Open Access Highly Accessed Research article

Immunohistological assessment of the synovial tissue in small joints in rheumatoid arthritis: validation of a minimally invasive ultrasound-guided synovial biopsy procedure

Carlo Alberto Scirè1, Oscar Epis1, Veronica Codullo1, Frances Humby2, Patrizia Morbini3, Antonio Manzo2, Roberto Caporali1, Costantino Pitzalis2 and Carlomaurizio Montecucco1*

Author Affiliations

1 Chair and Division of Rheumatology, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Piazzale Golgi 12, I 27100 Pavia, Italy

2 Centre for Experimental Medicine and Rheumatology, 2nd floor John Vane Science Centre, William Harvey Research Institute, St Bartholomew's and Royal London School of Medicine. Charter House Square, London, EC1M6BQ, UK

3 Department of Pathology, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Piazzale Golgi 12, I 27100 Pavia, Italy

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Arthritis Research & Therapy 2007, 9:R101  doi:10.1186/ar2302

Published: 28 September 2007


The aim of the present study was to perform an immunohistological assessment of the synovial tissue from involved small joints in rheumatoid arthritis (RA) and to explore the reliability of a mini-invasive ultrasound (US)-guided technique of small joint synovial biopsy for the histopathological assessment. Synovial tissue collected during arthrotomic surgery of small joints in nine patients served as the gold standard for the validation of the histological assessment. Small hand-joint synovial biopsies from an additional nine patients with erosive RA were obtained by a mini-invasive US-guided procedure, performed percutaneously by the portal and rigid forceps technique. Using digital image analysis, the area fractions of synovial macrophages (CD68 cells), T cells (CD3 cells) and B cells (CD20 cells) were measured in all high-power fields of every sample at different cutting levels. The representative sample was defined as the minimal number of high-power fields whose mean area fraction would reflect the overall mean area fraction within a percentage mean difference of 10%. For each patient, a range of three to five large samples for surgical biopsies and a range of 8–12 samples for US-guided biopsies were collected and analysed. In arthrotomic samples, the analysis of a randomly selected tissue area of 2.5 mm2 was representative of the overall value for CD68, CD3 and CD20 cells. US-guided samples allowed histological evaluation in 100% of cases, with a mean valid area of 18.56 mm2 (range 7.29–38.28 mm2). The analysis of a cumulative area of 2.5 mm2 from eight randomly selected sections (from different samples or from different cutting levels) allowed to reduce the percentage mean difference to less than 10% for CD68, CD3 and CD20 cells. In conclusion, US-guided synovial biopsy represents a reliable tool for the assessment of the histopathological features of RA patients with a mini-invasive approach.