Post on 21-Apr-2017
Introduction
• Synovial biopsy is not normally required for routine diagnostic or therapeutic purposes in patients with established arthritis.
• But synovial biopsy provides tissue available for immunohistochemistry, electron microscopy, cytochemistry, cell culture and molecular biology which helps in understanding pathophysiological mechanisms of arthritis in details
• New approaches to the treatment, including monoclonal antibody treatment and cytokine blockade which target specific pathogenic factors in the synovium are being evaluated in clinical trials
Historical aspects• 1932 – Forestier first time obtained synovial
tissue• 1963 – Parker and Pearson developed the
technique using 14 gauge biopsy needle • 1970 – Kinsella et al in their study highlighted
synovial lining layers in RA• 1972 – Schumacher studied early features of
synovitis • 1990 – Arthroscopic biopsy was introduced
Normal Indications Tech of BX Processing Classification HP findings Peculiar findings Special stains: Gm, ZN, PAS,SM,PB Polarised microscopy, Xray diffraction, IR spectroscopy=
crystals Dark ground illumination= spirochetes in lyme ds
Indications • Infective synovitis – to differentiate Bacterial,
viral, fungal • Autoimmune and degenerative diseases – RA,
SPA, Osteoarthritis, SLE, Neuropathic • Crystal induced synovitis – Gout, Pseudogout,
Basic calcium phosphate, corticosteroids, Implant material
• Metabolic and inherited disorders – Hemochromatosis, Wilson’s disease, Onchronosis, Hemophilia
• Amyloidosis • Sarcoidosis • Tumour and tumour like lesions of synovium• Evaluation of treatment and treatment follow-
up
Normal histology• Gross : lines non – articular surface : pink , smooth & shiny : villi
microscopy• Synovial intima : type A cells : type B cells• Subintimal cells : mast cells : uncalassified
connective tissue cells : endothelial cells
Groud substance: mucoplysacharieds : hyaluronic acidCollagen fibers
Synovial biopsy• Definition - Procedure where a sample of joint
lining or synovial membrane is taken.• Synovial fluid examination is done prior to
synovial biopsy. Types :-1) Needle biopsy2) Orthoscopic biopsy3) Open surgical biopsy
Needle biopsy
• Most popular technique for diagnostic synovial biopsy is use of 14 gauge Parker – Pearson needle .
• Can be done hospital / clinic• Most common joint – knee• Other joints – shoulder, elbow, wrist.• With aseptic precautions biopsy area is prepared • Skin, subcutaneous tissue infiltrated with 1% lignocaine• Trocar is pushed into the joint space in suprapatellar pouch anterolaterally• Needle with an attached syringe is inserted to withdraw the synovial fluid
Needle biopsy• Then the biopsy needle is inserted• Hooked end of the biopsy needle withdraws
the sample• 5 to 7 samples from various sites are taken• Sample is kept in suitable fixative (formalin)• Aftercare :- Joint rested for 1 day
Normal activity resumed if there is no pain or swelling
• Complications:- Haemarthrosis, Infection Chances of injury to nerve or blood vessels
■ Disadvantage – Inadequate sampling
Orthoscopic biopsy • Advantages-provides larger tissue (granuloma,
tumour) under direct vision • Study of pathogenesis and effects of newer
therapeutic strategies• When the sample size is important as in studies
like in vitro experiments, cell separation or analysis of gene expression
• Disadvantages-more expensive and more complicated
Open surgical biopsy • Lesions which are deeper like focal granuloma ,
vasculitis in capsular vessels, tumours missed by needle biopsy and in small joint not suitable for needle biopsy.
Normal synovium and it’s immunohistochemistry
• Synovium is the inner layer of joint capsule
• Synovium formed when the primitive mesenchymal tissue cavitate forming a recognizable joint cavity.
• Synovium covers all surfaces of surfaces of joint spaces excepts articular cartilages and most cartilaginous structure
• The most superficial layer of synovium lines joint and also forms lining of tendon sheath
• Normally synovium appears smooth and transparent but may turns thick dull opaque cells with pathological changes
Normal synovium and it’s immunohistochemistry
Synovium
Intimal Subintimal
Synoviocytes
A
B
Loose highly vascular
Pecularities of synovium • The lining is discontinuous • Does not lie on basement membrane• Allows free exchange of solute and water
Functions of synoviumFunctions of synovium Phagocytic activity of type A synoviocytesPhagocytic activity of type A synoviocytes Lubrication of joint surfaces –hyaluronic acid Lubrication of joint surfaces –hyaluronic acid Regulation of movement of physiologically Regulation of movement of physiologically
important proteins and electrolytes in important proteins and electrolytes in conjugation with vascular and lymphatic conjugation with vascular and lymphatic channelschannels
Immunohistochemistry• T cells, macrophages, HLA DR+ cells, chlamydia
trachomatis (nucleic acid) with characteristically absense of ‘B’ cells
CD3+ T cells CD68+ macrophages
HLA DR+ cells
Infective synovitis• Hematogenous or spread from near by site (osteomyelitis) • BACTERIAL - Staph, streptococcus, gonococcus
Synovitis with dense neutrophilic infiltrate Staining and culture
• LYME DISEASE - Chronic papillary synovitis with synovial hyperplasia, fibrin deposition, mononuclear cell infiltration, onion skin thickening of arterial walls.Liederly stain/ silver stain
• Chronic Granulomatous synovitis -Tuberculosis - knee –Adult
Hip and spine -childrenM/E - Typical caseous epitheloid granuloma or non caseaous granuloma(HIV).Acid fast staning and culture
Infective synovitis Sarcoidosis-Non caseating granuloma with prominent
epitheloid cells& paucity of lymphocyte around granuloma FUNGI - Noncaseating granuloma (Cryptococcus, histoplasma) Staining and culture
VIRAL - Parvovirus,rubella, hepatitis C - Direct or as autoimmune reaction Culture and PCR
Rheumatoid Arthritis • Age - 40-70yr• Sex – F>M• C/F - Pain and swelling typically small joints of
hand• Morning stiffness• Arthritis of three or more joints • Symmetric arthritis • Rheumatoid nodules• Serum rheumatoid factor• Radiologically juxtaarticular osteopenia and bone
erosion and joint space narrowing
Pathogenesis
Rheumatoid Arthritis• Gross - Synovium is
oedematous thickened, hyperplastic with bulbous projections
• M/E – 1) Early - hyperplasia, hyperemia and infiltration by plasma cell and lymphocytes. Prominent lymphoid follicles, neovascularisation and fibrin depostion close to synovial lining and in stroma2) Pannus - causes destruction of articular cartilage
Role of immunohistochemistry• Diagnosis – Presence of CD3+, CD4+, CD20+,
CD38+ plasma cell, CD22+ B cells, lymphoid aggregates.
• αVβ3 integrin expression – synovial lining• αVβ5 integrin expression – subintimal layer• Early (1yr) vs late disease – synovial lining cell
layer increases in late disease• Prognosis –
No. of macrophages – in the synovial lining layer, if greater than 60% are macrophages – appearance of new erosions
MMP-2 – secreted by synoviocytes (FISH) associated with worst prognosis and appearance of new erosions.
Interleukin 10 – protective effect
Role of immunohistochemistry
• Evaluation of treatment – use of DMARD’s associated with histopathological changes in –- mononuclear cell population- adhesion molecule expression- cytokine production
Role of immunohistochemistry
Differential diagnosis – RA vs SPA
ααVVββ3 RA3 RA ααVVββ3 SPA3 SPA
ααVVββ3 SPA3 SPA
ααVVββ5 RA5 RA
ααVVββ5 SPA5 SPA
ααVVββ5 RA5 RA
Seronegative Spondiloarthropathy
• Ankylosing spondiloarthropathy• Reactive Arthritis (Reiter’s syndrome,
enteritis associated arthritis)• Psoariatic Arhritis • Arthritis Associated with inflammatory Bowel
diseases• Similar pathogenesis and histological picture
to RA but less intense inflammation and pannus formation and presence of entesopathy and different vascularisation pattern.
• IMMUNOHISTOCHEMESTRY - different integrin expression pattern than RA
Systemic lupus erythematosus
Multisystemic disease of autoimmune etiology F>M In 90% cases joint involved Non erosive synovitis with little deformities Histology similar to RA except for excessive fibrin
deposition,lesser degree of synovial hyperplasia
Osteoarthritis • MC joint disease• Degenerative joint disease• Primary or secondary ( trauma, hemochromatosis,
onchronosis)• Weight bearing joint like knee,ankle• C/F-Pain and swelling aggravated by work and
relived by rest• Radiology-joint space narrowing • Subchondral bone sclerosis• Formation of osteophytes/synovial hypertrophy/-
metaplasia• Chondromatosis-loose bodies in joint• GROSS-congested ,fibrotic synovium• M/E-Villus synovial hypertrophy with infiltration by
chronic inflammatory cells and subsequently pannus formation
Neuroarthropathy • Destructive joint disease• Sensory nerve damage is the key (syringomyelia,
tabes dorsalis)• M/E-presence of dead bone and cartilage within
synovium.osteochondromatosis leading to loose bodies within synovium
Crystal Induced Synovitis CrystalsCrystals
EndogenousEndogenous ExogenousExogenous
Gout (urate crystals)Gout (urate crystals)
Pseudogout (cppd)Pseudogout (cppd)
Basic calcium Basic calcium oxalate crystalsoxalate crystals
CorticosteroidCorticosteroid
Implant related Implant related changeschanges
Gout • Articular manifestation of systemic disease
1)Primary-idiopathic2)Secondary-myeloproliferative, lymphoproliferative disordersRenal failure, diuretics, Toxins-Lead, Alchohol
• Clinical features – 1) Asymptomatic hyperuricemia2)Acute gouty arthritis3)Intercritical gout4)Chronic tophaceous gout
• Gross - oedematous, congested synovium
Gout• Microscopy -
1) Acute - dense neutrophilic infiltrate small clusters of neutrophils containing monosodium urate crystals in cytoplasm with scattered lymphocytes,plasma cellsMonosodium urate crystals are needle shaped and negatively birefringent under polarized microscopy2)Chronic – Gross-hyperplastic, thickened and fibrotic M/E-presence of tophi surrounded by lymphocytes, plasma cells, foreign body giant cells
Pseudogout • Hereditary• Idiopathic• Secondary-
hyperparathyroidism, haemochromatosis
• Mechanism - altered activity of matrix protein that produce and degrades pyrophosphate resulting in its accumulation and eventual crystallision with calcium
• Crystals-chalky white friable deposit appears oval blue in histology
• positively birefrigent under polarized microscopy
Basic Calcium Phosphate Crystals
• Ca hydroxyappetite,tricalcium phosphate.alzarin red staining done to identify
Corticosteroid Crystals Corticosteroid Crystals Local or systemic treatment by corticosteroidLocal or systemic treatment by corticosteroid Fine granular faintly staining material in Fine granular faintly staining material in
synoviumsynovium
Tissue Reaction To Implant Material
Implant failure - Mechanical - Infection
Wear debries - metallic component of joint - high density polyethylene -
methyl methycrylate (support prosthesis)
Wear Wear debrisdebris
Tissue Reaction To Implant Material
Implant Implant materialmaterial
HistopathologyHistopathology
(Metallic) (Metallic) cobalt-chrome cobalt-chrome alloy Stainless alloy Stainless steel steel
Black coloured irregular Black coloured irregular granules within macrophages granules within macrophages & reactive tissue surrounding & reactive tissue surrounding prosthesis prosthesis
High density High density polyethylene polyethylene
Thread like element 10-20 Thread like element 10-20 micron within histiocytes & micron within histiocytes & giant cells apparent on giant cells apparent on polarized M/Epolarized M/E
Tissue Reaction To Tissue Reaction To Implant MaterialImplant Material
Implant Implant materialmaterial
HistopathologyHistopathology
Methyl Methyl methycrylate methycrylate
Dissolved in routine Dissolved in routine processing appears as processing appears as empty spaces with empty spaces with giant cells and foamy giant cells and foamy histiocytes containing histiocytes containing fine powdered cementfine powdered cement
Silicone Silicone rubber (small rubber (small joint) joint)
Bosselated and faintly Bosselated and faintly yellow particles which yellow particles which are highly refractile are highly refractile with histiocytic and with histiocytic and giant cell reactiongiant cell reaction
Inherited and Metabolic Diseases
• Haemophilia− chronic destructive disorder− haemophiliaA, haemophiliaB, vWD− C/F - Recurrent haemarthrosis− GROSS - hyperplastic red brown synovium− M/E - accumulation of hemosiderin laden macrophages
within synovial layer• Hemochromatosis
− AR, Increase uptake of iron , deposited in various tissue− Gross-brownish red synovium− M/E-hyperplastic synovium with proliferation of
fibroblast. Iron is deposited in synovial cells in perivascular location
• Hemosiderosis− hemosiderin laden macrophages within synovium
Onchronosis(Alkaptonuria) • AR,absence of homogentisic acid oxidase• Homogentesic acid polymers inhibits
hydroxylysine formation and chondrocyte metabolism ,cartilage destruction
• M/E-Inflammatory synovitis with shreds of blue black cartilage embedded in synovium
AMYLOIDOSIS • AL (Multiple myeloma) > AA Amyloid• In long term hemodialysis pt.- Beta 2microglobulin• Special staining and polarized microscopy
WilsonWilson’’s Diseases Disease AR, Multisystemic diseaseAR, Multisystemic disease Wrist joint McWrist joint Mc Synovium show mild hyperplastic changes Synovium show mild hyperplastic changes
with copper deposition with copper deposition
WhippleWhipple’’s Diseases Disease Presence of PAS+ material containing Presence of PAS+ material containing
macrophages within synovium with mild macrophages within synovium with mild hyperplasia. hyperplasia.
TUMOUR AND TUMOUR LIKE LESIONS
Synovial cysts (Baker’s Cyst)
• MC - knee joint (posterior capsule)
• Associated with RA or chronic inflammatory arthritis with increase intra articular pressure
• Cyst filled with clear or mucoid material
• M/E - cyst is lined by synovial lining and contains cartilage in its wall
• D/D - Ganglion cyst
Synovial Hemangioma • MC adult males• H/O recurrent hemarthrosis of long duration• Knee(mc),elbow, finger• GROSS-diffuse or nodular growth• M/E - Cavernous>Capillary>A-v hemangioma• D/D – pigmented villonodular synovitis, organizing
hemorrhage
Synovial Lipomatosis (Hoffa’s Disease)
• ADULT C/O pain and swelling in ant. compartment of knee, increase in infra patellar fat pad
• GROSS-synovium with marked papillary and yellowish appearance
• M/E-Mild hyperplasia of synovium with abundant fat extending to synovial lining cells. Mild chronic inflammation seen
Synovial Chondromatosis • M>F• AGE 30-50 yrs • MC – KNEE• GROSS - Nodules of
cartilage within synovium (loose bodies)
• M/E - foci of chondrometaplasia within synovium with cartilage cells showing cytological atypia (Binucleation)
• Recurs after excision• Rarely malignant
transformation to chondrosarcoma occurs
Tenosynovial Giant Cell Tumour (Benign synovioma)
W>M Young/middle age Wrist/finger tips GROSS - Single 1-3 cm.
well defined capsulated & lobulated grey white to yellow brown
Tenosynovial Giant Cell Tumour (Benign synovioma)
• M/E - Closely packed med sized polyhedral cells with variable admixture of giant cells contaning hemosiderin and fat, focal zones of hyalinisation seen
• Recurs after excision• Malignant
transformation to sarcoma occurs
Pigmented Villonodular Synovitis - (Xanthofibroma)
• M>F• 20-40yrs• MC-Knee• GROSS-villous
brownish yellow spongy mass
• C/S-Variegated appearance yellowish & brownish area with grey white fibrotic area
Pigmented Villonodular Synovitis - (Xanthofibroma)
• M/E-sheets of proliferating small ovoid or spindle shaped cells, multinucleated giant cells,hemosiderin deposit and aggregates of foam cells at the periphery of lesion & sparse lymphoplasmacytic infiltrate.abundant collagen deposition in long standing cases
• D/D – Hemosiderotic synovitis (hemophihlia / trauma)
Differential diagnosis with particular histological features
Synovial hyperplasia with lymphocytic ( CD4+, CD8+, CD3+), macrophages (CD68+), plasma cells, perivascular lymphocytic and fibrin deposition, lymphoid aggregates
RA SNA OA
Differential diagnosis with particular histological features
• Non caseating granuloma -– TB and Atypical MTB – Acid fast stain and culture- Fungal diseases - stain and culture- Sarcoidosis
Intense granulocytic response – - Septic arthritis – staining and culture- crystal induced synovitis – gout, pseudogout- Implant related changes
Heavy iron pigment deposition –- Hemophilia- Hemosiderosis and hemochromatosis- Pigmented villonodular synovitis- hemangioma, traumatic
Amyloid= AmyloidosisRh nodule= RACaseating granuloma= TBCrystals– needle neg biref= urate– Rhomboid pos birefringence= CPPD
Macrophages with Pas + material=Whipples ds
Ma, giant cells, foamy cells, hemosiderin= PVGS
Metaplastic cartilage islands= synovial chondomatosis
Evaluation of treatment and treatment follow up
• Biopsy sample taken before and after treatment • Evaluated for efficacy of several therapeutic
advances like use of monoclonal antibody to T cells, inhibition of proinflammatory cytokines, TNF-α, interleukin-β.
• Follow up is kept with effect on cellular infiltration, inhibition of adhesion molecule expression, decreased cytokine production
• Evaluation – macroscopic – orthoscopic- microscopic – conventional - digital image analysis – lining layers - T cells infiltration
Future challenges
• Increasing emphasis on need to recognise potentially erosive disease in patients presenting with early undifferentiated arthritis
• Recognisation of enhanced proinflammatory or degradative pathway or downregulation of inhibitory factors that participate in progression and prevention of arthritis
• Inclusion of pharmacogenomic and molecular techniques in analysis of synovial tissue from the patient with different categories and stages of arthritis presents some exciting possibilities of future research
Conclusion• Synovial biopsy is an easy, cheap and simplest
method of early diagnosis and quantification of diseases like rheumatoid arthritis, infectious metabolic tumour and tumour like lesions
• It provides window of opportunities to clincians to prevent early the potentially erosive diseases of joints