution CT images of the wrist and metacarpophalangeal joints 2-5 to study response to adalimumab/methotrexate therapy in 52 RA patients naive to biological agents. All images were obtained before the first dose of adalimumab injection and were repeated after 6 and 12 months of treatment (Ann. Rheum. Dis. 2011;70:252-8).

The median age of patients was 61 years, and 67% were women. From baseline, the researchers did not observe any statistically significant changes in overall bone destruction or repair at 6 or 12 months, but differences were seen when researchers used the smallest-detectable-change cutoff. For example, after 6 and 12 months, the scores of MRI synovitis, grey-scale synovitis, and power Doppler ultrasonography decreased. So did scores as assessed by DAS28 (disease activity score in 28 joints), a health assessment questionnaire, and tender and swollen joint counts.

Study participants with disease progression on CT had higher baseline MRI bone edema scores. In fact, when baseline MRI bone edema was present, the risk ratio for erosive progression in the same bone on CT at 12 months was 3.8. In addition, time-integrated MRI bone edema, power Doppler, and grey-scale synovitis scores were higher in bones and joints with CT progression.

With CT as the reference method, the researchers determined that the sensitivity and specificity for the other imaging modalities were 68% and 92%, respectively, on MRI; 44% and 95% on ultrasonography; and 26% and 98% on radiography.

In their concluding remarks in the editorial, Dr. McQueen and Dr. Naredo emphasized that the reduction of both synovitis and osteitis "is clearly an important therapeutic goal" in treating RA. "The detection and monitoring of synovitis is often more feasible in clinical practice using [ultrasound] than MRI scanning, but the latter does afford the opportunity to detect and monitor bone edema at the same time."

Dr. McQueen is with the department of molecular medicine and pathology at the University of Auckland (New Zealand). Dr. Naredo is with the department of rheumatology at the Hospital Universitario Severo Ochoa in Madrid.

Funding for the study was provided by Abbott Denmark, the Danish Rheumatism Association, and the Aase and Ejner Danielsen Foundation. Dr. Døhn reported no relevant financial conflicts, but many of the study’s coauthors disclosed that they have received consulting fees, speaking fees, or research grants from Abbott, Centocor, Roche, Schering-Plough, UCB-Nordic, and Wyeth. Dr. McQueen and Dr. Naredo stated that they have no conflicts of interest.

Erosive progression is arrested in rheumatoid arthritis patients who are treated with adalimumab and methotrexate combination therapy, judging from results of a novel longitudinal study comparing MRI, ultrasonography, CT, and radiography.

However, only MRI was sensitive enough to document repair of individual erosions. Both MRI and ultrasound could detect changes in bone edema, which "was predictive of subsequent erosive progression on CT, both at the individual bone/joint level and also for MRI bone edema at the patient level," reported lead author Dr. Uffe Møller Døhn of the department of rheumatology at the University of Copenhagen in the February 2011 edition of the Annals of the Rheumatic Diseases. "These data emphasize the predictive value of modern imaging, and especially highlight the importance of MRI bone edema for predicting erosive progression."

The findings also offer a different way of thinking about RA’s pathology. In an accompanying editorial, Dr. Fiona McQueen and Dr. Esperanza Naredo said that the study’s findings add to existing evidence suggesting that osteitis is more strongly predictive of bone erosion than is synovitis, which supports "the notion that there is a more direct connection between bone inflammation and bone damage than between synovial inflammation and bone damage" (Ann. Rheum. Dis. 2011;70:241-4). They described synovitis and osteitis as "cousins with a common ancestor, the process that ultimately drives both remaining obscure but possibly sited in the bone marrow."

Dr. Døhn and his associates used MRI, ultrasound, standard radiography, and high-resolution CT images of the wrist and metacarpophalangeal joints 2-5 to study response to adalimumab/methotrexate therapy in 52 RA patients naive to biological agents. All images were obtained before the first dose of adalimumab injection and were repeated after 6 and 12 months of treatment (Ann. Rheum. Dis. 2011;70:252-8).

The median age of patients was 61 years, and 67% were women. From baseline, the researchers did not observe any statistically significant changes in overall bone destruction or repair at 6 or 12 months, but differences were seen when researchers used the smallest-detectable-change cutoff. For example, after 6 and 12 months, the scores of MRI synovitis, grey-scale synovitis, and power Doppler ultrasonography decreased. So did scores as assessed by DAS28 (disease activity score in 28 joints), a health assessment questionnaire, and tender and swollen joint counts.

Study participants with disease progression on CT had higher baseline MRI bone edema scores. In fact, when baseline MRI bone edema was present, the risk ratio for erosive progression in the same bone on CT at 12 months was 3.8. In addition, time-integrated MRI bone edema, power Doppler, and grey-scale synovitis scores were higher in bones and joints with CT progression.

With CT as the reference method, the researchers determined that the sensitivity and specificity for the other imaging modalities were 68% and 92%, respectively, on MRI; 44% and 95% on ultrasonography; and 26% and 98% on radiography.

In their concluding remarks in the editorial, Dr. McQueen and Dr. Naredo emphasized that the reduction of both synovitis and osteitis "is clearly an important therapeutic goal" in treating RA. "The detection and monitoring of synovitis is often more feasible in clinical practice using [ultrasound] than MRI scanning, but the latter does afford the opportunity to detect and monitor bone edema at the same time."

Dr. McQueen is with the department of molecular medicine and pathology at the University of Auckland (New Zealand). Dr. Naredo is with the department of rheumatology at the Hospital Universitario Severo Ochoa in Madrid.

Funding for the study was provided by Abbott Denmark, the Danish Rheumatism Association, and the Aase and Ejner Danielsen Foundation. Dr. Døhn reported no relevant financial conflicts, but many of the study’s coauthors disclosed that they have received consulting fees, speaking fees, or research grants from Abbott, Centocor, Roche, Schering-Plough, UCB-Nordic, and Wyeth. Dr. McQueen and Dr. Naredo stated that they have no conflicts of interest.

Hologic’s Selenia Dimensions digital breast tomosynthesis system (Dimensions 3-D) is the first three-dimensional mammography system to reach the U.S. market following premarket approval by the Food and Drug Administration on Feb. 11. The low-dose x-ray device provides both 2-D and 3-D images of the breast for breast cancer screening and diagnosis.

Conventional 2-D mammography systems have limitations caused by overlapping tissue in the breast that may hide lesions or cause benign areas to appear suspicious, the company explained. Clinical trials of Dimensions 3-D showed significant gains in specificity and other benefits, including improved lesion and margin visibility and the ability to accurately localize structures in the breast, the firm noted.

The approval follows endorsement of the product’s safety and efficacy data by FDA’s Radiological Devices advisory panel last September.

This coverage is provided courtesy of "The Pink Sheet." "The Pink Sheet" and Internal Medicine News Digital Network are both owned by Elsevier.

Hologic’s Selenia Dimensions digital breast tomosynthesis system (Dimensions 3-D) is the first three-dimensional mammography system to reach the U.S. market following premarket approval by the Food and Drug Administration on Feb. 11. The low-dose x-ray device provides both 2-D and 3-D images of the breast for breast cancer screening and diagnosis.

Conventional 2-D mammography systems have limitations caused by overlapping tissue in the breast that may hide lesions or cause benign areas to appear suspicious, the company explained. Clinical trials of Dimensions 3-D showed significant gains in specificity and other benefits, including improved lesion and margin visibility and the ability to accurately localize structures in the breast, the firm noted.

The approval follows endorsement of the product’s safety and efficacy data by FDA’s Radiological Devices advisory panel last September.

This coverage is provided courtesy of "The Pink Sheet." "The Pink Sheet" and Internal Medicine News Digital Network are both owned by Elsevier.

Hologic’s Selenia Dimensions digital breast tomosynthesis system (Dimensions 3-D) is the first three-dimensional mammography system to reach the U.S. market following premarket approval by the Food and Drug Administration on Feb. 11. The low-dose x-ray device provides both 2-D and 3-D images of the breast for breast cancer screening and diagnosis.

Conventional 2-D mammography systems have limitations caused by overlapping tissue in the breast that may hide lesions or cause benign areas to appear suspicious, the company explained. Clinical trials of Dimensions 3-D showed significant gains in specificity and other benefits, including improved lesion and margin visibility and the ability to accurately localize structures in the breast, the firm noted.

The approval follows endorsement of the product’s safety and efficacy data by FDA’s Radiological Devices advisory panel last September.

This coverage is provided courtesy of "The Pink Sheet." "The Pink Sheet" and Internal Medicine News Digital Network are both owned by Elsevier.