ACR2010_TNF拮抗剂促进SpA患者椎体侵蚀的修复

初步数据认为 TNF 拮抗剂 对椎体侵蚀修复有效。椎体终板侵蚀疗效欠佳可能提示由于病灶更大和（或）病因不同，需要更长治疗时间。
               

原文	译文
[1959] - TNF Blocking Agents Promote Resolution of Vertebral Erosions in Patients with Spondyloarthritis. Walter P Maksymowych, MD, FRCPC1,Praveena Chiowchanwisawakit, MD2,Robert Lambert, F.R.C.P.(C)3. 1Medical Research Centre, University of Alberta, Edmonton, AB,2Mahidol University, Bangkok, Bangkok,3University of Alberta, Edmonton, Alberta Purpose: While the impact of anti-TNF agents on new bone formation remains unclear their impact on other structural lesions such as erosions has not yet been studied in SpA because these lesions are not commonly observed in the spine on radiography. Bone erosion is readily discerned on T1-weighted (T1W) MRI at vertebral corners (VC) and affecting the vertebral endplate. MRI can reliably detect these lesions and systematic study has demonstrated erosions in the majority of patients. It is possible that such lesions could be a secondary cause of symptoms in SpA. We aimed to assess the impact of both TNF blocking agents and standard treatment on the evolution of bone erosions using MRI. Method: MRI scans were performed at baseline and 2 years in 61 AS patients of whom 28 received TNF blocking agents in open label follow up of clinical trials while 33 received either TNF blocking agents (n = 16) or standard therapy (n = 17) in an observational cohort. A bone erosion on MRI was defined as full-thickness loss of the dark appearance of cortical bone at its anticipated location and loss of the normal bright appearance of adjacent bone marrow on T1W MRI. Via televideoconference, reference images were developed in which erosions were assigned by consensus amongst an international MRI working group. Lesions were independently recorded dichotomously (present/absent) from lower C2 to the upper sacrum of the spine at both anterior and posterior vertebral corners and at each vertebral endplate. Anonymized MRI scans were assessed independently by 2 readers who were blinded to treatment and time point. The primary analysis compared the resolution of lesions according to treatment and was based on concordant data indicating agreement on resolution of erosions. Improvement or complete resolution was defined on the basis of ≥ 50% and complete restoration, respectively, towards a normal vertebral contour. Proportions were compared by Fisher's exact test. Results: Analysis was based on concordant reads for 2801 VC and vertebral endplate sites. Complete resolution of VC erosions was recorded significantly more frequently in the TNF blocker treatment group (11 of 13 erosions (84.6%) whereas this was not observed in a single erosion in patients on standard therapy (p = 0.0002). Similar differences between treatments were noted for individual readers. Vertebral endplate erosions were more frequent than corner erosions but showed minimal resolution after 2 years regardless of treatment. Table. Number (percentage) of vertebral erosions resolving. Conclusion: Our preliminary data supports a beneficial effect of TNF blocker treatment on the resolution of vertebral erosions. The lack of impact on vertebral endplate erosions may reflect greater time dependence due to larger size and/or differences in etiology.	TNF拮抗剂促进SpA患者椎体侵蚀的修复        Maksymowych WP, et al. ACR 2010. Present No: 1959.                 目的：TNF拮抗剂对新骨形成的作用尚不明确，此外，由于SpA患者的脊柱X线片很少发现结构损害（如侵蚀），TNF拮抗剂对这些病变的影响也未鲜有研究。骨侵蚀可累及椎体终板，T1加权（T1W）MRI能发现这些病变。MRI是检测这些病变的可靠方法，系统研究显示大部分患者可发生侵蚀性病变。这些病变可能成为SpA症状的继发原因。本研究旨在通过MRI，评估TNF拮抗剂和常规治疗对骨侵蚀进展的影响。 方法：61例AS患者在基线期和2年后进行MRI扫描，其中28例在开放性临床试验中使用TNF拮抗剂，另外33例患者在观察性队列中使用TNF拮抗剂（16例）或常规治疗（17例）。MRI中骨侵蚀定义为T1W MRI中皮质骨暗区全层缺失，相邻骨髓正常亮区缺失。一个国际MRI工作组通过电视会议对MRI进行会诊，一致确定侵蚀病变。对C2至骶椎的前、后椎体角（VC）、终板，采用两分法（有/无）记录病变。2名阅片者进行独立盲态评估。根据治疗比较病变修复情况。改善和完全修复分别定义为好转≥ 50%和完全复原。采用Fisher精确检验进行比较。 结果：对2801个VC和椎体终板进行分析。TNF拮抗剂治疗组的VC侵蚀完全修复更为多见（13个侵蚀中11个[84.6%]完全修复），而常规治疗组中患者没有侵蚀完全修复（p = 0.0002）。不同阅片者结果相似。椎体终板侵蚀比VC侵蚀更为多见，不管采用何种治疗，2年后修复极少。 结论：初步数据认为TNF拮抗剂对椎体侵蚀修复有效。椎体终板侵蚀疗效欠佳可能提示由于病灶更大和（或）病因不同，需要更长治疗时间。
表. 椎体侵蚀修复的数目（百分比）   VC侵蚀 椎体终板侵蚀 治疗 修复 改善 无变化 修复 改善 无变化 抗TNF             判断一致 11(84.6) 0 2(15.4) 2(4.8) 2(4.8) 40(90.4) 判读者1 26(74.3) 2(5.7) 7(20) 8(9.4) 23(27.1) 54(63.5) 判读者2 19(59) 0 11(41) 17(15.7) 3(2.8) 88(81.5) 传统治疗             判断一致 0 0 8(100) 0 0 17(100) 判读者1 1(7.7) 4(30.8) 8(61.5) 0 6(22.2) 21(77.8) 判读者2 7(31.8) 4(18.2) 11(50) 4(11.4) 4(11.4) 27(77.2)

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