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. 2019 Jun;9(6):1110-1117.
doi: 10.21037/qims.2019.06.06.

The value of contrast-enhanced ultrasonography to detect the sacroiliac joint for predicting relapse after discontinuation of anti-tumor necrosis factor therapy in patients with ankylosing spondylitis

Jiayu Ren  1 , Jiaan Zhu  1 , Diancheng Li  1 , Wenxue Li  1 , Fang Liu  1
Affiliations

The value of contrast-enhanced ultrasonography to detect the sacroiliac joint for predicting relapse after discontinuation of anti-tumor necrosis factor therapy in patients with ankylosing spondylitis

Jiayu Ren et al. Quant Imaging Med Surg. 2019 Jun.

Abstract

Background: Ankylosing spondylitis (AS) is a chronic inflammatory disease characterized by high relapse. Therefore, the present study aimed to investigate the ultrasonographic features of contrast-enhanced ultrasonography (CEUS) in the sacroiliac joint (SIJ) in patients with AS in remission after discontinuation of anti-tumor necrosis factor (TNF) therapy, and also examined the role of CEUS in predicting relapse.

Methods: In this prospective observational study, 130 SIJs in 65 patients with AS (according to modified New York criteria) satisfying Ankylosing Spondylitis Disease Activity Score (ASDAS) inactive disease after discontinuation of anti-TNF therapy were investigated on color Doppler ultrasonography (CDUS) and CEUS. Vascularization and the resistive index (RI) of the SIJ were observed and measured. We defined no blood flow, high RI of arterial blood flow (RI ≥0.7), the reversed phase in the diastolic phase or venous blood flow in the bilateral SIJs, as negative CDUS/CEUS; meanwhile, low RI of arterial blood flow (RI <0.7) in the unilateral or bilateral SIJs was defined as positive CDUS/CEUS. All the patients were followed up for 52 weeks until relapse. Relapse was defined as an increase of two or more items in comparison with the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) at the time of anti-TNF withdrawal.

Results: After 52 weeks, 46 of the 65 patients (70.8%) had relapse. The mean time to relapse was 31.4 weeks (±8.4 weeks, range 20 to 52). After discontinuation of anti-TNF therapy, positive CEUS accounted for 61.5%; this was significantly more than positive CDUS (13.8%). The vascularization detected by CEUS for patients of relapse was significantly different from that of patients with remission (P<0.05). In addition, patients with negative CEUS had a longer duration of remission than the patients with positive CEUS (P=0.005). A Cox proportional hazards regression analysis found that the disease duration could also be regarded as a factor predictive of relapse in patients with AS.

Conclusions: The use of CEUS distinctly improved the detection of vascularization in the SIJ in patients with AS in remission after anti-TNF withdrawal. The presence of vascularization in the SIJ detected by CEUS at the time of anti-TNF withdrawal could yield a valuable predictor of relapse in patients with AS. A significant limit of this study is the lack of magnetic resonance imaging (MRI) as the standard reference.

Keywords: Ankylosing spondylitis (AS); color Doppler ultrasonography (CDUS); contrast-enhanced ultrasonography (CEUS); relapse; sacroiliac joint (SIJ).

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Conflict of interest statement

Conflicts of Interest: The authors have no conflicts of interest to declare.

Figures

Figure 1
Figure 1
Color Doppler ultrasonography and spectral Doppler images of negative CDUS but positive CEUS in the SIJ of patients with AS. (A) Negative CDUS: no color Doppler signals in either SIJ. (B) Contrast image at 29 seconds after administration of SonoVue. (C) Positive CEUS: spectral Doppler of low resistive index (0.47) in the left SIJ after administration of SonoVue. (D) Positive CEUS: spectral Doppler of high resistive index (0.80) in the right SIJ after administration of SonoVue. CDUS, color Doppler ultrasonography; CEUS, contrast-enhanced ultrasonography; SIJ, sacroiliac joint.
Figure 2
Figure 2
Kaplan-Meier curve of time to relapse in 65 patients with AS after discontinuation of anti-TNF therapy. AS, ankylosing spondylitis; TNF, tumor necrosis factor.
Figure 3
Figure 3
Kaplan-Meier curves of time to relapse for three results of CDUS and CEUS examinations after discontinuation of anti-TNF therapy in 65 patients with AS. CDUS, color Doppler ultrasonography; CEUS, contrast-enhanced ultrasonography; AS, ankylosing spondylitis; TNF, tumor necrosis factor.
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