Fast-Track Clinics and Visual Outcomes in Giant Cell Arteritis: A Systematic Review and Meta-Analysis.

Web of Confusion

Is Temporal Artery Biopsy Prudent?

Giant Cell Arteritis: Read the Fine Print!

THU0313 DISEASE PATTERN AND TIME TO DIAGNOSIS IN A FAST-TRACK GIANT CELL ARTERITIS CLINIC USING ULTRASOUND AS PRIMARY DIAGNOSTIC TOOL

AB0381 VALIDATING DRAFT DCVAS CRITERIA IN A SINGLE CENTER GCA COHORT IN SOUTHERN NORWAY

ObjectiveWe developed a fast‐track clinic (FTC) to expedite the evaluation of patients suspected of having giant cell arteritis (GCA) using vascular ultrasound. Though FTCs have demonstrated efficacy in Europe, no protocolized clinic in the United States has been developed. This study introduces a new FTC model unique to the United States, using vascular sonographers, and describes the protocols used to develop reliable findings. We evaluate clinical outcomes using vascular ultrasound and temporal artery biopsy (TAB).MethodsA retrospective review included all subjects referred to the University of Washington FTC aged 50 years old or older who received both ultrasound and TAB between November 2017 and November 2019. Ultrasound was performed by a vascular sonographer trained in GCA detection. Ultrasound results were read by a vascular surgeon and reviewed by four rheumatologists certified in musculoskeletal ultrasound who had completed a course in vascular ultrasound use in GCA and large‐vessel vasculitis.ResultsA total of 43 subjects underwent both vascular ultrasound and TAB. Six subjects had both positive ultrasound and TAB results. There were also seven positive ultrasound results in patients with negative TAB results, most due to detection of large‐vessel GCA (LV‐GCA). All 29 subjects with negative ultrasound results had negative TAB results.ConclusionThis is the first study in the United States to demonstrate a reliable FTC protocol using vascular sonographers. This protocol demonstrated good agreement between ultrasound and TAB and allowed for the detection of additional cases of LV‐GCA by vascular ultrasound. Vascular ultrasound improved the rate of GCA diagnosis primarily by detecting additional cases of LV‐GCA.

To evaluate the positivity rate of temporal artery biopsies (TAB) performed in suspects of giant cell arteritis (GCA) and to study the epidemiological and clinical factors associated to the biopsy result. A retrospective, multicenter, case-control study was performed, including three hundred and thirty-five patients who underwent TAB for a suspicion of GCA from 2001 to 2010. Clinical, epidemiological and pathology data were recovered from the patients' clinical records. Histologic diagnosis of GCA was made when active inflammation or giant cells were found in the arterial wall. Eighty-one biopsies (24.2%) were considered positive for GCA. Clinical factors independently associated to TAB result in a logistic regression analysis were temporal cutaneous hyperalgesia (OR = 10.8; p < 0.001), jaw claudication (OR = 4.6; p = 0.001), recent-onset headache (OR = 4.4; p = 0.001), decreased temporal pulse (OR = 2.8; p = 0.02), pain and stiffness in neck and shoulders (OR = 2.3; p = 0.05), unintentional weight loss (OR = 1.33; p = 0.003) and age (OR = 1.085; p = 0.004). Other factors such as length of the surgical specimen (OR = 1.079; p = 0.028) and erythrocyte sedimentation rate (OR = 1.042; p < 0.001) were also statistically significant. The model was accurate (C-index = 0.921), reliable (pHosmer-Lemeshow = 0.733) and consistent in the bootstrap sensitivity analysis. No significant association was detected between TAB result and number of days of previous systemic corticosteroid treatment (p = 0.146). However, an association was observed between TAB result and the total accumulated dose of previous systemic corticotherapy (p = 0.043). Exhaustive anamnesis and clinical examination remain of paramount importance in the diagnosis of GCA. To improve the yield of TAB, it should be performed specially in older patients with GCA-compatible clinic. TAB could be avoided in patients with an isolated elevation of acute phase reactants, without GCA-compatible clinic.

A retrospective chart review garnered patient demographics, symptoms, comorbidities, and steroid treatment duration in patients undergoing TAB at a single center. Steroid treatment was compared between TAB+ and TAB - patients. One hundred seven patients undergoing TAB were included. Patients were predominantly women (70.1%) with a median age of 74 years (46 -91). Of 107 TAB results, 74 (69.2%) were negative, 23 (21.5%) were positive, and 10 (9.3%) were found to be indeterminate. In TAB+ patients, the mean erythrocyte sedimentation rate was not significantly different than TAB - patients (60.2 versus 43.7, P = 0.45), nor was the median C-reactive protein (38.8 versus 18.1, P = 0.17). Regarding steroid use, both TAB+ and TAB - patients had a similarly high rate of prebiopsy steroid initiation (82.6% versus 70.3%, P = 0.32). More TAB+ patients remained on steroids at 6 weeks (95.0% versus 57.4%, P = 0.004), 6 months (95% versus 37.7%, P < 0.001), 1 year (65.0% versus 31.1%, P = 0.024), and 18 months (50.0% versus 19.7%, P = 0.045). By 2 years, the difference no longer met significance (35.0% versus 14.8%, P = 0.12). P = 0.12). TAB positivity does seem to influence maintenance of steroids up to 18 months after biopsy.

Background Jaw and tongue pain with constitutional symptoms and raised inflammatory markers are considered pathognomonic ischemic features of giant cell arteritis (GCA). Temporal artery ultrasound (US) (or biopsy) available in GCA fast-track clinics (FTC) for a rapid assessment of patients with suspected GCA. Atypical presentation and negative US or biopsy require further workup to look for an alternative diagnosis. ENT pathology can occur as a mimic of GCA. Herein we discuss two clinical cases of squamous cell cancer tongue presenting with signs and symptoms that resemble GCA. Methods We have put together a case report. Results Case-1: A 58-year-old male with a recent presumed diagnosis of relapsing GCA was referred with worsening visual symptoms and right eye pain despite ongoing steroid treatment (60mg), for consideration of Tocilizumab (TCZ). His initial presentation was 5 months ago with a right parietal and retro-orbital headache and blurred vision. He had a normal eye examination. His C-reactive protein (CRP) was raised (24). He was started on prednisolone 40 mg for GCA with complete resolution of symptoms with normalised CRP within weeks. Several weeks later, symptoms reoccurred. CT brain, abdomen and pelvis was normal and temporal artery biopsy negative. His prednisolone was increased to 60 mg. 6 months later, his jaw and tongue pain worsened, and he was treated with pulsed methylprednisolone. Due to partial response to steroids, he was referred to consider TCZ. He had tender left TMJ with normal temporal artery US. Urgent MRI head and neck revealed a left posterior tongue mass with the histology confirmed poorly differentiated squamous cell carcinoma. He was managed with chemo and radiotherapy. Case-2: A 75 years old female, presented with right scalp pain, tongue pain, painful swallowing and chewing. Her blood investigations were normal except a raised ESR (48) and presumed GCA she was started on steroids (60 mg). she had initially good response but, within a few weeks, her symptoms returned. She was then referred to our FTC. Temporal artery US and biopsy were normal. MRI of the head and neck showed a large mass seen in the right half of the posterior tongue extending into the deep aspect of the anterior tongue. Histology confirmed poorly differentiated Squamous cell carcinoma. She was treated with a combination of chemotherapy and radiotherapy. Conclusion GCA mimics represent a major diagnostic dilemma. FTC helps to stratify the GCA from mimics. Careful evaluation of the history, examination as well as a temporal artery US helps to exclude GCA and aids prompt requesting of appropriate tests to find an alternative diagnosis such as tongue cancers as in our cases. We have now introduced negative weightage for consideration of alternative diagnoses in our GCA probability score. Disclosures A. Kayani None. A. Sebastian None. L. Borukhson None. M. Whitlock None. B. Dasgupta Consultancies; Roche, Sanofi. Grants/research support; Roche.

Background: The role of temporal artery biopsy (TAB) as a reference test for the diagnosis of giant cell arteritis (GCA) is currently questioned by the use of non-invasive imaging techniques such as temporal artery ultrasonography (TA-US). Although TAB is highly specific, a subset of patients with a clinical diagnosis of GCA does not show the characteristic histopathological signs. The lack of knowledge of the proportion of GCA cases with positive findings on TAB hampers comparisons of the sensitivity of TAB and imaging tests for diagnosing GCA. Objectives: We performed a systematic literature review and meta-analysis to estimate the sensitivity of TAB in GCA and to identify factors that may influence the estimate. Methods: We searched MEDLINE via PubMed, EMBASE and CENTRAL databases for articles reporting TAB in GCA that were published from 1990 to 2017, with no language restriction. Eligibility criteria included studies with ≥30 GCA cases fulfilling the original or modified 1990 ACR classification criteria for GCA. From eligible publications, two independent researchers extracted the main methodological, geographic, demographic, and clinical characteristics and the number of TAB-positive cases among all cases with interpretable results for TAB. By meta-analysis, we computed the pooled proportion of TAB-positive GCA cases by using a random-effects model with a binomial-normal distribution and assessed heterogeneity by the I2 statistic. Subgroup and meta-regression analyses were used to examine the effect of 16 covariates (e.g., geographic, demographic, clinical and study descriptors) on TAB positivity. Results: Among 3820 screened publications, 32 independent studies (3092 GCA patients in total) were used for the analysis. The pooled proportion of TAB positivity was estimated at 77.3% (95% confidence interval 71.8–81.9%), with high between-study heterogeneity (I2=90%). Subgroup analysis suggested a potential influence of year of publication (Table). This result was confirmed by univariate (P=0.0008) and multivariate meta-regression (P=0.0004). No other analyzed covariate significantly influenced the sensitivity of TAB in GCA. Conclusion: The 77% estimated sensitivity of TAB in GCA indicates that it is not inferior to that of TA-US (1). The decline in TAB-positive GCA cases over time could reflect an increasing propensity of clinicians to accept GCA diagnosis in the absence of proof by TAB. The unexplained high between-study heterogeneity could also result from differences in TAB sampling, processing or interpretation. Reference [1] Duftner C, Dejaco C, Sepriano A, et al. Imaging in diagnosis, outcome prediction and monitoring of large vessel vasculitis: a systematic literature review and meta-analysis informing the EULAR recommendations. RMD Open. 2018;4:e000612. Disclosure of Interests: Emma Rubenstein: None declared, Carla Maldini: None declared, Solange GONZALEZ-CHIAPPE: None declared, Sylvie Chevret: None declared, Alfred Mahr Consultant for: Chugai Pharma France, Speakers bureau: Roche SAS Chugai Pharma France

The Early History of Giant Cell Arteritis and Polymyalgia Rheumatica: First Descriptions to 1970

OP0142 THE IMPACT OF DISEASE EXTENT AND SEVERITY DETECTED BY QUANTITATIVE ULTRASOUND ANALYSIS IN THE DIAGNOSIS AND OUTCOME OF GIANT CELL ARTERITIS: RESULTS FROM THE TEMPORAL ARTERYBIOPSY VERSUS ULTRASOUND (TABUL) STUDY AND VALIDATION IN AN INDEPENDENT COHORT

Resident Perspectives

Background: Ultrasound (US) is recommended as the first-line investigation for suspected giant cell arteritis (GCA). Integration of US into fast-track clinics has transformed GCA management and improved outcomes across Europe. While incorporation of US into fast-track clinics has transformed GCA management in Europe, variability in operator technique and reporting may limit its utility in Australia. This audit evaluated US reports for suspected GCA against international standards. Methods: US reports for suspected GCA from two Australian tertiary hospitals were reviewed. Reports from 1 January to 31 December 2024 will be included. Preliminary analysis compared 25 reports from a dedicated fast-track GCA clinic (FT) and 25 from a tertiary hospital radiology department (RD). Reports were assessed against European Alliance of Associations for Rheumatology (EULAR) recommendations, focusing on clinical indications, anatomical clarity, vessel descriptors, measurements, and clinical correlation. Results: FT reports consistently documented clinical indications and clinical correlation, whereas RD reports were more variable and often lacked conclusions or recommendations. Anatomical terminology was generally clearer in RD reports, though occasional mislabelling of parietal branches occurred. Vessel specification was frequently omitted in FT reports. FT reports more often included axillary artery assessment (11/25 vs 6/25). Both groups primarily described the “halo sign,” though wall descriptors varied. RD reports more frequently documented compressibility, and some included non-standard descriptors such as “tenderness on probe.” Wall thickness measurements were uncommon (FT 1/25; RD 4/25), and only one FT report included an OMERACT GCA Ultrasound Score (OGUS). Conclusion: This first Australian audit highlights substantial variability in US reporting for suspected GCA, with inconsistencies in terminology, omission of key findings, and absence of structured conclusions. Adoption of standardised reporting aligned with EULAR recommendations may improve diagnostic confidence and support consistent clinical decision-making in GCA.

AB0439 Contribution of anti-ferritin antibodies to the diagnosis of giant cell arteritis