15-ЛЕТНИЙ ОПЫТ ПРИМЕНЕНИЯ ГИСТОПАТОЛОГИЧЕСКОЙ ШКАЛЫ И ДИАГНОСТИЧЕСКОГО АЛГОРИТМА СИНОВИТА: ОЦЕНКА И ДАЛЬНЕЙШЕЕ РАЗВИТИЕ

The diagnostic  histopathology scales are mainly  the  multilevel  evaluation systems. The same principle  is lying in the  basis of synovitis  scale elaboration. This  scale gradually  and  semi-quantitatively assesses the  inflammatory and immunological changes in case of synovitis  considering  three  synovial components: thickness  of synovial cellular layer, cellular  stroma  density  and  severity  of inflammatory infiltration. The  scale comprises  four semi-quantitative  grades: normal 0, mild, moderate  and severe. Scale points from 0 to 9 are summated. Such sum evaluation allows to identify high and low degree synovitis.  Scale points  from 1 to ≤4 correspond to low degree synovitis  which determines and includes the following diagnosis: arthritis associated  synovitis;  synovitis  associated  with  meniscus  pathology;  hemochromatosis associated  synovitis.  Scale points  from ≥5 to  9 determine high  degree  synovitis  including  diagnosis  like rheumatoid arthritis; psoriatic  arthritis; Lyme arthritis; post  infection  (reactive) arthritis and  peripheral arthritis in Bekhterev’s disease. Thus, the synovitis scale allows to assess degenerative or posttraumatic (low degree synovitis) and inflammatoryrheumatoid pathology  (high  degree  synovitis) based  on histopathological diagnostics with  sensitivity of 61,7% and specificity  of 96,1%. The scale is characterized by a good diagnostics significance  by ROC  analysis (area  under  curve: 0,8–0,9).  Two versions of synovitis  scale was published:  first in 2002, second reworked  in 2006 and the latter includes the concept  of subdivision  into two groups of high and low degree synovitis.  Thanking to both  versions a national  and international recognition of histological  evaluation during  15 years was gained.   To clarity  diagnosis description using synovitis  scale particularly in rheumatology various  inflammatory antigens  were suggested  for immunohistochemical analysis (including Ki-67, CD68-, CD3-, CD15и CD20).  This immunohistochemical scale and subdivision into low and high degree synovitis  provided  a possibility  to assess the risk of development and biological sensitivity of rheumatoid arthritis. Thus, an important histological  input  was made into primary rheumatology diagnostics which did not consider tissue  changes.  Due  to  formal  integration of synovitis  scale into  the  algorithm of synovial  pathology  diagnostics a comprehensive classification was developed specifically for differentiated orthopaedics diagnostics.Предложенная  авторами   шкала   позволяет   оценивать   воспалительные  и  иммунологические  изменения при  синовите,   учитывая   три  компонента:   ширину   синовиального  клеточного   слоя,  клеточную   плотность стромы   и   выраженность  воспалительной  инфильтрации.   Шкала   включает   четыре   полуколичественных степени:  нормальную   (0),  легкую,  среднюю  и  выраженную.   Суммарное   количество   баллов,  варьирующихся  от 0 до 9, рассчитывается путем  сложения,  что позволяет  выделить  синовит  высокой  и низкой  степени выраженности. значения шкалы  синовита  от 1 до ≤4 соответствуют  синовиту  низкой  степени  выраженности (артроз-ассоциированный синовит;  посттравматический синовит;  синовит, связанный с патологией  менисков; гемохроматоз-ассоциированный синовит). При значениях шкалы от ≥5 до 9 выделяют синовит высокой степени выраженности (ревматоидный артрит, псориатический артрит, лайм-артрит, постинфекционный (реактивный) артрит и периферический артрит при болезни Бехтерева). Шкала позволяет  на основании гистопатологической диагностики  судить  о  дегенеративном  или  посттравматическом  (синовит  низкой   степени  выраженности) и воспалительно-ревматическом заболевании (синовит высокой  степени выраженности) с чувствительностью 61,7% и специфичностью 96,1%. Благодаря интеграции  шкалы синовита в алгоритм диагностики синовиальной патологии появилась комплексная классификация в дифференцированном контексте ортопедической диагностики

15 years of the histopathological synovitis score, further development and review: A diagnostic score for rheumatology and orthopaedics.

The histopathological synovitis score evaluates the immunological and inflammatory changes of synovitis in a graduated manner generally customary for diagnostic histopathological scores. The score results from semiquantitative evaluation of the width of the synovial surface cell layer, the cell density of the stroma and the density of the inflammatory infiltration into 4 semiquantitative levels (normal 0, mild 1, moderate 2, severe 3). The addition of these values results in a final score of 0-9 out of 9. On the basis of this summation the condition is divided into low-grade synovitis and high-grade synovitis: A synovitis score of 1 to≤4 is called low-grade synovitis (arthrosis-associated/OA synovitis, posttraumatic synovitis, meniscopathy-associated synovitis and synovitis with haemochromatosis). A synovitis score of≥5 to 9 is called high-grade synovitis (rheumatoid arthritis, psoriatic arthritis, Lyme arthritis, postinfection/reactive arthritis and peripheral arthritis with Bechterew's disease). By means of the synovitis score it is therefore possible to distinguish between degenerative/posttraumatic diseases (low-grade synovitis) and inflammatory rheumatic diseases (high-grade synovitis) with a sensitivity of 61.7% and a specificity of 96.1%. The diagnostic accuracy according to ROC analysis (AUC: 0.8-0.9) is good. Since the first publication (2002) and an associated subsequent publication (2006), the synovitis score has nationally and internationally been accepted for histopathological assessment of the synovitis. In a PubMed data analysis (status: 14.02.2017), the following citation rates according to Cited by PubMed Central articles resulted for the two synovitis score publications: For DOI: 10.1078/0344-0338-5710261 there were 29 Cited by PubMed Central articles and for the second extended publication DOI:10.1111/j.1365-2559.2006.02508 there were 44 Cited by PubMed Central articles. Therefore a total of 73 PubMed citations are observed over a period of 15 years, which demonstrates an international acceptance of the score. This synovitis score provides for the first time a diagnostic, standardised and reproducible histopathological evaluation method enabling a contribution to the differential diagnosis of chronic inflammatory general joint diseases. This is particularly the case by incorporation into the joint pathology algorithm. To specify the synovitis score an immunohistochemical determination of various inflammation-relevant CD antigens is proposed to enable a risk stratification of high-grade synovitis (e.g.: progression risk and sensitivity for biologicals)