|Year : 2015 | Volume
| Issue : 3 | Page : 159-161
Radiosynovectomy of ankle joint synovitis in juvenile rheumatoid arthritis treated with rhenium-188 tin colloid and imaging with SPECT/CT
Koramadai K Kamaleshwaran1, Thirumalaisamy S Gounder2, Boopathy Krishnan2, Madhav Mallia3, Radhakrishnan Kalarikal1, Ajit S Shinto1
1 Department of Nuclear Medicine, PET/CT and Radionuclide Therapy, Comprehensive Cancer Care Center, Coimbatore, Tamil Nadu, India
2 Department of Orthopedics, Kovai Medical Center and Hospital Limited, Coimbatore, Tamil Nadu, India
3 Radiopharmaceuticals Chemistry Section (RPhCS), Bhabha Atomic Research Centre, Mumbai, India
|Date of Submission||10-Nov-2014|
|Date of Acceptance||21-Jun-2015|
|Date of Web Publication||31-Aug-2015|
Koramadai K Kamaleshwaran
Department of Nuclear Medicine, PET/CT and Radionuclide Therapy, Comprehensive Cancer Care Center, Kovai Medical Center and Hospital Limited, Coimbatore - 641 014, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Rheumatoid arthritis is a chronic disease that is mainly characterized by asymmetric erosive synovitis, particularly affecting peripheral joints. Radiation synovectomy, or radiosynovectomy, was first described in 1950s as an adjuvant treatment for rheumatoid arthritis. Radiosynovectomy is based on the irradiation of the synovial joint by means of intra-articular administration of various b-emitting radiopharmaceuticals. As a generator-produced beta-emitting radionuclide, the importance of rhenium-188 (Re-188) in radionuclide therapy is increasing rapidly. There are previous studies that used Re-188 tin colloid in knee joint synovitis, but its use in ankle joint has not yet been reported. We describe the use of Re-188 tin colloid in a 19-year-old male patient who presented with ankle joint synovitis.
Keywords: ankle joint, radiosynovectomy, rhenium-188 tin colloid, SPECT/CT
|How to cite this article:|
Kamaleshwaran KK, Gounder TS, Krishnan B, Mallia M, Kalarikal R, Shinto AS. Radiosynovectomy of ankle joint synovitis in juvenile rheumatoid arthritis treated with rhenium-188 tin colloid and imaging with SPECT/CT. Egypt Rheumatol Rehabil 2015;42:159-61
|How to cite this URL:|
Kamaleshwaran KK, Gounder TS, Krishnan B, Mallia M, Kalarikal R, Shinto AS. Radiosynovectomy of ankle joint synovitis in juvenile rheumatoid arthritis treated with rhenium-188 tin colloid and imaging with SPECT/CT. Egypt Rheumatol Rehabil [serial online] 2015 [cited 2019 Oct 21];42:159-61. Available from: http://www.err.eg.net/text.asp?2015/42/3/159/163949
| Introduction|| |
Rheumatoid arthritis (RA) is a chronic, progressive, inflammatory joint disorder, the primary treatment for which consists of medical regimens aimed at controlling synovial inflammation of the joint  . Radiation synovectomy (RS) involves the injection of a radiopharmaceutical into the joint with the intention of destroying the inflamed synovium, in the expectation that the regenerated synovium will be disease-free and symptoms will thereby be alleviated  . Rhenium-188 (Re-188) is considered to be a promising radionuclide for use in RS of joints owing to its favorable decay characteristics. Re-188 is readily available on routine bases from the tungsten-188/Re-188 generator system  , which has a shelf-life of several months. Re-188 tin colloid RS is a useful treatment modality for patients with chronic inflammatory knee joint conditions refractory to conventional treatment  . We describe the first case of application of Re-188 tin colloid in the treatment of ankle joint synovitis in RA.
| Case report|| |
A 19-year-old male patient presented with right ankle joint pain and swelling for a duration of 6 months. His blood investigations revealed elevated C-reactive protein (60 mg/ml) and was diagnosed to have juvenile RA. He was treated with antirheumatoid drugs and had no symptom relief. He was referred for three-phase bone scintigraphy and RS. Blood pool images ([Figure 1]) shows increased blood pooling consistent with synovitis. Whole-body images ([Figure 2]) showed increased uptake in the right ankle joint. RS injection was performed according to EANM guidelines  . RS was performed with precise intra-articular injection of a typical dose of 555 MBq Re-188 tin colloid under sterile conditions and fluroscopic guidance. Before joint puncture, local anesthesia was administered with 2% lidocaine-hydrochloride. Before the injection of Re-188 tin colloid, Depo Medrol (40 mg in 1 ml) was injected into the joint to reduce the risk of acute radiation-induced synovitis and to avoid skin radiation necrosis. Subsequently, 555 MBq dispersed in 1 ml of sterile, apyrogenic normal saline was administered intra-articularly into the ankle, subtalar, and calcaneocuboid joint and then the needle was flushed with 2-4 ml of normal saline. Arthrography was performed to check the correct location. An orthopedic bandage was applied as a semirigid splint. Images were acquired with a dual-head gamma camera (Siemens Symbia True point, Siemens Medical Solutions, Illinois, USA) in a high-energy general-purpose collimator with 155 ± 20 keV. Re-188 tin colloid static of the ankle joint ([Figure 3]), and SPECT/CT images ([Figure 4]) showed good distribution of tracer in the ankle, subtalar, and calcaneocuboid joint. His ankle was immobilized for 48 h. On follow-up after 3 months, pain and swelling of the ankle joint decreased significantly.
|Figure 1: Anterior and posterior blood pool images demonstrate increased blood pool concentration in the right ankle joint consistent with synovitis.|
Click here to view
|Figure 2: Whole-body images showing increased tracer uptake in the right ankle joint.|
Click here to view
|Figure 3: Re-188 tin colloid images of ankle joint showing good tracer distribution in the right ankle joint.|
Click here to view
|Figure 4: Coronal SPECT/CT of ankle joint showing good tracer distribution in the ankle, subtalar, and calcaneocuboid joint.|
Click here to view
| Discussion|| |
RS is a local intra-articular injection of radionuclides in colloidal form. RS may relieve synovitis, joint pain, knee flexibility, and joint effusion in about 60-80% of the cases  . First used by Fellinger et al.  in 1952, the technique has been applied for over 50 years in the treatment of resistant synovitis in individual joints after the failure of long-term systemic pharmacotherapy and intra-articular steroid injections. Three radionuclides are currently in use: yttrium-90 (Y-90 silicate/citrate), rhenium-186 (Re-186 sulfide), and erbium-169 (Er-169 citrate), which have been indicated for large, medium, and small joints, respectively  .
Re-188 is an attractive radionuclide for RS because of its suitable chemistry, t1/2 =16.9 h and average beta energy of 776 keV (Emax =2.11 MeV, 79%). These properties enable ankle treatment due to its maximal tissue penetration of 11 mm and its mean range of 3.8 mm  . Re-188 decays to the stable Os-188, with a gamma ray emission of 155 keV (15%) that is suitable for image acquisition. Leakage has been particularly difficult to quantify when the isotope used has been Y-90 or P-32, both of which are pure beta emitters with no accompanying gamma emissions that might be used to quantify biodistribution and dosimetry. This fact allows target uptake evaluation, as well as the estimation of the absorbed radiation dose. Besides this, Re-188 is readily available on routine bases from the tungsten-188/Re-188 generator system, which has a shelf-life of several months , .
Re-188 tin colloid can be potentially used as an ideal agent for RS of the joints. As per the limited number of stability and animal studies performed by scientists, it has been observed that Re-188 tin colloid is highly stable and that leakage from the synovial site is negligible compared with that from Re-188 sulfur colloid  . Studies by Savio et al.  and Jeong et al.  concluded that Re-188 tin colloid could be selected as the best formulation for RS, taking into account the ease in labeling procedure, kit formulation, requirement of minimum facilities, suitable physical and biological characteristics, and the lowest absorbed dose for the patient. Because of this the highest benefit/risk relation was found for Re-188 tin in comparison with Re-188 ferric hydroxide macroaggregates coated with tin colloid and Re-188 hydroxyapatite particles. In a study by Shin et al.  on ovalbumin-induced arthritic rabbits, the Re-188 tin colloid improved the macroscopic and histological score and reduced the knee joint diameter when compared with the arthritic control. In conclusion, a Re-188 tin colloid is considered a strong candidate for RS with a superior efficacy and safety.
Lee et al.  performed the first human study of RS using Re-188 tin colloid in 22 knees from 21 RA patients refractory to intra-articular corticosteroid injection. No clinical side-effects or abnormalities in leukocyte count, platelet count, liver function tests, or urine analysis were observed in any patient. In conclusion, in that first study of RS using Re-188 tin colloid for patients with RA, the treatment resulted in the improvement of arthritis and was well tolerated. Shin et al.  showed that RS using Re-188 tin colloid in refractory RA patients improved MRI findings as well as clinical parameters. Shamim et al.  studied 61 knee joints in 48 patients with chronic synovitis and concluded that Re-188 tin colloid RS is a useful treatment modality in patients with chronic inflammatory knee joint conditions refractory to conventional treatment. Patients with shorter duration of disease, normal or minor X-ray findings, little or no swelling, mild tenderness, and better mobility are better candidates for RS. Our case describes the use of Re-188 tin colloid in ankle joint synovitis and has shown good response to therapy.
| Conclusion|| |
Radiation synovectomy is a useful treatment modality in patients with rheumatoid synovitis. We have used Re-188 tin colloid as a new radiopharmaceutical agent and evaluated its efficacy and safety in patient with RA in ankle joint. No clinical side-effects were observed in the patient. Radiation synovectomy using Re-188 tin colloid for patients with RA in ankle joint resulted in the improvement of arthritis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Zuckerman JD, Sledge CB, Shortkroff S, Venkatesan P. Treatment of rheumatoid arthritis using radiopharmaceuticals. Int J Rad Appl Instrum B 1987; 14
Schneider P, Farahati J, Reiners C. Radiosynovectomy in rheumatology, orthopedics, and hemophilia. J Nucl Med 2005; 46 Suppl 1: 48S-54S.
Kamioki H, Mirzadeh S, Lambrecht RM, Knapp FF Jr, Dadachova K. 188W/188 Re generator for biomedical applications. Radiochim Acta 1994; 65
Shamim SA, Kumar R, Halanaik D, Kumar A, Shandal V, Shukla J, et al.
Role of rhenium-188 tin colloid radiosynovectomy in patients with inflammatory knee joint conditions refractory to conventional therapy. Nucl Med Commun 2010; 31
Clunie G, Fischer M. EANM procedure guidelines for radiosynovectomy. Eur J Nucl Med Mol Imaging 2003; 30
Kampen WU, Brenner W, Kroeger S, Sawula JA, Bohuslavizki KH, Henze E. Long-term results of radiation synovectomy: a clinical follow-up study. Nucl Med Commun 2001; 22
Fellinger K, Schmid J. Local therapy of rheumatic diseases. Wien Z Inn Med 1952; 33
Deutsch E, Brodack JW, Deutsch KF. Radiation synovectomy revisited. Eur J Nucl Med 1993; 20
Wang SJ, Lin WY, Hsieh BT, Shen LH, Tsai ZT, Ting G, Knapp FF Jr. Rhenium-188 sulphur colloid as a radiation synovectomy agent. Eur J Nucl Med 1995; 22
Ures M, Savio E, Malanga A, Fernández M, Paolino A, Gaudiano J. Physico-chemical characterisation and biological evaluation of 188-Rhenium colloids for radiosynovectomy. BMC Nucl Med 2002; 2
Savio E, Ures MC, Zeledón P, Trindade V, Paolino A, Mockford V, et al.
188-Re radiopharmaceuticals for radiosynovectomy: evaluation and comparison of tin colloid, hydroxyapatite and tin-ferric hydroxide macroaggregates. BMC Nucl Med 2004; 4
Jeong JM, Lee YJ, Kim YJ, Chang YS, Lee DS, Chung JK, et al.
Preparation of rhenium-188-tin colloid as a radiation synovectomy agent and comparison with rhenium-188-sulfur colloid. Appl Radiat Isot 2000; 52
Shin CY, Son M, Ko JI, Jung MY, Lee IK, Kim SH, et al.
DA-7911, 188-Rhenium-tin colloid, as a new therapeutic agent of rheumatoid arthritis. Arch Pharm Res 2003; 26
Lee EB, Shin KC, Lee YJ, Lee YJ, Cheon GJ, Jeong JM, et al.
188-Re-tin-colloid as a new therapeutic agent for rheumatoid arthritis. Nucl Med Commun 2003; 24
Shin K, Lee JC, Choi HJ, Jeong JM, Son M, Lee YJ. Radiation synovectomy using 188-Re-tin colloid improves knee synovitis as shown by MRI in refractory rheumatoid arthritis. Nucl Med Commun 2007; 2:239-244.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]