Imaging techniques such as ultrasonography and MRI have gained ground in the diagnosis and management of inflammatory arthritis, as these imaging modalities allow a sensitive assessment of musculoskeletal inflammation and damage. However, these techniques cannot discriminate between disease subsets and are currently unable to deliver an accurate prediction of disease progression and therapeutic response in individual patients. This major shortcoming of today’s technology hinders a targeted and personalized patient management approach. Technological advances in the areas of high-resolution imaging (for example, high-resolution peripheral quantitative computed tomography and ultra-high field MRI), functional and molecular-based imaging (such as chemical exchange saturation transfer MRI, positron emission tomography, fluorescence optical imaging, optoacoustic imaging and contrast-enhanced ultrasonography) and artificial intelligence-based data analysis could help to tackle these challenges. These new imaging approaches offer detailed anatomical delineation and an in vivo and non-invasive evaluation of the immunometabolic status of inflammatory reactions, thereby facilitating an in-depth characterization of inflammation. By means of these developments, the aim of earlier diagnosis, enhanced monitoring and, ultimately, a personalized treatment strategy looms closer.
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The work of I.M., A.K., M.Y.-M., F.F., S.K., C.S., A.A., M.P., L.F., F.R., M.W., G.S. and D.S. is supported by the Deutsche Forschungsgemeinschaft (FOR2886, CRC1181, CRC1483), the Bundesministerium für Bildung und Forschung (BMBF; MASCARA), the European Union (ERC Synergy grant 4D Nanoscope) and the IMI-funded projects RTCure and HIPPOCRATES. The work of D.S. is supported by a 2022 GRAPPA Pilot Research Grant. The authors would like to thank Adrian Regensburger and Ferdinand Knieling for their constructive advice on this manuscript.
K.E. is an employee of Siemens Healthineers (Erlangen, Germany) and was involved in the development of the cinematic rendering technology used to generate Figs. 3 and 5 and Supplementary videos 1 and 2. M.W. is a shared patent holder together with iThera Medical (Munich, Germany) on an optoacoustic imaging system. All other authors declare that they have no competing interests.
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Nature Reviews Rheumatology thanks B. Stoel, A. Alavi, S. Manske and A. Burghardt for their contribution to the peer review of this work.
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Supplementary video 1 | 68Ga-FAPI-04 PET–CT in a patient with psoriatic arthritis. Hands of a patient with psoriatic arthritis by 68Ga-FAPI-04 PET–CT imaging, showing increased fibroblast activation proteins inhibitor (FAPI) uptake in the radiocarpal and carpometacarpal, suggestive of synovitis, as well as dactylitis of the third and fifth fingers of the right hand before treatment with a biologic DMARD. Improvement of synovitis and dactylitis evident after 6 months of IL-17 inhibition.
Supplementary video 2 | 68Ga-FAPI-04 PET–CT imaging in a patient with rheumatoid arthritis. Hands of a patient with rheumatoid arthritis by 68Ga-FAPI-04 PET–CT, showing increased FAPI uptake in the carpometacarpal joints of both hands and in the metacarpophalangeal joints 2 and 3 of the left hand, indicative of synovitis. Resolution of synovitis evident after treatment with a Janus kinase inhibitor.
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Minopoulou, I., Kleyer, A., Yalcin-Mutlu, M. et al. Imaging in inflammatory arthritis: progress towards precision medicine. Nat Rev Rheumatol 19, 650–665 (2023). https://doi.org/10.1038/s41584-023-01016-1