By Janet F Eary; Winfried Brenner
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The biological effects within the irradiated tissue are caused by both direct damage and indirect interaction. Secondary oxygen radicals generated by tissue irradiation are known to destroy the cellular membranes by lipid peroxidation and result in DNA strand damage and breaks. Oxygen radicals are also potent inductors of apoptosis. All these interactions result in fibrinoid necrosis, sclerosis, and fibrosis of the synovial stroma, the inflammatory cells, and the capillaries within the synovial membrane.
Fluoroscopic arthrography should be performed in all joints to reduce the risk of para-articular injection and subsequent tissue necrosis. Only in the knee joint, the injection can be given without imaging guidance although the radionuclide should not be injected unless correct intra-articular needle placement has been ensured by aspiration of synovial fluid. In the phalangeal joints arthrography is hampered by the small intra-articular volume. A small drop of contrast medium in the conus of the needle may be helpful to check for proper intra-articular injection in these joints although this is not mandatory.
Commonly applied indications are listed in Table 3. As treatment success is achieved by radiogenic ablation of inflamed synovial tissue, an elevated blood-pool pattern in the joint synovia in a pretherapeutic three-phase bone scan is considered an useful tool for diagnosis of synovitis. Besides this positive “blood-pool scan” for treatment indication, the patient must suffer from pain or effusion in the respective joint. Radiation synovectomy is for symptomatic treatment only. Finally, adequate standard baseline pharmacotherapy with anti-inflammatory or antiproliferative drugs for at least six months prior to radiation synovectomy is mandatory in patients with rheumatoid arthritis, because intra-articular radiotherapy is not considered a primary treatment modality.