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.
Raashid Luqmani,Ellen Lee,Surjeet Singh,M Gillett,Wolfgang A. Schmidt,Mike Bradburn,Bhaskar Dasgupta,Andreas P. Diamantopoulos,Wulf Forrester-Barker,William Hamilton,Shauna Masters,Brendan McDonald,Eugene McNally,Colin T. Pease,Jennifer Piper,John F Salmon,Allan Wailoo,Konrad Wolfe,Andrew Hutchings +18 more
TLDR
The feasibility of providing training in ultrasound for the diagnosis of giant cell arteritis has been demonstrated and the results indicate better sensitivity but poorer specificity of ultrasound compared with biopsy and suggest some scope for reducing the role of biopsy.Abstract:
Background: Giant cell arteritis (GCA) is a relatively common form of primary systemic vasculitis, which, if left untreated, can lead to permanent sight loss. We compared ultrasound as an alternative diagnostic test with temporal artery biopsy, which may be negative in 9–61% of true cases.
Objective: To compare the clinical effectiveness and cost-effectiveness of ultrasound with biopsy in diagnosing patients with suspected GCA.
Design: Prospective multicentre cohort study.
Setting: Secondary care.
Participants: A total of 381 patients referred with newly suspected GCA.
Main outcome measures: Sensitivity, specificity and cost-effectiveness of ultrasound compared with biopsy or ultrasound combined with biopsy for diagnosing GCA and interobserver reliability in interpreting scan or biopsy findings.
Results: We developed and implemented an ultrasound training programme for diagnosing suspected GCA. We recruited 430 patients with suspected GCA. We analysed 381 patients who underwent both ultrasound and biopsy within 10 days of starting treatment for suspected GCA and who attended a follow-up assessment (median age 71.1 years; 72% female). The sensitivity of biopsy was 39% [95% confidence interval (CI) 33% to 46%], which was significantly lower than previously reported and inferior to ultrasound (54%, 95% CI 48% to 60%); the specificity of biopsy (100%, 95% CI 97% to 100%) was superior to ultrasound (81%, 95% CI 73% to 88%). If we scanned all suspected patients and performed biopsies only on negative cases, sensitivity increased to 65% and specificity was maintained at 81%, reducing the need for biopsies by 43%. Strategies combining clinical judgement (clinician’s assessment at 2 weeks) with the tests showed sensitivity and specificity of 91% and 81%, respectively, for biopsy and 93% and 77%, respectively, for ultrasound; cost-effectiveness (incremental net monetary benefit) was £485 per patient in favour of ultrasound with both cost savings and a small health gain. Inter-rater analysis revealed moderate agreement among sonographers (intraclass correlation coefficient 0.61, 95% CI 0.48 to 0.75), similar to pathologists (0.62, 95% CI 0.49 to 0.76).
Limitations: There is no independent gold standard diagnosis for GCA. The reference diagnosis used to determine accuracy was based on classification criteria for GCA that include clinical features at presentation and biopsy results.
Conclusion: We have demonstrated the feasibility of providing training in ultrasound for the diagnosis of GCA. Our results indicate better sensitivity but poorer specificity of ultrasound compared with biopsy and suggest some scope for reducing the role of biopsy. The moderate interobserver agreement for both ultrasound and biopsy indicates scope for improving assessment and reporting of test results and challenges the assumption that a positive biopsy always represents GCA.
Future work: Further research should address the issue of an independent reference diagnosis, standards for interpreting and reporting test results and the evaluation of ultrasound training, and should also explore the acceptability of these new diagnostic strategies in GCA.
Funding: he National Institute for Health Research Health Technology Assessment programme.read more
Citations
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EULAR recommendations for the use of imaging in large vessel vasculitis in clinical practice.
Christian Dejaco,Sofia Ramiro,Christina Duftner,Florent L. Besson,Thorsten A. Bley,Daniel Engelbert Blockmans,Elisabeth Brouwer,Marco A. Cimmino,Eric Clark,Bhaskar Dasgupta,Bhaskar Dasgupta,Andreas P. Diamantopoulos,Haner Direskeneli,Annamaria Iagnocco,Thorsten Klink,Lorna Neill,Cristina Ponte,Carlo Salvarani,Riemer H. J. A. Slart,Madeline Whitlock,Wolfgang A. Schmidt +20 more
TL;DR: The task force recommends an early imaging test in patients with suspected LVV, with ultrasound and MRI being the first choices in GCA and TAK, respectively, which are the first EULAR recommendations providing up-to-date guidance for the role of imaging in the diagnosis and monitoring of patients with (suspected) LVV.
Journal ArticleDOI
2018 Update of the EULAR recommendations for the management of large vessel vasculitis.
Bernhard Hellmich,Ana Filipa Águeda,Sara Monti,Frank Buttgereit,Hubert de Boysson,Elisabeth Brouwer,Rebecca Cassie,Maria C. Cid,Bhaskar Dasgupta,Christian Dejaco,Gulen Hatemi,Nicole Hollinger,Alfred Mahr,Susan P Mollan,Chetan Mukhtyar,Cristina Ponte,Carlo Salvarani,Rajappa Sivakumar,Xinping Tian,Gunnar Tomasson,Carl Turesson,Wofgang Schmidt,Peter M. Villiger,Richard A. Watts,Chris Young,Raashid Luqmani +25 more
TL;DR: The recommendations for the management of LVV have been updated to facilitate the translation of current scientific evidence and expert opinion into better management and improved outcome of patients in clinical practice.
Journal ArticleDOI
Imaging in diagnosis, outcome prediction and monitoring of large vessel vasculitis: a systematic literature review and meta-analysis informing the EULAR recommendations
Christina Duftner,Christian Dejaco,Alexandre Sepriano,Louise Falzon,Wolfgang A. Schmidt,Sofia Ramiro +5 more
TL;DR: Ultrasound and MRI provide a high diagnostic value for cranial GCA, and more data on the role of imaging for diagnosis of extracranial large vessel GCA and TAK, as well as for outcome prediction and monitoring in LVV are warranted.
Journal ArticleDOI
Giant cell arteritis and polymyalgia rheumatica: current challenges and opportunities
Christian Dejaco,Elisabeth Brouwer,Justin C Mason,Frank Buttgereit,Eric L. Matteson,Bhaskar Dasgupta +5 more
TL;DR: The implications of recent developments in the understanding of GCA and PMR are discussed, as well as the unmet needs concerning epidemiology, pathogenesis, imaging and treatment of these diseases.
Journal ArticleDOI
2021 American College of Rheumatology/Vasculitis Foundation Guideline for the Management of Giant Cell Arteritis and Takayasu Arteritis
Mehrdad Maz,Sharon A. Chung,Andy Abril,Carol A. Langford,Mark Gorelik,Gordon H. Guyatt,Amy M. Archer,Doyt L. Conn,Kathy A. Full,Peter C. Grayson,Maria Ibarra,Lisa Imundo,Susan Kim,Peter A. Merkel,Rennie L. Rhee,Philip Seo,John H. Stone,Sangeeta Sule,Robert P. Sundel,Omar I. Vitobaldi,Ann Warner,Kevin Byram,Anisha B. Dua,Nedaa Husainat,Karen E. James,Mohamad A. Kalot,Yih Chang Lin,Jason M. Springer,Marat Turgunbaev,Alexandra Villa-Forte,Amy S. Turner,Reem A. Mustafa +31 more
TL;DR: In this paper, the authors provide evidence-based recommendations and expert guidance for the management of giant cell arteritis (GCA) and Takayasu arteritis as exemplars of large vessel vasculitis.
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