Correlation between radiation dose, synovial thickness, and efficacy of radiosynoviorthesis.
OBJECTIVE
To correlate the therapeutic efficacy of radiosynoviorthesis (RSO) to radiation doses achieved.


METHODS
In 20 patients with known rheumatoid arthritis, radiosynoviorthesis was performed in 36 joints. Arthritis disease activity was assessed by "blood pool scintigraphy" (n = 29) score after injection of 370 MBq 99mTc-MDP, before and at 1, 2, and 5 months after the RSO in 12 patients. For semiquantitative measurements, a region-of-interest technique was applied. Synovial thickness and response to the RSO were evaluated by joint ultrasonography. Pain levels were evaluated semiquantitatively. Dosimetry (n = 20) was calculated using planar quantification according to the MIRD scheme.


RESULTS
The mean radiation absorbed dose of 186Re-sulfate to the whole body was 5.3+/-2.7 cGy, liver 10.0+/-8.1 cGy, spleen 20.3+/-22.9 cGy, kidneys 9.4+/-11.4 cGy, and at the injected joints of the shoulder 120.5+/-32.2 Gy, hand 130.0+/-12.6 Gy, elbow 83.6+/-38.7 Gy, and talar/subtalar joint 84.1+/-30.7 Gy. In 7 cases, where mandatory immobilization of the joint was not possible, the dose to the lymph nodes (n = 25) was 25.9+/-53.8 Gy (maximum 189 Gy) and to single lymph nodes 14.6+/-11.2 Gy (maximum 63 Gy). The reduced doses to the synovia (at 40% leakage) were: 169Er-citrate 73.10+/-25.25 Gy; 90Y-citrate 59.25+/-46.45 Gy; 186Re-sulfate 65.40+/-32.55 Gy. In cases of complete immobilization, the dose to the lymph nodes was negligible: 169Er-citrate (n = 7), whole body dose 0.4 cGy, lymph nodes 2.3 Gy, finger joints 132.3+/-34.3 Gy; 90Y-citrate (n = 6), whole body dose 15.5 cGy, liver dose 26.5 cGy, splenic dose 11.9 cGy, kidney dose 67 cGy, joint knee joint dose 130.1 Gy. Regarding therapeutic effect, mean reduction of the 99mTc-MDP blood pool activity was 41% at first month, 48% at second month, 48% at the fifth month, 48% in larger joints, and 63% in finger joints. Three and 6 months after RSO, sonography showed a mean reduction in synovial swelling: in the knee joint 1.67 and 4.38 mm, respectively; in the larger joints (shoulder, elbow, hand, talar/subtalar) 0.88/1.93 mm; and in finger joints 0.53/1.76 mm. Clinically, best results were observed in the finger joints.


CONCLUSIONS
1. We observed a significantly higher radiation absorbed dose to the lymph nodes and lower dose to the synovia in the absence of joint immobilization. Immobilization of the joint is essential. 2. At 2 months after treatment, a significant reduction of blood pool activity and synovial swelling was observed, with further improvement in the following months, especially in the finger joints. 3. There is a strong correlation between the reduction of blood pool activity, synovial swelling, and improvement of pain.
Gratz
S
S
Department of Nuclear Medicine and Orthopedics, Georg August University, Göttingen, Germany. sgratz@WisLAN1.med.uni-goettingen.de
Göbel
D
D
Behr
T M
TM
Herrmann
A
A
Becker
W
W
D001172:Arthritis, Rheumatoid / Q000000981:diagnostic imaging / Q000532:radiotherapy*; D004307:Dose-Response Relationship, Radiation; D004871:Erbium / Q000493:pharmacokinetics / Q000627:therapeutic use; D005260:Female; D006801:Humans; D007103:Immobilization; D007596:Joints / Q000000981:diagnostic imaging; D008297:Male; D008875:Middle Aged; D011877:Radionuclide Imaging; D019275:Radiopharmaceuticals / Q000493:pharmacokinetics / Q000627:therapeutic use; D012211:Rhenium / Q000493:pharmacokinetics / Q000627:therapeutic use; D013583:Synovial Membrane / Q000528:radiation effects*; D013585:Synovitis / Q000000981:diagnostic imaging / Q000532:radiotherapy; D013669:Technetium Tc 99m Medronate; D014018:Tissue Distribution; D016896:Treatment Outcome; D015021:Yttrium Radioisotopes / Q000493:pharmacokinetics / Q000627:therapeutic use
D019275:Radiopharmaceuticals; D015021:Yttrium Radioisotopes; D012211:Rhenium; D004871:Erbium; D013669:Technetium Tc 99m Medronate