ArticleEULAR rheumatology open2026
Synovial histopathology in rheumatoid arthritis treated with biological disease-modifying antirheumatic drugs: an analysis of 1593 surgical specimens using the Rooney score.
Article in EULAR rheumatology open, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 1 paper.
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9 authors.
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Abstract
Objectives: This study aims to evaluate synovial histopathological inflammation in rheumatoid arthritis (RA) using the Rooney score (RS) and to investigate histopathological heterogeneity within difficult-to-treat (D2T) RA. Methods: We analysed 1593 synovial specimens from 1043 patients with RA who underwent joint surgery between 2013 and 2023. Histological inflammation was assessed by a blinded pathologist using a modified RS (total score, 0-60). Patients were classified as biological disease-modifying antirheumatic drug (bDMARD)-naïve or bDMARD-treated; the treated group was further subdivided into D2T and non-D2T RA according to the 2021 European League Against Rheumatism definition. Associations between RS and clinical markers, including C-reactive protein (CRP), Disease Activity Score 28-erythrocyte sedimentation rate (DAS28-ESR), matrix metalloproteinase-3 (MMP-3), and power Doppler (PD) grade, were examined. Exploratory analyses further stratified D2T RA into inflammatory and noninflammatory subtypes based on objective inflammatory markers. Results: RS was significantly lower in bDMARD-treated patients than in bDMARD-naïve patients, indicating histological attenuation of synovial inflammation. Item-wise analysis showed lower scores for synoviocyte hyperplasia and lymphocytic infiltration and higher fibrosis scores in the treated group. Total RS correlated with CRP, DAS28-ESR, MMP-3, and PD grade. Among bDMARD-treated patients, RS did not differ between D2T and non-D2T RA, whereas MMP-3 levels were higher in D2T RA. In exploratory analyses, inflammatory D2T RA showed higher RS and MMP-3 levels than noninflammatory D2T RA. Conclusions: bDMARD therapy attenuates synovial inflammation histologically, and RS reflects local inflammatory activity. Exploratory analyses suggested that the synovial histopathology may provide complementary information on inflammatory heterogeneity within D2T RA, which may not be fully captured by the conventional clinical indices.
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