Brouwer, Elisabeth

Mackie, Sarah L

English

University of Groningen

   University of GroningenWhat can negative temporal artery biopsies tell us?Mackie, Sarah L; Brouwer, ElisabethPublished in:RheumatologyDOI:10.1093/rheumatology/kez628IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2020Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):Mackie, S. L., & Brouwer, E. (2020). What can negative temporal artery biopsies tell us? Rheumatology,59(5), 925-927. https://doi.org/10.1093/rheumatology/kez628CopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 19-11-2022EditorialWhat can negative temporal artery biopsies tell us?This editorial refers to Sensitivity of temporal arterybiopsy in the diagnosis of giant cell arteritis: a sys-tematic literature review and meta-analysis byRubenstein et al. doi:10.1093/rheumatology/kez385GCA is not always straightforward to diagnose, andthis has never been more important than in this era oftargeted therapies. Temporal artery biopsy (TAB) hashistorically been a key part of the diagnostic workup forGCA [1]. Early authors described multiple subcategoriesof temporal artery biopsies [2], but since publication ofthe 1990 ACR classification criteria [3] the primary valueof TAB is usually seen as confirming the presence ofdisease. The results are often communicated simply as‘positive’ or ‘negative’ [4], as to date there has been lit-tle research on whether clinically relevant pathologicalsubtypes exist. Recent recommendations state thatimaging and biopsy have ‘similar diagnostic value’ [4]and that it is acceptable to perform either of these testsin the diagnostic workup. The literature review underly-ing these recommendations focused on the diagnosticproperties of imaging, rather than biopsy [5]. The imper-fect sensitivity of TAB is often attributed to skip lesions[6], glucocorticoid treatment (although this particular fac-tor may be overstated [7]) or sparing of the temporalarteries by GCA. Depending on the study methodology,TAB sensitivity has been variously estimated at 39%(based on a diagnostic accuracy study designed primar-ily to assess the accuracy of US rather than TAB [8])and 87.1% (based on concordance of bilateral TAB [9]).A new meta-analysis reports the pooled sensitivity ofTAB based on a systematic review of the published lit-erature [10].Rubenstein et al. [10] designed their study to estimatethe proportion of TAB-positive patients within cohorts ofpatients who were clinically diagnosed with GCA, sup-ported by ACR classification criteria [3] The authors tooka robust, systematic approach to extract the relevant in-formation from the literature and to identify and exploreheterogeneity. The search identified all publications after1990 (the date of publication of the ACR criteria [3]) thathad at least 30 cases of GCA, including a mixture ofdiagnostic, epidemiological and therapeutic studies.Various pre-specified steps were taken to explore thepotential sources of heterogeneity, including a systemat-ic assessment of risk of bias. Meta-regression was usedto investigate the effect of various attributes of eachstudy on the overall estimate of sensitivity.Notably, there was substantial clinical heterogeneitybetween the 32 independent cohorts identified, includingsubstantial variation in the proportions of GCA patientsthat had PMR, visual manifestations, and large-vesselinvolvement. This heterogeneity could reflect differencesin care pathways, patient selection criteria, protocols forclinical evaluation and differences in definitions ofthe various GCA clinical phenotypes, particularly visualmanifestations. Many of the potential sources of hetero-geneity were found to be difficult to assess in the pub-lished papers. For example, pathologists independentlyassessing the same TAB do not always agree onwhether it should be classified as ‘positive’ or ‘negative’[8], but most studies identified by Rubenstein et al. didnot include a specific histopathological review.It was found that the proportion of GCA with a posi-tive TAB varied from 49.5% to 95.1%, and the overallpooled proportion was 77.3% [10]. No single study wasidentified as having disproportionate effect on the overallestimate. The proportion was higher in later publications,but no other clear explanation for the heterogeneitycould be identified from the data extracted.Assuming a 99% specificity of TAB (corresponding tothe usual clinical assumption that a positive TAB essen-tially confirms the diagnosis of GCA), then a 77%sensitivity for a clinical diagnosis of GCA compares fa-vourably with the accuracy of imaging tests for GCA(Table 1). Calculation of positive or negative predictivevalues requires an estimate of the prevalence of GCA inthe population being studied. This was the topic of a re-cent systematic review [11], which gave an estimatedmedian TAB yield of 25% (higher yield in older cohorts,lower in younger cohorts). Therefore, for calculation ofnegative predictive value (the probability that a negativetest is a true negative), we assumed a GCA prevalenceof 25%, although clearly this could vary depending onhow patients with suspected GCA are identified,selected and referred for TAB. It can be seen that con-trary to the oft-heard clinical assertion that ‘a negativebiopsy should not change management decisions be-cause false negatives can occur’, a negative TAB has a93% negative predictive value given a 25% diseaseprevalence. Even if the pre-test probability were ex-tremely high (80%), then based on these sensitivity andspecificity values, a negative TAB would have a negativepredictive value of 52%, and therefore would still castdoubt on the original clinical diagnosis of GCA.Clinicians should exercise caution before applyingthese data on accuracy of TAB or imaging to their clinic-al practice because of limitations of the primary litera-ture reveiwed. First, variation in surgical technique,specimen processing and staining protocols, and lack ofstandardized TAB reporting guidelines for clinical prac-tice may produce inconsistency in classifying TAB [8,12]. Second, with regard to the accuracy of US, if theEDITORIALVC The Author(s) 2020. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For permissions, please email: journals.permissions@oup.comRheumatologyRheumatology 2019;0:1–3doi:10.1093/rheumatology/kez628Downloaded from https://academic.oup.com/rheumatology/article-abstract/doi/10.1093/rheumatology/kez628/5717444 by University of Groningen user on 16 April 2020diagnostician and sonographer are not blinded to eachothers’ observations, then this could introduce bias intodiagnostic accuracy studies, resulting in an overestimateof the diagnostic accuracy of US for GCA. Third andmost importantly with regard to the TAB data, sensitivityand specificity are paired values and have limited valuewhen taken by themselves. Published cohorts generallyfocused on unequivocal cases of GCA. Cases with diag-nostic uncertainty who have negative TAB are not usual-ly included in published cohorts; this omission couldintroduce spectrum bias. A ‘single-gate’ study design ofthe primary studies would be preferable for calculatingthe more clinically useful predictive values or likelihoodratios, as this would not exclude the ‘grey’ (uncertain)cases. In summary, the between-study heterogeneityobserved by Rubenstein et al. is a warning signal thathidden biases could be present in the primary literaturethey drew upon to produce their pooled estimate.However, genuine, between-centre variation in the diag-nostic accuracy of TAB still cannot be excluded.The bottom line here is that TAB remains a clinicallyvaluable test that is in general well tolerated, with a verylow complication rate if the temporal artery (preferablyof 2–3 cm length) is taken out by an experienced sur-geon. Neither TAB nor temporal artery US is a perfecttest; both tests are reliant on the expertise of the oper-ator. For patients, clinical decisions made on the basisof these tests have huge consequences. Given the im-perfect reference standard, research in this area mustbe carefully designed to identify potential sources ofvariation and to minimize bias. Ultimately, rapid clinicalassessment of patients with suspected GCA by a dedi-cated service that has the appropriate clinical, imagingand biopsy expertise is likely to provide optimal care.Funding: S.L.M. was supported by MRC TARGETPartnership Grant (MR/N011775/1) during the period ofthis work. No specific funding was received from anyfunding bodies in the public, commercial or not-for-profitsectors to carry out the work described in this manuscript.Disclosure statement: E.B. as an employee of theUMCG received speaker fees and consulting fees fromRoche in 2017 and 2018, which were paid to theUMCG. S.L.M., as an employee of the University ofLeeds, received consulting fees from Roche and Sanofi,which were paid to the University of Leeds. S.L.M. wassponsored to attend EULAR 2019 by Roche. S.L.M. is apast/present investigator on GCA clinical trials (Roche,GSK, Sanofi).Sarah L. Mackie1 and Elisabeth Brouwer21Leeds Institute of Rheumatic and Musculoskeletal Medicine,University of Leeds and NIHR Leeds Biomedical ResearchCentre, Leeds Teaching Hospitals NHS Trust, Leeds, UK and2Department of Rheumatology and Clinical Immunology,UMCG Groningen, Groningen, The NetherlandsCorrespondence to: Sarah Mackie, University of Leeds andLeeds Biomedical Research Centre, Chapel Allerton Hospital,Harrogate Road, Leeds LS7 4SA, UK.E-mail: s.l.mackie@leeds.ac.ukReferences1 Horton BT. An undescribed form of arteritis of thetemporal vessels. Proc Staff Meet Mayo Clinic 1932;7:700–1.2 McDonnell PJ, Moore GW, Miller NR, Hutchins GM,Green WR. Temporal arteritis. A clinicopathologic study.Ophthalmology 1986;93:518–30.3 Hunder GG, Bloch DA, Michel BA, Stevens MB, ArendWP et al. The American College of Rheumatology 1990criteria for the classification of giant cell arteritis. ArthritisRheum 2010;33:1122–8.4 Hellmich B, Agueda A, Monti S et al. 2018 Update of theEULAR recommendations for the management of largevessel vasculitis. Ann Rheum Dis 2019; doi:10.1136/annrheumdis-2019-215672.5 Duftner C, Dejaco C, Sepriano A et al. Imaging indiagnosis, outcome prediction and monitoring of largeTABLE 1 Summary of recent evidence relating to sensitivity and specificity of temporal artery biopsy, temporal artery USand MRITemporalartery biopsyTemporalartery US [5]MRI of temporalarteries [5]Sensitivity for clinical diagnosis of GCA 77% [10] 77% 73%Specificity for clinical diagnosis of GCA 99% (assumed) 96% 88%Positive predictive value (assuming 25% prevalence [11]) 96% 87% 67%Negative predictive value (assuming 25% prevalence [11]) 93% 93% 91%Positive likelihood ratio 77 19 6.1Negative likelihood ratio 0.23 0.24 0.31Notes: For clinical context, the sensitivity/specificity results are also presented in the form of the corresponding positiveand negative predictive values, assuming a prevalence of 25%, as well as the corresponding positive and negative likeli-hood ratios. Note that these predictive values and likelihood ratios are not necessarily directly applicable to clinical prac-tice; in the case of TAB they depend on an assumed specificity of 99%, which may be an overestimate. Note that we didnot include here 18-fluorodeoxyglucose PET studies, as few diagnostic accuracy studies have been done to date.Editorial2 https://academic.oup.com/rheumatologyDownloaded from https://academic.oup.com/rheumatology/article-abstract/doi/10.1093/rheumatology/kez628/5717444 by University of Groningen user on 16 April 2020vessel vasculitis: a systematic literature review andmeta-analysis informing the EULAR recommendations.RMD Open 2018;4:e000612.6 Klein RG, Campbell RJ, Hunder GG, Carney JA. Skiplesions in temporal arteritis. Mayo Clin Proc 1976;51:504–10.7 Maleszewski JJ, Younge BR, Fritzlen JT et al. Clinicaland pathological evolution of giant cell arteritis: aprospective study of follow-up temporal artery biopsiesin 40 treated patients. Mod Pathol 2017;30:788–96.8 Luqmani R, Lee E, Singh S et al. The Role of UltrasoundCompared to Biopsy of Temporal Arteries in theDiagnosis and Treatment of Giant Cell Arteritis (TABUL):a diagnostic accuracy and cost-effectiveness study.Health Technol Assess 2016;20:1–238.9 Niederkohr RD, Levin LA. A Bayesian analysis of the truesensitivity of a temporal artery biopsy. Invest OphthalmolVis Sci 2007;48:675–80.10 Rubenstein E, Maldini C, Gonzalez-Chiappe S, ChevretS, Mahr A. Sensitivity of temporal artery biopsy in thediagnosis of giant cell arteritis: a systematic literaturereview and meta-analysis. Rheumatology 2019;58;kez385.11 Ing EB, Wang DN, Kirubarajan A et al. Systematicreview of the yield of temporal artery biopsy forsuspected giant cell arteritis. Neuroophthalmology 2019;43:18–25.12 Chakrabarty A, Mackie S, Harden C, Morgan AW.Temporal artery biopsy: audit of histological diagnosis.Rheumatology 2019;kez396.Editorialhttps://academic.oup.com/rheumatology 3Downloaded from https://academic.oup.com/rheumatology/article-abstract/doi/10.1093/rheumatology/kez628/5717444 by University of Groningen user on 16 April 2020

What can negative temporal artery biopsies tell us?

ARTS repository - University of Groningen

   University of GroningenWhat can negative temporal artery biopsies tell us?Mackie, Sarah L; Brouwer, ElisabethPublished in:RheumatologyDOI:10.1093/rheumatology/kez628IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2020Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):Mackie, S. L., & Brouwer, E. (2020). What can negative temporal artery biopsies tell us? Rheumatology,59(5), 925-927. Advance online publication. https://doi.org/10.1093/rheumatology/kez628CopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 31-10-2023EditorialWhat can negative temporal artery biopsies tell us?This editorial refers to Sensitivity of temporal arterybiopsy in the diagnosis of giant cell arteritis: a sys-tematic literature review and meta-analysis byRubenstein et al. doi:10.1093/rheumatology/kez385GCA is not always straightforward to diagnose, andthis has never been more important than in this era oftargeted therapies. Temporal artery biopsy (TAB) hashistorically been a key part of the diagnostic workup forGCA [1]. Early authors described multiple subcategoriesof temporal artery biopsies [2], but since publication ofthe 1990 ACR classification criteria [3] the primary valueof TAB is usually seen as confirming the presence ofdisease. The results are often communicated simply as‘positive’ or ‘negative’ [4], as to date there has been lit-tle research on whether clinically relevant pathologicalsubtypes exist. Recent recommendations state thatimaging and biopsy have ‘similar diagnostic value’ [4]and that it is acceptable to perform either of these testsin the diagnostic workup. The literature review underly-ing these recommendations focused on the diagnosticproperties of imaging, rather than biopsy [5]. The imper-fect sensitivity of TAB is often attributed to skip lesions[6], glucocorticoid treatment (although this particular fac-tor may be overstated [7]) or sparing of the temporalarteries by GCA. Depending on the study methodology,TAB sensitivity has been variously estimated at 39%(based on a diagnostic accuracy study designed primar-ily to assess the accuracy of US rather than TAB [8])and 87.1% (based on concordance of bilateral TAB [9]).A new meta-analysis reports the pooled sensitivity ofTAB based on a systematic review of the published lit-erature [10].Rubenstein et al. [10] designed their study to estimatethe proportion of TAB-positive patients within cohorts ofpatients who were clinically diagnosed with GCA, sup-ported by ACR classification criteria [3] The authors tooka robust, systematic approach to extract the relevant in-formation from the literature and to identify and exploreheterogeneity. The search identified all publications after1990 (the date of publication of the ACR criteria [3]) thathad at least 30 cases of GCA, including a mixture ofdiagnostic, epidemiological and therapeutic studies.Various pre-specified steps were taken to explore thepotential sources of heterogeneity, including a systemat-ic assessment of risk of bias. Meta-regression was usedto investigate the effect of various attributes of eachstudy on the overall estimate of sensitivity.Notably, there was substantial clinical heterogeneitybetween the 32 independent cohorts identified, includingsubstantial variation in the proportions of GCA patientsthat had PMR, visual manifestations, and large-vesselinvolvement. This heterogeneity could reflect differencesin care pathways, patient selection criteria, protocols forclinical evaluation and differences in definitions ofthe various GCA clinical phenotypes, particularly visualmanifestations. Many of the potential sources of hetero-geneity were found to be difficult to assess in the pub-lished papers. For example, pathologists independentlyassessing the same TAB do not always agree onwhether it should be classified as ‘positive’ or ‘negative’[8], but most studies identified by Rubenstein et al. didnot include a specific histopathological review.It was found that the proportion of GCA with a posi-tive TAB varied from 49.5% to 95.1%, and the overallpooled proportion was 77.3% [10]. No single study wasidentified as having disproportionate effect on the overallestimate. The proportion was higher in later publications,but no other clear explanation for the heterogeneitycould be identified from the data extracted.Assuming a 99% specificity of TAB (corresponding tothe usual clinical assumption that a positive TAB essen-tially confirms the diagnosis of GCA), then a 77%sensitivity for a clinical diagnosis of GCA compares fa-vourably with the accuracy of imaging tests for GCA(Table 1). Calculation of positive or negative predictivevalues requires an estimate of the prevalence of GCA inthe population being studied. This was the topic of a re-cent systematic review [11], which gave an estimatedmedian TAB yield of 25% (higher yield in older cohorts,lower in younger cohorts). Therefore, for calculation ofnegative predictive value (the probability that a negativetest is a true negative), we assumed a GCA prevalenceof 25%, although clearly this could vary depending onhow patients with suspected GCA are identified,selected and referred for TAB. It can be seen that con-trary to the oft-heard clinical assertion that ‘a negativebiopsy should not change management decisions be-cause false negatives can occur’, a negative TAB has a93% negative predictive value given a 25% diseaseprevalence. Even if the pre-test probability were ex-tremely high (80%), then based on these sensitivity andspecificity values, a negative TAB would have a negativepredictive value of 52%, and therefore would still castdoubt on the original clinical diagnosis of GCA.Clinicians should exercise caution before applyingthese data on accuracy of TAB or imaging to their clinic-al practice because of limitations of the primary litera-ture reveiwed. First, variation in surgical technique,specimen processing and staining protocols, and lack ofstandardized TAB reporting guidelines for clinical prac-tice may produce inconsistency in classifying TAB [8,12]. Second, with regard to the accuracy of US, if theEDITORIALVC The Author(s) 2020. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For permissions, please email: journals.permissions@oup.comRheumatologyRheumatology 2019;0:1–3doi:10.1093/rheumatology/kez628Downloaded from https://academic.oup.com/rheumatology/article-abstract/doi/10.1093/rheumatology/kez628/5717444 by University of Groningen user on 16 April 2020diagnostician and sonographer are not blinded to eachothers’ observations, then this could introduce bias intodiagnostic accuracy studies, resulting in an overestimateof the diagnostic accuracy of US for GCA. Third andmost importantly with regard to the TAB data, sensitivityand specificity are paired values and have limited valuewhen taken by themselves. Published cohorts generallyfocused on unequivocal cases of GCA. Cases with diag-nostic uncertainty who have negative TAB are not usual-ly included in published cohorts; this omission couldintroduce spectrum bias. A ‘single-gate’ study design ofthe primary studies would be preferable for calculatingthe more clinically useful predictive values or likelihoodratios, as this would not exclude the ‘grey’ (uncertain)cases. In summary, the between-study heterogeneityobserved by Rubenstein et al. is a warning signal thathidden biases could be present in the primary literaturethey drew upon to produce their pooled estimate.However, genuine, between-centre variation in the diag-nostic accuracy of TAB still cannot be excluded.The bottom line here is that TAB remains a clinicallyvaluable test that is in general well tolerated, with a verylow complication rate if the temporal artery (preferablyof 2–3 cm length) is taken out by an experienced sur-geon. Neither TAB nor temporal artery US is a perfecttest; both tests are reliant on the expertise of the oper-ator. For patients, clinical decisions made on the basisof these tests have huge consequences. Given the im-perfect reference standard, research in this area mustbe carefully designed to identify potential sources ofvariation and to minimize bias. Ultimately, rapid clinicalassessment of patients with suspected GCA by a dedi-cated service that has the appropriate clinical, imagingand biopsy expertise is likely to provide optimal care.Funding: S.L.M. was supported by MRC TARGETPartnership Grant (MR/N011775/1) during the period ofthis work. No specific funding was received from anyfunding bodies in the public, commercial or not-for-profitsectors to carry out the work described in this manuscript.Disclosure statement: E.B. as an employee of theUMCG received speaker fees and consulting fees fromRoche in 2017 and 2018, which were paid to theUMCG. S.L.M., as an employee of the University ofLeeds, received consulting fees from Roche and Sanofi,which were paid to the University of Leeds. S.L.M. wassponsored to attend EULAR 2019 by Roche. S.L.M. is apast/present investigator on GCA clinical trials (Roche,GSK, Sanofi).Sarah L. Mackie1 and Elisabeth Brouwer21Leeds Institute of Rheumatic and Musculoskeletal Medicine,University of Leeds and NIHR Leeds Biomedical ResearchCentre, Leeds Teaching Hospitals NHS Trust, Leeds, UK and2Department of Rheumatology and Clinical Immunology,UMCG Groningen, Groningen, The NetherlandsCorrespondence to: Sarah Mackie, University of Leeds andLeeds Biomedical Research Centre, Chapel Allerton Hospital,Harrogate Road, Leeds LS7 4SA, UK.E-mail: s.l.mackie@leeds.ac.ukReferences1 Horton BT. An undescribed form of arteritis of thetemporal vessels. Proc Staff Meet Mayo Clinic 1932;7:700–1.2 McDonnell PJ, Moore GW, Miller NR, Hutchins GM,Green WR. Temporal arteritis. A clinicopathologic study.Ophthalmology 1986;93:518–30.3 Hunder GG, Bloch DA, Michel BA, Stevens MB, ArendWP et al. The American College of Rheumatology 1990criteria for the classification of giant cell arteritis. ArthritisRheum 2010;33:1122–8.4 Hellmich B, Agueda A, Monti S et al. 2018 Update of theEULAR recommendations for the management of largevessel vasculitis. Ann Rheum Dis 2019; doi:10.1136/annrheumdis-2019-215672.5 Duftner C, Dejaco C, Sepriano A et al. Imaging indiagnosis, outcome prediction and monitoring of largeTABLE 1 Summary of recent evidence relating to sensitivity and specificity of temporal artery biopsy, temporal artery USand MRITemporalartery biopsyTemporalartery US [5]MRI of temporalarteries [5]Sensitivity for clinical diagnosis of GCA 77% [10] 77% 73%Specificity for clinical diagnosis of GCA 99% (assumed) 96% 88%Positive predictive value (assuming 25% prevalence [11]) 96% 87% 67%Negative predictive value (assuming 25% prevalence [11]) 93% 93% 91%Positive likelihood ratio 77 19 6.1Negative likelihood ratio 0.23 0.24 0.31Notes: For clinical context, the sensitivity/specificity results are also presented in the form of the corresponding positiveand negative predictive values, assuming a prevalence of 25%, as well as the corresponding positive and negative likeli-hood ratios. Note that these predictive values and likelihood ratios are not necessarily directly applicable to clinical prac-tice; in the case of TAB they depend on an assumed specificity of 99%, which may be an overestimate. Note that we didnot include here 18-fluorodeoxyglucose PET studies, as few diagnostic accuracy studies have been done to date.Editorial2 https://academic.oup.com/rheumatologyDownloaded from https://academic.oup.com/rheumatology/article-abstract/doi/10.1093/rheumatology/kez628/5717444 by University of Groningen user on 16 April 2020vessel vasculitis: a systematic literature review andmeta-analysis informing the EULAR recommendations.RMD Open 2018;4:e000612.6 Klein RG, Campbell RJ, Hunder GG, Carney JA. Skiplesions in temporal arteritis. Mayo Clin Proc 1976;51:504–10.7 Maleszewski JJ, Younge BR, Fritzlen JT et al. Clinicaland pathological evolution of giant cell arteritis: aprospective study of follow-up temporal artery biopsiesin 40 treated patients. Mod Pathol 2017;30:788–96.8 Luqmani R, Lee E, Singh S et al. The Role of UltrasoundCompared to Biopsy of Temporal Arteries in theDiagnosis and Treatment of Giant Cell Arteritis (TABUL):a diagnostic accuracy and cost-effectiveness study.Health Technol Assess 2016;20:1–238.9 Niederkohr RD, Levin LA. A Bayesian analysis of the truesensitivity of a temporal artery biopsy. Invest OphthalmolVis Sci 2007;48:675–80.10 Rubenstein E, Maldini C, Gonzalez-Chiappe S, ChevretS, Mahr A. Sensitivity of temporal artery biopsy in thediagnosis of giant cell arteritis: a systematic literaturereview and meta-analysis. Rheumatology 2019;58;kez385.11 Ing EB, Wang DN, Kirubarajan A et al. Systematicreview of the yield of temporal artery biopsy forsuspected giant cell arteritis. Neuroophthalmology 2019;43:18–25.12 Chakrabarty A, Mackie S, Harden C, Morgan AW.Temporal artery biopsy: audit of histological diagnosis.Rheumatology 2019;kez396.Editorialhttps://academic.oup.com/rheumatology 3Downloaded from https://academic.oup.com/rheumatology/article-abstract/doi/10.1093/rheumatology/kez628/5717444 by University of Groningen user on 16 April 2020

NARCIS 

   University of GroningenWhat can negative temporal artery biopsies tell us?Mackie, Sarah L; Brouwer, ElisabethPublished in:RheumatologyDOI:10.1093/rheumatology/kez628IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2020Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):Mackie, S. L., & Brouwer, E. (2020). What can negative temporal artery biopsies tell us? Rheumatology,59(5), 925-927. https://doi.org/10.1093/rheumatology/kez628CopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 21-06-2022EditorialWhat can negative temporal artery biopsies tell us?This editorial refers to Sensitivity of temporal arterybiopsy in the diagnosis of giant cell arteritis: a sys-tematic literature review and meta-analysis byRubenstein et al. doi:10.1093/rheumatology/kez385GCA is not always straightforward to diagnose, andthis has never been more important than in this era oftargeted therapies. Temporal artery biopsy (TAB) hashistorically been a key part of the diagnostic workup forGCA [1]. Early authors described multiple subcategoriesof temporal artery biopsies [2], but since publication ofthe 1990 ACR classification criteria [3] the primary valueof TAB is usually seen as confirming the presence ofdisease. The results are often communicated simply as‘positive’ or ‘negative’ [4], as to date there has been lit-tle research on whether clinically relevant pathologicalsubtypes exist. Recent recommendations state thatimaging and biopsy have ‘similar diagnostic value’ [4]and that it is acceptable to perform either of these testsin the diagnostic workup. The literature review underly-ing these recommendations focused on the diagnosticproperties of imaging, rather than biopsy [5]. The imper-fect sensitivity of TAB is often attributed to skip lesions[6], glucocorticoid treatment (although this particular fac-tor may be overstated [7]) or sparing of the temporalarteries by GCA. Depending on the study methodology,TAB sensitivity has been variously estimated at 39%(based on a diagnostic accuracy study designed primar-ily to assess the accuracy of US rather than TAB [8])and 87.1% (based on concordance of bilateral TAB [9]).A new meta-analysis reports the pooled sensitivity ofTAB based on a systematic review of the published lit-erature [10].Rubenstein et al. [10] designed their study to estimatethe proportion of TAB-positive patients within cohorts ofpatients who were clinically diagnosed with GCA, sup-ported by ACR classification criteria [3] The authors tooka robust, systematic approach to extract the relevant in-formation from the literature and to identify and exploreheterogeneity. The search identified all publications after1990 (the date of publication of the ACR criteria [3]) thathad at least 30 cases of GCA, including a mixture ofdiagnostic, epidemiological and therapeutic studies.Various pre-specified steps were taken to explore thepotential sources of heterogeneity, including a systemat-ic assessment of risk of bias. Meta-regression was usedto investigate the effect of various attributes of eachstudy on the overall estimate of sensitivity.Notably, there was substantial clinical heterogeneitybetween the 32 independent cohorts identified, includingsubstantial variation in the proportions of GCA patientsthat had PMR, visual manifestations, and large-vesselinvolvement. This heterogeneity could reflect differencesin care pathways, patient selection criteria, protocols forclinical evaluation and differences in definitions ofthe various GCA clinical phenotypes, particularly visualmanifestations. Many of the potential sources of hetero-geneity were found to be difficult to assess in the pub-lished papers. For example, pathologists independentlyassessing the same TAB do not always agree onwhether it should be classified as ‘positive’ or ‘negative’[8], but most studies identified by Rubenstein et al. didnot include a specific histopathological review.It was found that the proportion of GCA with a posi-tive TAB varied from 49.5% to 95.1%, and the overallpooled proportion was 77.3% [10]. No single study wasidentified as having disproportionate effect on the overallestimate. The proportion was higher in later publications,but no other clear explanation for the heterogeneitycould be identified from the data extracted.Assuming a 99% specificity of TAB (corresponding tothe usual clinical assumption that a positive TAB essen-tially confirms the diagnosis of GCA), then a 77%sensitivity for a clinical diagnosis of GCA compares fa-vourably with the accuracy of imaging tests for GCA(Table 1). Calculation of positive or negative predictivevalues requires an estimate of the prevalence of GCA inthe population being studied. This was the topic of a re-cent systematic review [11], which gave an estimatedmedian TAB yield of 25% (higher yield in older cohorts,lower in younger cohorts). Therefore, for calculation ofnegative predictive value (the probability that a negativetest is a true negative), we assumed a GCA prevalenceof 25%, although clearly this could vary depending onhow patients with suspected GCA are identified,selected and referred for TAB. It can be seen that con-trary to the oft-heard clinical assertion that ‘a negativebiopsy should not change management decisions be-cause false negatives can occur’, a negative TAB has a93% negative predictive value given a 25% diseaseprevalence. Even if the pre-test probability were ex-tremely high (80%), then based on these sensitivity andspecificity values, a negative TAB would have a negativepredictive value of 52%, and therefore would still castdoubt on the original clinical diagnosis of GCA.Clinicians should exercise caution before applyingthese data on accuracy of TAB or imaging to their clinic-al practice because of limitations of the primary litera-ture reveiwed. First, variation in surgical technique,specimen processing and staining protocols, and lack ofstandardized TAB reporting guidelines for clinical prac-tice may produce inconsistency in classifying TAB [8,12]. Second, with regard to the accuracy of US, if theEDITORIALVC The Author(s) 2020. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For permissions, please email: journals.permissions@oup.comRheumatologyRheumatology 2019;0:1–3doi:10.1093/rheumatology/kez628Downloaded from https://academic.oup.com/rheumatology/article-abstract/doi/10.1093/rheumatology/kez628/5717444 by University of Groningen user on 16 April 2020diagnostician and sonographer are not blinded to eachothers’ observations, then this could introduce bias intodiagnostic accuracy studies, resulting in an overestimateof the diagnostic accuracy of US for GCA. Third andmost importantly with regard to the TAB data, sensitivityand specificity are paired values and have limited valuewhen taken by themselves. Published cohorts generallyfocused on unequivocal cases of GCA. Cases with diag-nostic uncertainty who have negative TAB are not usual-ly included in published cohorts; this omission couldintroduce spectrum bias. A ‘single-gate’ study design ofthe primary studies would be preferable for calculatingthe more clinically useful predictive values or likelihoodratios, as this would not exclude the ‘grey’ (uncertain)cases. In summary, the between-study heterogeneityobserved by Rubenstein et al. is a warning signal thathidden biases could be present in the primary literaturethey drew upon to produce their pooled estimate.However, genuine, between-centre variation in the diag-nostic accuracy of TAB still cannot be excluded.The bottom line here is that TAB remains a clinicallyvaluable test that is in general well tolerated, with a verylow complication rate if the temporal artery (preferablyof 2–3 cm length) is taken out by an experienced sur-geon. Neither TAB nor temporal artery US is a perfecttest; both tests are reliant on the expertise of the oper-ator. For patients, clinical decisions made on the basisof these tests have huge consequences. Given the im-perfect reference standard, research in this area mustbe carefully designed to identify potential sources ofvariation and to minimize bias. Ultimately, rapid clinicalassessment of patients with suspected GCA by a dedi-cated service that has the appropriate clinical, imagingand biopsy expertise is likely to provide optimal care.Funding: S.L.M. was supported by MRC TARGETPartnership Grant (MR/N011775/1) during the period ofthis work. No specific funding was received from anyfunding bodies in the public, commercial or not-for-profitsectors to carry out the work described in this manuscript.Disclosure statement: E.B. as an employee of theUMCG received speaker fees and consulting fees fromRoche in 2017 and 2018, which were paid to theUMCG. S.L.M., as an employee of the University ofLeeds, received consulting fees from Roche and Sanofi,which were paid to the University of Leeds. S.L.M. wassponsored to attend EULAR 2019 by Roche. S.L.M. is apast/present investigator on GCA clinical trials (Roche,GSK, Sanofi).Sarah L. Mackie1 and Elisabeth Brouwer21Leeds Institute of Rheumatic and Musculoskeletal Medicine,University of Leeds and NIHR Leeds Biomedical ResearchCentre, Leeds Teaching Hospitals NHS Trust, Leeds, UK and2Department of Rheumatology and Clinical Immunology,UMCG Groningen, Groningen, The NetherlandsCorrespondence to: Sarah Mackie, University of Leeds andLeeds Biomedical Research Centre, Chapel Allerton Hospital,Harrogate Road, Leeds LS7 4SA, UK.E-mail: s.l.mackie@leeds.ac.ukReferences1 Horton BT. An undescribed form of arteritis of thetemporal vessels. Proc Staff Meet Mayo Clinic 1932;7:700–1.2 McDonnell PJ, Moore GW, Miller NR, Hutchins GM,Green WR. Temporal arteritis. A clinicopathologic study.Ophthalmology 1986;93:518–30.3 Hunder GG, Bloch DA, Michel BA, Stevens MB, ArendWP et al. The American College of Rheumatology 1990criteria for the classification of giant cell arteritis. ArthritisRheum 2010;33:1122–8.4 Hellmich B, Agueda A, Monti S et al. 2018 Update of theEULAR recommendations for the management of largevessel vasculitis. Ann Rheum Dis 2019; doi:10.1136/annrheumdis-2019-215672.5 Duftner C, Dejaco C, Sepriano A et al. Imaging indiagnosis, outcome prediction and monitoring of largeTABLE 1 Summary of recent evidence relating to sensitivity and specificity of temporal artery biopsy, temporal artery USand MRITemporalartery biopsyTemporalartery US [5]MRI of temporalarteries [5]Sensitivity for clinical diagnosis of GCA 77% [10] 77% 73%Specificity for clinical diagnosis of GCA 99% (assumed) 96% 88%Positive predictive value (assuming 25% prevalence [11]) 96% 87% 67%Negative predictive value (assuming 25% prevalence [11]) 93% 93% 91%Positive likelihood ratio 77 19 6.1Negative likelihood ratio 0.23 0.24 0.31Notes: For clinical context, the sensitivity/specificity results are also presented in the form of the corresponding positiveand negative predictive values, assuming a prevalence of 25%, as well as the corresponding positive and negative likeli-hood ratios. Note that these predictive values and likelihood ratios are not necessarily directly applicable to clinical prac-tice; in the case of TAB they depend on an assumed specificity of 99%, which may be an overestimate. Note that we didnot include here 18-fluorodeoxyglucose PET studies, as few diagnostic accuracy studies have been done to date.Editorial2 https://academic.oup.com/rheumatologyDownloaded from https://academic.oup.com/rheumatology/article-abstract/doi/10.1093/rheumatology/kez628/5717444 by University of Groningen user on 16 April 2020vessel vasculitis: a systematic literature review andmeta-analysis informing the EULAR recommendations.RMD Open 2018;4:e000612.6 Klein RG, Campbell RJ, Hunder GG, Carney JA. Skiplesions in temporal arteritis. Mayo Clin Proc 1976;51:504–10.7 Maleszewski JJ, Younge BR, Fritzlen JT et al. Clinicaland pathological evolution of giant cell arteritis: aprospective study of follow-up temporal artery biopsiesin 40 treated patients. Mod Pathol 2017;30:788–96.8 Luqmani R, Lee E, Singh S et al. The Role of UltrasoundCompared to Biopsy of Temporal Arteries in theDiagnosis and Treatment of Giant Cell Arteritis (TABUL):a diagnostic accuracy and cost-effectiveness study.Health Technol Assess 2016;20:1–238.9 Niederkohr RD, Levin LA. A Bayesian analysis of the truesensitivity of a temporal artery biopsy. Invest OphthalmolVis Sci 2007;48:675–80.10 Rubenstein E, Maldini C, Gonzalez-Chiappe S, ChevretS, Mahr A. Sensitivity of temporal artery biopsy in thediagnosis of giant cell arteritis: a systematic literaturereview and meta-analysis. Rheumatology 2019;58;kez385.11 Ing EB, Wang DN, Kirubarajan A et al. Systematicreview of the yield of temporal artery biopsy forsuspected giant cell arteritis. Neuroophthalmology 2019;43:18–25.12 Chakrabarty A, Mackie S, Harden C, Morgan AW.Temporal artery biopsy: audit of histological diagnosis.Rheumatology 2019;kez396.Editorialhttps://academic.oup.com/rheumatology 3Downloaded from https://academic.oup.com/rheumatology/article-abstract/doi/10.1093/rheumatology/kez628/5717444 by University of Groningen user on 16 April 2020

   University of GroningenWhat can negative temporal artery biopsies tell us?Mackie, Sarah L; Brouwer, ElisabethPublished in:RheumatologyDOI:10.1093/rheumatology/kez628IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2020Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):Mackie, S. L., & Brouwer, E. (2020). What can negative temporal artery biopsies tell us? Rheumatology,59(5), 925-927. https://doi.org/10.1093/rheumatology/kez628CopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 29-04-2023EditorialWhat can negative temporal artery biopsies tell us?This editorial refers to Sensitivity of temporal arterybiopsy in the diagnosis of giant cell arteritis: a sys-tematic literature review and meta-analysis byRubenstein et al. doi:10.1093/rheumatology/kez385GCA is not always straightforward to diagnose, andthis has never been more important than in this era oftargeted therapies. Temporal artery biopsy (TAB) hashistorically been a key part of the diagnostic workup forGCA [1]. Early authors described multiple subcategoriesof temporal artery biopsies [2], but since publication ofthe 1990 ACR classification criteria [3] the primary valueof TAB is usually seen as confirming the presence ofdisease. The results are often communicated simply as‘positive’ or ‘negative’ [4], as to date there has been lit-tle research on whether clinically relevant pathologicalsubtypes exist. Recent recommendations state thatimaging and biopsy have ‘similar diagnostic value’ [4]and that it is acceptable to perform either of these testsin the diagnostic workup. The literature review underly-ing these recommendations focused on the diagnosticproperties of imaging, rather than biopsy [5]. The imper-fect sensitivity of TAB is often attributed to skip lesions[6], glucocorticoid treatment (although this particular fac-tor may be overstated [7]) or sparing of the temporalarteries by GCA. Depending on the study methodology,TAB sensitivity has been variously estimated at 39%(based on a diagnostic accuracy study designed primar-ily to assess the accuracy of US rather than TAB [8])and 87.1% (based on concordance of bilateral TAB [9]).A new meta-analysis reports the pooled sensitivity ofTAB based on a systematic review of the published lit-erature [10].Rubenstein et al. [10] designed their study to estimatethe proportion of TAB-positive patients within cohorts ofpatients who were clinically diagnosed with GCA, sup-ported by ACR classification criteria [3] The authors tooka robust, systematic approach to extract the relevant in-formation from the literature and to identify and exploreheterogeneity. The search identified all publications after1990 (the date of publication of the ACR criteria [3]) thathad at least 30 cases of GCA, including a mixture ofdiagnostic, epidemiological and therapeutic studies.Various pre-specified steps were taken to explore thepotential sources of heterogeneity, including a systemat-ic assessment of risk of bias. Meta-regression was usedto investigate the effect of various attributes of eachstudy on the overall estimate of sensitivity.Notably, there was substantial clinical heterogeneitybetween the 32 independent cohorts identified, includingsubstantial variation in the proportions of GCA patientsthat had PMR, visual manifestations, and large-vesselinvolvement. This heterogeneity could reflect differencesin care pathways, patient selection criteria, protocols forclinical evaluation and differences in definitions ofthe various GCA clinical phenotypes, particularly visualmanifestations. Many of the potential sources of hetero-geneity were found to be difficult to assess in the pub-lished papers. For example, pathologists independentlyassessing the same TAB do not always agree onwhether it should be classified as ‘positive’ or ‘negative’[8], but most studies identified by Rubenstein et al. didnot include a specific histopathological review.It was found that the proportion of GCA with a posi-tive TAB varied from 49.5% to 95.1%, and the overallpooled proportion was 77.3% [10]. No single study wasidentified as having disproportionate effect on the overallestimate. The proportion was higher in later publications,but no other clear explanation for the heterogeneitycould be identified from the data extracted.Assuming a 99% specificity of TAB (corresponding tothe usual clinical assumption that a positive TAB essen-tially confirms the diagnosis of GCA), then a 77%sensitivity for a clinical diagnosis of GCA compares fa-vourably with the accuracy of imaging tests for GCA(Table 1). Calculation of positive or negative predictivevalues requires an estimate of the prevalence of GCA inthe population being studied. This was the topic of a re-cent systematic review [11], which gave an estimatedmedian TAB yield of 25% (higher yield in older cohorts,lower in younger cohorts). Therefore, for calculation ofnegative predictive value (the probability that a negativetest is a true negative), we assumed a GCA prevalenceof 25%, although clearly this could vary depending onhow patients with suspected GCA are identified,selected and referred for TAB. It can be seen that con-trary to the oft-heard clinical assertion that ‘a negativebiopsy should not change management decisions be-cause false negatives can occur’, a negative TAB has a93% negative predictive value given a 25% diseaseprevalence. Even if the pre-test probability were ex-tremely high (80%), then based on these sensitivity andspecificity values, a negative TAB would have a negativepredictive value of 52%, and therefore would still castdoubt on the original clinical diagnosis of GCA.Clinicians should exercise caution before applyingthese data on accuracy of TAB or imaging to their clinic-al practice because of limitations of the primary litera-ture reveiwed. First, variation in surgical technique,specimen processing and staining protocols, and lack ofstandardized TAB reporting guidelines for clinical prac-tice may produce inconsistency in classifying TAB [8,12]. Second, with regard to the accuracy of US, if theEDITORIALVC The Author(s) 2020. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For permissions, please email: journals.permissions@oup.comRheumatologyRheumatology 2019;0:1–3doi:10.1093/rheumatology/kez628Downloaded from https://academic.oup.com/rheumatology/article-abstract/doi/10.1093/rheumatology/kez628/5717444 by University of Groningen user on 16 April 2020diagnostician and sonographer are not blinded to eachothers’ observations, then this could introduce bias intodiagnostic accuracy studies, resulting in an overestimateof the diagnostic accuracy of US for GCA. Third andmost importantly with regard to the TAB data, sensitivityand specificity are paired values and have limited valuewhen taken by themselves. Published cohorts generallyfocused on unequivocal cases of GCA. Cases with diag-nostic uncertainty who have negative TAB are not usual-ly included in published cohorts; this omission couldintroduce spectrum bias. A ‘single-gate’ study design ofthe primary studies would be preferable for calculatingthe more clinically useful predictive values or likelihoodratios, as this would not exclude the ‘grey’ (uncertain)cases. In summary, the between-study heterogeneityobserved by Rubenstein et al. is a warning signal thathidden biases could be present in the primary literaturethey drew upon to produce their pooled estimate.However, genuine, between-centre variation in the diag-nostic accuracy of TAB still cannot be excluded.The bottom line here is that TAB remains a clinicallyvaluable test that is in general well tolerated, with a verylow complication rate if the temporal artery (preferablyof 2–3 cm length) is taken out by an experienced sur-geon. Neither TAB nor temporal artery US is a perfecttest; both tests are reliant on the expertise of the oper-ator. For patients, clinical decisions made on the basisof these tests have huge consequences. Given the im-perfect reference standard, research in this area mustbe carefully designed to identify potential sources ofvariation and to minimize bias. Ultimately, rapid clinicalassessment of patients with suspected GCA by a dedi-cated service that has the appropriate clinical, imagingand biopsy expertise is likely to provide optimal care.Funding: S.L.M. was supported by MRC TARGETPartnership Grant (MR/N011775/1) during the period ofthis work. No specific funding was received from anyfunding bodies in the public, commercial or not-for-profitsectors to carry out the work described in this manuscript.Disclosure statement: E.B. as an employee of theUMCG received speaker fees and consulting fees fromRoche in 2017 and 2018, which were paid to theUMCG. S.L.M., as an employee of the University ofLeeds, received consulting fees from Roche and Sanofi,which were paid to the University of Leeds. S.L.M. wassponsored to attend EULAR 2019 by Roche. S.L.M. is apast/present investigator on GCA clinical trials (Roche,GSK, Sanofi).Sarah L. Mackie1 and Elisabeth Brouwer21Leeds Institute of Rheumatic and Musculoskeletal Medicine,University of Leeds and NIHR Leeds Biomedical ResearchCentre, Leeds Teaching Hospitals NHS Trust, Leeds, UK and2Department of Rheumatology and Clinical Immunology,UMCG Groningen, Groningen, The NetherlandsCorrespondence to: Sarah Mackie, University of Leeds andLeeds Biomedical Research Centre, Chapel Allerton Hospital,Harrogate Road, Leeds LS7 4SA, UK.E-mail: s.l.mackie@leeds.ac.ukReferences1 Horton BT. An undescribed form of arteritis of thetemporal vessels. Proc Staff Meet Mayo Clinic 1932;7:700–1.2 McDonnell PJ, Moore GW, Miller NR, Hutchins GM,Green WR. Temporal arteritis. A clinicopathologic study.Ophthalmology 1986;93:518–30.3 Hunder GG, Bloch DA, Michel BA, Stevens MB, ArendWP et al. The American College of Rheumatology 1990criteria for the classification of giant cell arteritis. ArthritisRheum 2010;33:1122–8.4 Hellmich B, Agueda A, Monti S et al. 2018 Update of theEULAR recommendations for the management of largevessel vasculitis. Ann Rheum Dis 2019; doi:10.1136/annrheumdis-2019-215672.5 Duftner C, Dejaco C, Sepriano A et al. Imaging indiagnosis, outcome prediction and monitoring of largeTABLE 1 Summary of recent evidence relating to sensitivity and specificity of temporal artery biopsy, temporal artery USand MRITemporalartery biopsyTemporalartery US [5]MRI of temporalarteries [5]Sensitivity for clinical diagnosis of GCA 77% [10] 77% 73%Specificity for clinical diagnosis of GCA 99% (assumed) 96% 88%Positive predictive value (assuming 25% prevalence [11]) 96% 87% 67%Negative predictive value (assuming 25% prevalence [11]) 93% 93% 91%Positive likelihood ratio 77 19 6.1Negative likelihood ratio 0.23 0.24 0.31Notes: For clinical context, the sensitivity/specificity results are also presented in the form of the corresponding positiveand negative predictive values, assuming a prevalence of 25%, as well as the corresponding positive and negative likeli-hood ratios. Note that these predictive values and likelihood ratios are not necessarily directly applicable to clinical prac-tice; in the case of TAB they depend on an assumed specificity of 99%, which may be an overestimate. Note that we didnot include here 18-fluorodeoxyglucose PET studies, as few diagnostic accuracy studies have been done to date.Editorial2 https://academic.oup.com/rheumatologyDownloaded from https://academic.oup.com/rheumatology/article-abstract/doi/10.1093/rheumatology/kez628/5717444 by University of Groningen user on 16 April 2020vessel vasculitis: a systematic literature review andmeta-analysis informing the EULAR recommendations.RMD Open 2018;4:e000612.6 Klein RG, Campbell RJ, Hunder GG, Carney JA. Skiplesions in temporal arteritis. Mayo Clin Proc 1976;51:504–10.7 Maleszewski JJ, Younge BR, Fritzlen JT et al. Clinicaland pathological evolution of giant cell arteritis: aprospective study of follow-up temporal artery biopsiesin 40 treated patients. Mod Pathol 2017;30:788–96.8 Luqmani R, Lee E, Singh S et al. The Role of UltrasoundCompared to Biopsy of Temporal Arteries in theDiagnosis and Treatment of Giant Cell Arteritis (TABUL):a diagnostic accuracy and cost-effectiveness study.Health Technol Assess 2016;20:1–238.9 Niederkohr RD, Levin LA. A Bayesian analysis of the truesensitivity of a temporal artery biopsy. Invest OphthalmolVis Sci 2007;48:675–80.10 Rubenstein E, Maldini C, Gonzalez-Chiappe S, ChevretS, Mahr A. Sensitivity of temporal artery biopsy in thediagnosis of giant cell arteritis: a systematic literaturereview and meta-analysis. Rheumatology 2019;58;kez385.11 Ing EB, Wang DN, Kirubarajan A et al. Systematicreview of the yield of temporal artery biopsy forsuspected giant cell arteritis. Neuroophthalmology 2019;43:18–25.12 Chakrabarty A, Mackie S, Harden C, Morgan AW.Temporal artery biopsy: audit of histological diagnosis.Rheumatology 2019;kez396.Editorialhttps://academic.oup.com/rheumatology 3Downloaded from https://academic.oup.com/rheumatology/article-abstract/doi/10.1093/rheumatology/kez628/5717444 by University of Groningen user on 16 April 2020

https://pure.rug.nl/ws/files/122190635/What_can_negative_temporal_artery_biopsies_tell_us.pdf

What can negative temporal artery biopsies tell us?

Abstract

Similar works

Full text

Available Versions

University of Groningen

ARTS repository - University of Groningen

NARCIS

ARTS repository - University of Groningen

University of Groningen