Use of Magnetic Resonance Imaging to Identify Immune Checkpoint Inhibitor–Induced Inflammatory Arthritis
Authors: Ananta Subedi, Sandra G. Williams, Lawrence Yao, Suresh Maharjan, Julius Strauss, Elad Sharon, Anish Thomas, Andrea B. Apolo, Pravitt Gourh, Sarfaraz A. Hasni, James L. Gulley, Mariana J. Kaplan, James D. Katz, Sarthak Gupta
Journal: JAMA Network Open (2020)

<h3>Importance</h3> Immune checkpoint inhibitors (ICIs) have transformed the treatment paradigm for an ever-increasing number of cancers. However, their use has also led to the emergence of immune-related adverse events, such as ICI-induced inflammatory arthritis. A reproducible, reliable, and accessible modality is needed to assess and distinguish early ICI-induced inflammatory arthritis and help in management. Magnetic resonance imaging (MRI) of joints may be helpful for early diagnosis, guiding therapeutic decision-making, and identifying patients at high risk for erosive disease. <h3>Objective</h3> To assess the role of MRI of joints in patients with ICI-induced inflammatory arthritis. <h3>Design, Setting, and Participants</h3> This retrospective case series included patients enrolled at the National Institutes of Health Clinical Center in Bethesda, Maryland. Patients were evaluated by the rheumatology consultation service between December 27, 2016, and May 28, 2019. A retrospective health record review was performed to determine demographic characteristics, clinical characteristics of inflammatory arthritis and malignant tumors, and imaging findings. Inclusion criteria were patients who were enrolled on various institutional review board–approved protocols of ICIs, developed joint-related symptoms, and had MRI data for at least 1 joint. Data were analyzed from June 1, 2019, to September 1, 2019. <h3>Exposures</h3> Undergoing MRI of at least 1 joint. <h3>Main Outcomes and Measures</h3> All MRIs were reviewed for synovitis, tenosynovitis, bone marrow edema, and soft tissue conditions. <h3>Results</h3> A total of 8 patients (mean [SD] age, 58.8 [5.2] years; 6 women and 2 men) between the ages of 50 and 65 years who were undergoing ICI therapy for a variety of malignant tumors were included in this study. Only 1 patient was receiving combined ICI therapy. The results of 13 separate MRI examinations were reviewed. The most commonly performed MRIs were of the hands and wrists (9 MRIs), followed by knee examinations (3 MRIs). Tenosynovitis and synovitis were frequently seen in the hands and wrists. Bone marrow edema and erosions were also found in 3 patients, suggesting early damage. In larger joints (ie, knees and ankles), joint effusions and synovial thickening were characteristic. Most patients (5 patients) were treated with corticosteroids and had good responses. In patients with high-risk features on MRI imaging (eg, bone marrow edema, erosions), disease-modifying antirheumatic drug therapy was also discussed as a treatment option. <h3>Conclusions and Relevance</h3> These findings suggest that advanced imaging may help to distinguish ICI-induced inflammatory arthritis from other causes of joint pain, aid in identifying patients at increased risk of joint damage, and provide utility in monitoring inflammatory arthritis treatment response in patients receiving ICI therapy.