Temporal Artery Biopsy Results Research Articles

Diagnostic Strategy Using Color Doppler Ultrasound of Temporal Arteries in Patients With High Clinical Suspicion of Giant Cell Arteritis : A Prospective Cohort Study.

Giant cell arteritis (GCA) is the most prevalent systemic vasculitis in people older than 50 years. Any delay in diagnosis impairs patients' quality of life and can lead to permanent damage, particularly vision loss. To evaluate a diagnostic strategy for GCA using color Doppler ultrasound of the temporal artery as a first-line diagnostic test, temporal artery biopsy (TAB) as a secondary test, and physician expertise as the reference method. Prospective multicenter study with a 2-year follow-up. (ClinicalTrials.gov: NCT02703922). Patients were referred by their general practitioner or ophthalmologist to a physician with extensive experience in GCA diagnosis and management in one of the participating centers: 4 general and 2 university hospitals. 165 patients with high clinical suspicion of GCA, aged 79 years (IQR, 73 to 85 years). The diagnostic procedure was ultrasound, performed less than 7 days after initiation of corticosteroid therapy. Only ultrasound-negative patients underwent TAB. Bilateral temporal halo signs seen on ultrasound were considered positive. Ultrasound and TAB results were compared with physician-diagnosed GCA based on clinical findings and other imaging. Diagnosis of GCA was confirmed in 44%, 17%, and 21% of patients by ultrasound, TAB, and clinical expertise and/or other imaging tests, respectively. Their diagnosis remained unchanged at 1 month, and 2 years for those with available follow-up data. An alternative diagnosis was made in 18% of patients. The proportion of ultrasound-positive patients among patients with a clinical GCA diagnosis was 54% (95% CI, 45% to 62%). Small sample size, no blinding of ultrasound and TAB results, lack of an objective gold-standard comparator, and single diagnostic strategy. By using ultrasound of the temporal arteries as a first-line diagnostic tool in patients with high clinical suspicion of GCA, further diagnostic tests for patients with positive ultrasound were avoided. Tender "Recherche CH-CHU Poitou-Charentes 2014."

Estimating overdiagnosis in giant cell arteritis diagnostic pathways using genetic data: genetic association study.

Giant cell arteritis (GCA) may be confirmed by temporal artery biopsy (TAB) but false negatives can occur. GCA may be overdiagnosed in TAB-negative cases, or if neither TAB nor imaging is done. We used Human Leucocyte Antigen (HLA) genetic association of TAB-positive GCA as an "unbiased umpire" test to estimate historic overdiagnosis of GCA. Patients diagnosed with GCA between 1990-2014 were genotyped. During this era, vascular imaging alone was rarely used to diagnose GCA. HLA region variants were jointly imputed from genome-wide genotypic data of cases and controls. Per-allele frequencies across all HLA variants with p< 1.0x1 0 -5 were compared with population control data to estimate overdiagnosis rates in cases without a positive TAB. Genetic data from 663 GCA patients were compared with data from 2619 population controls. TAB-negative GCA (n = 147) and GCA without TAB result (n = 160) had variant frequencies intermediate between TAB-positive GCA (n = 356) and population controls. For example, the allele frequency of HLA-DRB1*04 was 32% for TAB-positive GCA, 29% for GCA without TAB result, 27% for TAB-negative GCA and 20% in population controls. Making several strong assumptions, we estimated that around two-thirds of TAB-negative cases and one-third of cases without TAB result may have been overdiagnosed. From these data, TAB sensitivity is estimated as 88%. Conservatively assuming 95% specificity, TAB has a negative likelihood ratio of around 0.12. Our method for utilising standard genotyping data as an "unbiased umpire" might be used as a way of comparing the accuracy of different diagnostic pathways.

Questioning the Utility of Temporal Artery Biopsy in Giant Cell Arteritis: A Negative Biopsy May Facilitate Decision-making.

We undertook a prospective study of adult patients undergoing TAB for GCA in Calgary. Consecutive, multicenter recruitment was performed over 2 years. Primary outcomes included initiation or discontinuation and duration of corticosteroids. Twenty-one TABs were performed in 20 patients. Nineteen percent of TABs were positive, and 71.4%, negative. In 9.5% of patients, accidental sampling of a vessel other than the superficial temporal artery occurred. Fifty-two percent of patients received steroids before TAB, of which the mean duration was 8.0 days for TAB+ (postive temporal artery biopsy result) patients and 8.4 days for TAB- (negative temporal artery biopsy result; P = 0.22) patients. Before TAB, the American College of Rheumatology score was 2.5 for TAB+ patients and 2.4 for TAB- (P = 0.74). Postbiopsy, the American College of Rheumatology score was 3.5 for TAB+ patients (therefore reaching diagnostic threshold of 3) but remained 2.4 for TAB- (P = 0.02). TAB+ patients were treated for 352.3 days, whereas TAB- patients for 16.7 days (P = 0.29). Complications were more likely with long-term (>6 weeks) steroids (P = 0.17). In patients with a low suspicion of GCA, a negative TAB helps bolster physician confidence and leads to a shorter steroid duration.

OA34 To determine the diagnostic test accuracy of different ultrasound diagnostic criteria in the diagnosis of giant cell arteritis: a secondary data analysis

Abstract Background/Aims To determine the diagnostic test accuracy of compression ultrasound compared to combined compression and halo techniques in the diagnosis of giant cell arteritis. Methods A retrospective secondary data analysis was conducted of 111 consecutive patients referred with suspected giant cell arteritis (GCA). All patients had an ultrasound of superficial temporal arteries using halo and compression techniques. All had a temporal artery biopsy (TAB), directed by clinical suspicion. Diagnosis was confirmed at six months based on clinical diagnosis. Exclusion criteria included flare, or relapsing patients. Two by two frequency tables were used to calculate sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratios of compression and combined halo and compression in comparison to TAB results and clinical diagnosis at six months. Multiple logistic regressions were calculated adjusting for the identified confounders of gender, steroid dose at time of ultrasound and ischemic symptoms of jaw claudication, transient or permanent vision loss. Local NHS Trust Caldicott approval was given for this study. Results Of the 111 patients referred, 56 were clinically diagnosed with GCA. A positive TAB result was recorded in 33. Compression ultrasound had a high sensitivity of 90.6 % (95%CI 75.0, 98.0) but a low specificity of 32.9 % (95% CI 22.8, 44.4) when compared to TAB. Compression had a sensitivity of 83.6% (95% CI 71.2, 92.2) and specificity 34.5% (95% CI 22.2, 48.6) when compared to clinical diagnosis. This is in contrast to compression and halo combined, which had a sensitivity of 71.9% (95% CI 53.3, 86.3) when compared to TAB and 56.4 % (95% CI 42.3.69.7) when compared to clinical diagnosis. However, specificity of the combined techniques was much higher (73.4% [95% CI 62.3, 82.7] and 76.4% [95% CI 62.3, 86.38]) when compared to TAB and clinical diagnosis respectively. A summary of results can be seen in Table 1. Conclusion Compression ultrasound has a high sensitivity; this coupled with the relatively high negative predictive value suggests compression ultrasound may be useful in screening and stratification of patient management. The perceived ease of compression ultrasound suggests further evaluation of compression ultrasound in clinical practice is required. Disclosure K. Smith: Grants/research support; HEE/NIHR Pre-doctoral clinical academic fellowship. B. Sarker: None. J. Lim: None. C. Burnett: None. D. Taze: None. A. Chakrabarty: None. R.J. Wakefield: None. S.L. Mackie: Consultancies; SLM has provided consultancy on behalf of her institution for Roche/Chugai, Sanofi, AbbVie and AstraZeneca. Honoraria; SLM has given talks on behalf of her institution for Pfizer, Vifor and UCB. In all cases fees were paid to her institution and no personal fees were received. Grants/research support; SLM has been an investigator on clinical trials for Sanofi and GSK. As a research grant co-applicant, SLM has received research funding (partial salary support) from Vifor, paid to her institution.

Temporal Artery Biopsy Debate: Positive TAB Result Prolongs Steroid Use in Giant Cell Arteritis.

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.

Necessity of Temporal Artery Biopsy for Giant Cell Arteritis: A Systematic Review.

Background:Temporal artery biopsy (TAB) is currently the gold standard procedure to diagnose giant cell arteritis. Despite low sensitivity, TAB is routinely performed even if a clinical diagnosis has already been made. The objective of this study was to determine the usefulness of TAB for giant cell arteritis management.Methods:We performed a systematic review to identify studies that compared steroid treatment between TAB+ and TAB− patients. EMBASE, MEDLINE, and the Cochrane Central Register of Controlled Trials were searched from inception until April 4, 2020. Titles, abstracts, and full texts were reviewed by two independent reviewers and conflicts resolved by consensus. Studies reporting TAB result and steroid treatment were included. Information pertaining to steroid treatment was compared between TAB+ and TAB− groups. Steroid duration was compared by grouping patients in a less than 6 month group, a 6–24 month group, and a more than 24 month group.Results:An estimated 5288 abstracts were screened and 13 studies involving 1355 patients were included. Rate of prebiopsy steroid treatment was higher in TAB+ patients compared with TAB− patients [93% versus 63% (P < 0.001)]. The TAB+ group was more likely to be started on steroids prebiopsy [28% versus 8% (P < 0.001)]. TAB+ and TAB− patients had similar steroid duration for all groups [<6-month group 17% versus 19% (P-0.596), the 6-24-month group 16% versus 19% (P-0.596), and the >24-month group 66% versus 63% (P-0.642)].Conclusion:TAB results have minimal impact on treatment, and the utility should be reconsidered when a clinical diagnosis of giant cell arteritis is possible.

OA42 Evaluating the effects on a clinical service of introducing ultrasound for diagnosis of giant cell arteritis using Lean methodology

Abstract Background/Aims In our trust, patients with suspected giant cell arteritis (GCA) were promptly started on high-dose prednisolone. However, until 2019, patients were waiting on average 28.5 days (median) for confirmation of diagnostic decision, which was mostly due to the time taken for temporal artery biopsy (TAB) to be performed and reported. We have made two major changes to our pathway: firstly (Jan 2019) adding temporal artery ultrasound (TAUS), and secondly (Mar 2020), routing GP referrals through our Primary Care Access Line (PCAL) to an allocated rheumatology registrar based at the same site as the TAUS. We used Lean methodology to pre-specify metrics to evaluate our pathway. Aim and Purpose: To assess changes over time across our five prespecified domains: delivery, quality, service, morale and cost. Methods We defined lead time as median time between entry to pathway and diagnostic confirmation. This was our delivery domain. We defined treatment for GCA as clinical diagnosis plus at least 6 months of treatment with “GCA-dose” steroids. Quality was measured for patients treated as GCA as the percentage with a positive confirmatory test; and for patients not treated as GCA as the cumulative prednisolone dose received for suspected GCA. Service and morale were assessed from patient and staff feedback, respectively. Cost was assessed via the patient-level costings team using standard NHS tariffs. We plotted a run chart by month and significant shift in delivery or quality was defined as six consecutive monthly values below the baseline median. Results TAUS was performed a median of 2.5 days from referral. Agreement between TAB and TAUS results was good. The run chart showed a significant shift in our delivery. Lead time fell from 28.7 days to 19.2 days after introduction of ultrasound, and further down to 7.7 days after the utilisation of PCAL. A significant shift was also seen in quality metrics. Proportion of GCA with positive TAB/TAUS increased from 29% to 56.3% following the introduction of TAUS, and further to 75% on the utilisation of PCAL. The total mean prednisolone dose for patient without GCA fell from 1.335g to 0.439g after introducing TAUS, and down to 0.139g after introduction of PCAL. Within costs, average per-patient costs of TAB/TAUS declined from £1004/patient to £718/patient to £378/patient. However, total GCA pathway referrals increased from 6/month to 10/month to 24/month, increasing overall costs. Staff and patient feedback (service, morale) were overall positive, but revealed the need for further improvements to manage the additional complexity and volume. Conclusion Lean methodology identified multiple metrics for evaluating the impact of TAUS and PCAL on our service. We have seen an improvement in delivery and quality. Measuring costs, morale and service helped identify unintended consequences and target further improvement. Disclosure T. Rajeswaran: None. A. Barr: None. V. Bassi: None. A. Chakrabarty: None. A. Cracknell: None. R. Darwood: None. S. Dass: None. S. Farrell: None. J. Hunter: None. T. Mitchell: None. J. Parvin: None. B. Sarker: None. I. Simmons: None. K. Sinclair: None. K. Smith: None. A. Sweeting: None. R. Tue: None. M. Troxler: None. R. Wakefield: None. S.L. Mackie: Consultancies; consultancy for Roche, Sanofi, AstraZeneca, Abbvie on behalf of her institution. Other; support from Roche to attend EULAR2019.

Effect of Temporal Artery Biopsy Length and Laterality on Diagnostic Yield.

Giant cell arteritis (GCA) is the most common vasculitis in adults and is associated with significant morbidity and mortality. Temporal artery biopsy (TAB) remains the gold standard for diagnosis in the United States; however, practices vary in the length of artery obtained and whether bilateral simultaneous biopsies are obtained. Retrospective chart review of all TABs performed at the Johns Hopkins Wilmer Eye Institute between July 1, 2007, and September 30, 2017. Five hundred eighty-six patients underwent TAB to evaluate for GCA. Of 404 unilateral biopsies, 68 (16.8%) were positive. Of 182 patients with bilateral biopsies, 25 (13.7%) had biopsies that were positive and 5 patients (2.7%) had biopsies that were discordant, meaning only 1 side was positive. There was no significant difference in the average postfixation length of positive and negative TAB specimens (positive mean length 1.38 ± 0.61 cm, negative mean length 1.39 ± 0.62 cm, P = 0.9). There is no significant association between greater length of biopsy and a positive TAB result in our data. Although the rate of positive results was not higher in the bilateral group compared with the unilateral group, 2.7% of bilateral biopsies were discordant, similar to previously published rates. Overall, this suggests that initial bilateral biopsy may increase diagnostic yield, albeit by a small amount.

The Clinical Significance of Small Vessel Vasculitis on Temporal Artery Biopsies.

Giant cell arteritis (GCA) is the most common type of systemic vasculitis in the elderly. Untreated, it can lead to irreversible blindness. Its diagnosis relies on a temporal artery biopsy (TAB). However, a proportion of patients have small vessel vasculitis (SVV) on biopsy; the prognosis of which remains unclear. The aim of this study is to compare the clinical presentation and long-term outcomes of those with SVV with negative and positive biopsies to determine whether long-term corticosteroid therapy can be avoided in these patients. Post hoc analysis of patients with suspected GCA who underwent TAB and fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) scan as part of a prospective GCA and PET cohort. Patients were divided in to 3 groups based on TAB result: positive (inflammation in the main artery wall), negative (no inflammation), and SVV (isolated vasa vasorum or periadventitial SVV). Clinical, serological, and PET/CT data of patients with SVV were compared with those with positive and those with negative biopsies. For the 58 eligible patients recruited between May 2016 and December 2017, 11 had SVV, 12 had positive, and 35 had negative biopsies. Patients with SVV had similar clinical, serological, and PET/CT findings to those with negative biopsies. Compared with those with positive biopsies, patients with SVV had lower erythrocyte sedimentation rate (25 vs 78 mm/hour; P = 0.02), platelet count (296 vs 385 ×109/L; P = 0.03), and a lower median total vascular score on PET/CT scan (1.0 vs 13.5; P = 0.01). Median prednisone dose was lower (4.8 vs 11.7 mg; P = 0.015) and fewer were on steroid-sparing agents (20% vs 67%; P = 0.043) at 6 months. The percentage of patients with a clinical diagnosis of GCA was similar between those with SVV (3/11, 27.3%) and those with negative biopsies (5/35, 14.3%; P = 0.374). Patients with SVV on TAB had similar clinical features, PET/CT findings, and 6-month outcomes to those with negative biopsies. Small vessel vasculitis can be treated as equivalent to a negative biopsy when being considered for diagnosis and treatment of GCA.

Scienced by blinding: ultrasound for giant cell arteritis.

Accurate diagnosis of giant cell arteritis is crucial. Prompt diagnosis can prevent visual loss, but misdiagnosis risks toxicity from unnecessary glucocorticoid treatment. What is the current place of vascular ultrasound in the diagnosis of giant cell arteritis? According to European Alliance of Associations for Rheumatology (EULAR) recommendations, ultrasound is now the first-choice test, 1 Dejaco C Ramiro S Duftner C et al. EULAR recommendations for the use of imaging in large vessel vasculitis in clinical practice. Ann Rheum Dis. 2018; 77: 636-643 Crossref PubMed Scopus (389) Google Scholar whereas the British Society of Rheumatology guideline places ultrasound alongside temporal artery biopsy. 2 Mackie SL Dejaco C Appenzeller S et al. British Society for Rheumatology guideline on diagnosis and treatment of giant cell arteritis. Rheumatology (Oxford). 2020; 59: e1-23 Crossref PubMed Scopus (48) Google Scholar The landmark TABUL study 3 Luqmani R Lee E Singh S et al. The Role of Ultrasound Compared to Biopsy of Temporal Arteries in the Diagnosis and Treatment of Giant Cell Arteritis (TABUL): a diagnostic accuracy and cost-effectiveness study. Health Technol Assess. 2016; 20: 1-238 Crossref PubMed Scopus (209) Google Scholar assessed the role of temporal and axillary artery ultrasound in diagnosis of giant cell arteritis, with the diagnostician masked to the ultrasound result. Diagnosis of giant cell arteritis was made by an experienced clinician and adjudicated by an expert panel, incorporating the temporal artery biopsy result. In TABUL, ultrasound had a sensitivity of 54% and specificity of 81% for a diagnosis of giant cell arteritis, whereas temporal artery biopsy had a sensitivity of 39% and a specificity of 100%, reflecting its disease-defining role. 3 Luqmani R Lee E Singh S et al. The Role of Ultrasound Compared to Biopsy of Temporal Arteries in the Diagnosis and Treatment of Giant Cell Arteritis (TABUL): a diagnostic accuracy and cost-effectiveness study. Health Technol Assess. 2016; 20: 1-238 Crossref PubMed Scopus (209) Google Scholar The low sensitivity of ultrasound in the TABUL study has been attributed to limited sonographer training (requiring ten normal scans and one scan of a so-called hot case) and the limitations of ultrasound machines available during the study period. Subsequent studies have suggested a higher sensitivity for ultrasound for clinical diagnosis, but these studies did not use formal blinding and are therefore potentially biased. 4 Croft AP Thompson N Duddy MJ et al. Cranial ultrasound for the diagnosis of giant cell arteritis. A retrospective cohort study. J R Coll Physicians Edinb. 2015; 45: 268-272 Crossref PubMed Scopus (13) Google Scholar In some centres where temporal artery biopsies are now rarely done, some ultrasound findings are reported to have 100% specificity for giant cell arteritis, 5 Monti S Floris A Ponte C et al. The use of ultrasound to assess giant cell arteritis: review of the current evidence and practical guide for the rheumatologist. Rheumatology (Oxford). 2018; 57: 227-235 Crossref PubMed Google Scholar suggesting that ultrasound might now have become disease-defining in some institutes. Is this shift justified, or is it still premature? Diagnostic accuracy of vascular ultrasound in patients with suspected giant cell arteritis (EUREKA): a prospective, multicentre, non-interventional, cohort studyVascular ultrasound might effectively replace temporal artery biopsy as a first-line diagnostic method in patients suspected of having giant cell arteritis when done by systematically trained ultrasonographers using appropriate equipment and settings. Full-Text PDF

Vascular Ultrasound for Giant Cell Arteritis: Establishing a Protocol Using Vascular Sonographers in a Fast-Track Clinic in the United States.

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.

Clinical presentation and treatment response in patients with polymyalgia rheumatica and giant cell arteritis during a 40-week follow-up.

ObjectivesThe aim was to study the clinical features of PMR/GCA and clinical predictors of treatment response during a 40-week follow-up period.MethodsClinical data on 77 patients with newly diagnosed PMR/GCA who were treated with oral glucocorticoids were gathered at baseline and during a 40-week follow-up period. A unilateral temporal artery biopsy (TAB) and 18F-fluorodeoxyglucose (18F-FDG) PET/CT were undertaken at diagnosis. In total, each patient was seen on five occasions (i.e. baseline and weeks 4, 16, 28 and 40). Treatment response was assessed by considering clinical evaluations and results of inflammatory markers.ResultsOf 77 patients [49 (63.6%) female; mean age 71.8 (8.0) years], 64 (83.1%) patients had pure PMR, 10 (13.0%) concomitant PMR and GCA, and 3 (3.9%) pure GCA. The patients reported that clinical symptoms, apart from scalp pain and duration of morning stiffness, improved significantly at week 4 and remained lower at week 40 compared with the relative frequencies at baseline. Besides, all components of physical examination showed significant improvement and remained lower at week 40 compared with the baseline. A complete response was seen in 68.7, 62.9, 44.1 and 33.3% of patients at weeks 4, 16, 28 and 40, respectively. Several clinical features, including female biological sex, younger age, fewer relapses and a lower level of baseline ESR, were significantly associated with a better treatment response. Treatment response during the follow-up period was independent of TAB results and fluorodeoxyglucose uptakes on 18F-FDG PET/CT at diagnosis.ConclusionObtaining valid disease-specific outcome measures for evaluating treatment efficacy in PMR and GCA that can be applied universally is clearly an unmet clinical need.Trial registrationClinicalTrials.gov, https://clinicaltrials.gov, NCT02985424.

P006 The potential of colour Doppler ultrasound in reducing temporal artery biopsies in suspected giant cell arteritis

Abstract Background/Aims Giant cell arteritis (GCA) is an emergency. The initial treatment with high dose glucocorticoids (GC) is often started on clinical suspicion without waiting for temporal artery biopsy (TAB) results. Colour Doppler ultrasound (CDUS) is a simple, non-invasive test which is readily available. However, like any other ultrasound, it is operator dependent. Non-compressible ‘halo sign’ is the most specific abnormality on CDUS. British society for Rheumatology (BSR) guidelines advises to avoid TAB in patients with low clinical probability and negative CDUS as well as in high clinical probability and positive CDUS. Methods We adopted the quality improvement methodology for assessment. Retrospective data of suspected GCA patients was collected over the last two years. CDUS was introduced to investigative plan midway, after eleven months. Two rheumatology consultants were trained in CDUS. Results were compared before and after the introduction of ultrasound as a diagnostic tool. In collecting the data, our main focus for documentation was based on clinical symptoms, CDUS and TAB results. Patient were divided into high, medium and low probability groups based on clinical assessment by a rheumatologist. Final diagnosis was decided on the basis of clinical assessment at 6 months. Results It was a retrospective review from January 2018 to November 2019, 101 patients were referred with suspected GCA. Median age was 72 years (50 - 91 years) with male to female ratio of 1:3. Thirty five patients were referred in the first 11 months and 28.6% were diagnosed with GCA. CDUS and TAB was done in 20% and 49% of patients respectively. Sixty six patients were referred in the next 12 months after CDUS was introduced and 21.2% were diagnosed as GCA. CDUS and TAB were done in 82% and 38% of the patients respectively. We reviewed all TABs in the second phase of QIP (38%). As per current BSR guideline, 8 TABs could have been avoided in patients with positive CDUS and high probability of GCA or negative CDUS and low probability of GCA. Even if we deduct these 8 TABs from total of 25, 26% of our suspected GCA referrals would still require TAB for diagnostic workup. Conclusion After the routine introduction of CDUS, the percentage of patients requiring TAB has declined. Approximately one fourth patients would still require TAB as per BSR guidelines. To improve the clinical relevance of biopsies further we recommended; the routine use of GCA probability score, improve CDUS skills and arrange availability of urgent slots in clinic for CDUS. We also noticed that the number of patients referred has almost doubled. This might be due to better education and awareness at the primary and secondary care level which was done as part of the project. Disclosure A.A. Sidhu: None. A. Nandagudi: None. A. Bharadwaj: None.

Prognostic impacts of glucocorticoid treatment in patients with polymyalgia rheumatica and giant cell arteritis

Identifying comorbidities in polymyalgia rheumatica/giant cell arteritis (PMR/GCA) is crucial for patients’ outcomes. The present study aimed to evaluate the impact of the inflammatory process and glucocorticoid treatment on aortic arterial stiffness and body composition in PMR/GCA. 77 patients with newly diagnosed PMR/GCA were treated with oral glucocorticoids and followed for 40 weeks. Aortic pulse wave velocity (PWV) was measured at baseline and during the follow-up period and compared to the results of temporal artery biopsy (TAB) and 18F-FDG PET/CT. Body composition was assessed by total body DXA at baseline and the end of the study. Of 77 patients (49 (63.6%) female, mean of age: (71.8 ± 8.0)), 64 (83.1%) had pure PMR, 10 (13.0%) concomitant PMR and GCA, and 3 (3.9%) pure GCA. Compared to baseline values, aortic PWV was initially decreased at week 16 (p = 0.010) and remained lower than baseline at week 28 (p = 0.002) and week 40 (p < 0.001), with no association with results of TAB and 18F-FDG PET/CT. Aortic PWV was significantly associated with age, male gender, left systolic and diastolic blood pressure, right diastolic blood pressure, and CRP. Total bone mineral content (BMC) was decreased in both genders (p < 0.001), while fat mass (FM) was significantly increased (p < 0.001). However, lean body mass did not significantly change during the study. Changes in FM were correlated with cumulative prednisolone dose (rho: 0.26, p = 0.031). Glucocorticoid treatment of patients with PMR/GCA had several prognostic impacts. Arterial stiffness was decreased due either to the treatment or a reduction in the inflammatory load. Additionally, treatment led to changes in body composition, including a decrease in BMC and FM excess.

Association Between Specimen Length and Number of Sections and Diagnostic Yield of Temporal Artery Biopsy for Giant Cell Arteritis.

To investigate the association between specimen length and number of sections evaluated and the diagnostic yield of temporal artery biopsy (TAB) for giant cell arteritis (GCA). A pathologist reviewed all TABs performed for suspected GCA between January 1991 and December 2012. The blocks of all the inadequate and negative biopsy specimens were recut, and further slides at deeper levels were stained with hematoxylin and eosin in order to avoid missing inflammatory changes. In total, findings from 662 TABs were included in the study (71% female; mean age 73.2 years). A total of 427 TAB specimens (65%) were classified as negative, and 235 (35%) were classified as positive for GCA. Compared to those with negative TAB results, patients with positive TAB results were older and more frequently female. There was no difference in postfixation TAB specimen length between TAB specimens negative and positive for GCA (mean 6.5 mm versus 6.9 mm; P = 0.068). Cuts of additional biopsy sections revealed inflammation at deeper levels in 26 of 408 TAB specimens (6.4%) originally reported as uninflamed. The inflamed section was the second in 14 TAB specimens, the third in 9 specimens, and the fourth in 3 specimens. Piecewise logistic regression identified 5 mm as the TAB specimen length change point for diagnostic sensitivity. Compared to a TAB specimen length of <5 mm, the age- and sex-adjusted odds ratio for positive TAB results in samples ≥5 mm long was 1.5 (95% confidence interval 1.0-2.0), P = 0.032. A postfixation TAB specimen length of at least 5 mm should be sufficient to make a histologic diagnosis of GCA. In order not to miss inflammatory changes, at least 3 further sections at deeper levels should be evaluated in all negative TAB specimens.

Gadolinium leakage in ocular structures after stroke in giant-cell arteritis

An 82-year-old woman with a history of treated hypertension and hypercholesterolemia presented with headache, jaw claudication and elevated C-reactive protein (106 mg/L). Based on temporal artery biopsy results, a diagnosis...

Determinants of Positive Temporal Artery Biopsies in the Veterans Health Administration National Database Cohort.

This study sought to determine the effect of temporal artery biopsy (TAB) postfixation length, laterality, age, and prior prednisone exposure on TAB positivity utilizing the Veterans Health Administration national database. Subjects with procedure code for TAB between 1999 and 2017 were queried, and pathology reports were reviewed manually. Demographic, laboratory, and prescription data were extracted. Multivariate analyses and logistic regression were run using Stata, version 13.0. A total of 3,057 pathology reports were reviewed; 306 biopsies (10%) were designated positive. The likelihood of a positive TAB significantly correlated with TAB postfixation length of >3.0 cm (odds ratio [OR] 1.58 [95% confidence interval (95% CI) 1.06, 2.36], P < 0.05) as well as with bilateral biopsy in 1 sitting (OR 1.83 [95% CI 1.29, 2.59], P < 0.01). Positive TAB also significantly correlated with age >71 years. Prednisone administration up to and beyond 42 days prior to TAB did not influence TAB result. This retrospective study examined predictors of TAB positivity and utilized national data collected on US veterans over the span of 18 years. The results suggest consideration of pursuing initial bilateral TAB or achieving a TAB postfixation length of at least 3 cm to improve yield. The results also agree with prior studies showing that pre-TAB steroid exposure does not appear to affect yield even up to and beyond 42 days prior to biopsy.

Anatomoclinical results of temporal artery biopsies at a university hospital in Argentina

Giant cell arteritis (GCA) is the most frequent systemic vasculitis in patients older than 50 years. The diagnosis is based on the clinical history, laboratory findings and imaging studies associated with a temporal artery biopsy (TAB). However, the biopsy result could be inconclusive in up to 40% of the cases. The aim of this study was to review the current management of the patients with clinical suspect of GCA in the university hospital CEMIC in Buenos Aires, Argentina, and correlate the disease behavior with the TAB result. Retrospective study that reviewed consecutive patients to whom a TAB was made in an 11-year period (2005-2016). Clinical and pathology reports were reviewed. Descriptive statistics were performed. Quantitative variables were described as mean (S.D.) or median [range or inter- quartile range (IQR)] and qualitative variables as number (%). To compare the characteristics of the groups, bivariate analyzes were performed using contingency tables and logistic regression models if necessary. Sixty three patients were included, 68% women. The mean age was 72 years old (SD 8.4). Seventeen biopsies (26.9%) were positive for GCA. The average post fixation length was 1.68 cm (SD 1.2). Patients were divided into 3 groups taking into account the result of the TAB, the ACR criteria and the imaging studies. We could not identify predictors of biopsy positivity. The group of patients with GCA and negative TAB showed a higher percentage of patients with abnormal temporal artery at physical examination. The TAB positive percentage (26.9%) was similar to the reported in other series as well as the post fixation length. We could not identify predictors of biopsy positivity.

Giant cell arteritis-related aortitis with positive or negative temporal artery biopsy: a French multicentre study

Objective: To compare the clinical presentation and outcome of giant cell arteritis (GCA)-related aortitis according to the results of temporal artery biopsy (TAB).Method: Patients with GCA-related aortitis diagnosed between 2000 and 2017, who underwent TAB, were retrospectively included from a French multicentre database. They all met at least three American College of Rheumatology criteria for the diagnosis of GCA. Aortitis was defined by aortic wall thickening > 2 mm on computed tomography scan and/or an aortic aneurysm, associated with an inflammatory syndrome. Patients were divided into two groups [positive and negative TAB (TAB+, TAB−)], which were compared regarding aortic imaging characteristics and aortic events, at aortitis diagnosis and during follow-up.Results: We included 56 patients with TAB+ (70%) and 24 with TAB− (30%). At aortitis diagnosis, patients with TAB− were significantly younger than those with TAB+ (67.7 ± 9 vs 72.3 ± 7 years, p = 0.022). Initial clinical signs of GCA, inflammatory parameters, and glucocorticoid therapy were similar in both groups. Coronary artery disease and/or lower limb peripheral arterial disease was more frequent in TAB− patients (25% vs 5.3%, p = 0.018). Aortic wall thickness and type of aortic involvement were not significantly different between groups. Diffuse arterial involvement from the aortic arch was more frequent in TAB− patients (29.1 vs 8.9%, p = 0.03). There were no differences between the groups regarding overall, aneurism-free, relapse-free, and aortic event-free survival.Conclusion: Among patients with GCA-related aortitis, those with TAB− are characterized by younger age and increased frequency of diffuse arterial involvement from the aortic arch compared to those with TAB+, without significant differences in terms of prognosis.

Malignancies in Giant Cell Arteritis: A Population-based Cohort Study

To investigate the risk of cancer in patients with biopsy-proven giant cell arteritis (GCA) from a defined population in southern Sweden. The study cohort consisted of 830 patients (mean age at GCA diagnosis was 75.3 yrs, 74% women) diagnosed with biopsy-proven GCA between 1997 and 2010. Temporal artery biopsy results were retrieved from a regional database and reviewed to ascertain GCA diagnosis. The cohort was linked to the Swedish Cancer Registry. The patients were followed from GCA diagnosis until death or December 31, 2013. Incident malignancies registered after GCA diagnosis were studied. Based on data on the first malignancy in each organ system, age- and sex-standardized incidence ratios (SIR) with 95% CI were calculated compared to the background population. One hundred seven patients (13%) were diagnosed with a total of 118 new malignancies after the onset of GCA. The overall risk for cancer after the GCA diagnosis was not increased (SIR 0.98, 95% CI 0.81-1.17). However, there was an increased risk for myeloid leukemia (2.31, 95% CI 1.06-4.39) and a reduced risk for breast cancer (0.33, 95% CI 0.12-0.72) and upper gastrointestinal tract cancer (0.16, 95% 0.004-0.91). Rates of other site-specific cancers were not different from expected. In this Swedish population-based cohort of GCA, the overall risk for cancer was not increased compared to the background population. However, there was an increased risk for leukemia and a decreased risk for breast and upper gastrointestinal tract cancer.