99mTc-DTPA SPECT/CT provided guide on triamcinolone therapy in Graves' ophthalmopathy patients

The application of extraocular muscle maximum standardized uptake value of 99mTc-diethylenetriamine pentaacetic acid orbital single photon emission computed tomography/computed tomography in the assessment of Graves' orbitopathy

PURPOSE

To study the feasibility and value of assessing patients with Graves' orbitopathy (GO) in 99mTc-diethylenetriamine pentaacetic acid (DTPA) orbital single photon emission computed tomography/computed tomography (SPECT/CT) with extraocular muscle maximum standardized uptake value (SUVmax).

METHODS

A total of 235 patients underwent 99mTc-DTPA orbital SPECT/CT, including 176 patients with GO and 59 patients with Graves' disease (GD) as controls. The SUVmax of extraocular muscles, including right medial rectus muscle (RMR), right lateral rectus muscle (RLR), left medial rectus muscle (LMR), left lateral rectus muscle (LLR), was compared between groups, correlation analyses with clinical activity scores (CAS) and serological indices was performed, and the diagnostic efficacy was evaluated using receiver operating characteristic curves. The consistency of SPECT/CT and MRI in assessing extraocular muscle activity was compared.

RESULTS

SUVmax in the extraocular muscles of active GO patients was significantly higher than in inactive GO patients and controls. In GO patients, SUVmax of the medial rectus (LMR most prominent) was higher than that of the lateral rectus. SUVmax correlated with CAS, thyroid-stimulating hormone, total cholesterol, low-density lipoprotein (positively) and free triiodothyronine and free thyroxine (negatively), but not with GO duration. The optimal cutoff values for distinguishing between active and inactive SUVmax were identified. RLR had high sensitivity and RMR had high specificity. SPECT/CT and MRI showed moderate agreement in assessing extraocular muscle activity in 87 GO patients, with high concordance.

CONCLUSIONS

The extraocular muscle SUVmax of 99mTc-DTPA orbital SPECT/CT may be used as an adjunct method in combination with CAS to more accurately assess GO activity, which can help in clinical diagnosis and individualized treatment.

Evaluation of Inflammatory Activity of Extraocular Muscles in Thyroid Associated Orbitopathy by [68Ga]DOTATATE PET/CT

PURPOSE

The accurate assessment of inflammatory activity of the extraocular muscles (EOMs) in thyroid associated ophthalmopathy (TAO) is crucial for formulating subsequent treatment strategies and prognostic judgments. This study aims to explore the efficacy of using [68Ga]DOTATATE PET/CT to assess the inflammatory activity of EOMs in TAO patients.

PROCEDURES

This study enrolled 22 TAO patients and 6 healthy volunteers, all of whom underwent orbital [68Ga]DOTATATE PET/CT. Among these, 18 patients underwent orbital [99mTc]DTPA SPECT/CT within one week, and the other 4 patients received orbital MRI. All imaging data were independently assessed, followed by comparative data analysis. The patients then received different treatment schemes, and their prognosis was followed up.

RESULTS

[68Ga]DOTATATE PET/CT could effectively evaluate the inflammatory activity of the EOMs in TAO patients and demonstrate good consistency with [99mTc]DTPA SPECT/CT and orbital MRI, but show a better resolution to distinguish EOMs and surrounding structure. The receiver operating characteristic (ROC) curves for each EOM, treated as individual research units, exhibited an area under the curve (AUC) exceeding 0.9. The medial rectus demonstrated the highest involvement and diagnostic accuracy(AUC = 0.976, P < 0.001). Patients treated with glucocorticoids showed significantly higher SUVmax in EOMs compared to those receiving symptomatic treatment (P < 0.01).

CONCLUSIONS

[68Ga]DOTATATE PET/CT is a reliable method for assessing the inflammatory activity of EOMs in TAO patients, providing strong objective evidence for the precise diagnosis and treatment.

Triamcinolone injection in the treatment of lid retraction for thyroid-associated ophthalmopathy: A systematic review

INTRODUCTION AND OBJECTIVES

Lid retraction is one of the most common symptoms of Thyroid-Associated Ophthalmopathy (TAO), which potentially precipitates various complications, such as dry eyes, exposure keratopathy, and cosmetic concerns. Local corticosteroid injections, such as triamcinolone, have been proposed as a choice of treatment for TAO. This approach may be a favorable alternative for patients intolerant to the systemic effects of high-dose methylprednisolone. However, the efficacy of this intervention remains unestablished. Hence, our review aims to evaluate the efficacy of triamcinolone injection in reducing lid retraction.

METHODS

This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline and was conducted in three databases (PubMed, Science Direct, and ProQuest). This review included studies that use local triamcinolone injections for patients with thyroid-associated ophthalmopathy. The outcome of interest in this review is lid retraction parameters.

RESULTS

From six studies, a total of 392 patients were included. All studies showed significant improvement in lid retraction in the patient who received triamcinolone (all p < 0.05) as shown by ΔMRD (-0.93 mm in 1 month and -1.38 mm in 3 months), ΔMLD (-1.98 mm at 6 months), and Δpalpebral fissure height (-1.68 in 1 month). The majority of studies showed rapid improvement in lid retraction in the first month of therapy.

CONCLUSION

Triamcinolone injection is an effective therapy for lid retraction related to thyroid-associated ophthalmopathy.

Evaluation of 99Tcm-DTPA orbit SPECT/CT combined with thyroid function test in the treatment of radioactive iodine I-131 in patients with thyroid-associated ophthalmopathy-hyperthyroidism

Background

Thyroid-associated ophthalmopathy (TAO) is an autoimmune response to inflammation of the thyroid and orbital tissue. This research evaluated the efficacy of 99Tcm-DTPA orbital SPECT/CT combined with thyroid function test in radioactive iodine I-131 (RAI) treatment of TAO-hyperthyroidism.

Methods

We retrospectively studied clinical activity score (CAS), blood thyrotropine (TSH), free triiodothyronine (FT3), free thyroxine (FT4), thickness of extra-ocular muscle (EOM), and uptake rate (UR) of 99Tcm-DTPA orbital SPECT/CT of 43 patients after 6 months of treatment with 20 mCi RAI. Parameters were compared before and after RAI in patients assessed as effectively treated (normal thyroid function or hypothyroidism), and correlations between blood FSH, FT3, FT4, thickness of EOM, and UR were analyzed after treatment.

Results

After RAI, 35 cases (70 eyes, 81.4%) had normal or hypothyroidism, and 8 cases (16 eyes, 18.6%) had hyperthyroidism. Compared with the patients who failed treatment, effectively treated patients had lower CAS, FT3, FT4, and UR and higher blood TSH. In patients with effective treatment, UR of the inferior rectus muscle was positively correlated with FT3 and FT4. Adverse RAI outcomes were associated with smoking and higher iodine-thyroid iodine uptake before treatment.

Conclusions

Combined with TSH, FT3, and FT4 levels, the reduction of 99Tcm-DTPA orbital SPECT/CT UR also indicates an improvement in the disease course of patients. The UR of the inferior rectus muscle can be an objective index to evaluate the curative effect of TAO patients.

Diagnostic precision in thyroid-associated ophthalmopathy using multi-center radiomics with 99mTc-DTPA SPECT/CT

To explore the performance of 99mTc-diethylene triaminepentaacetic acid (DTPA) SPECT/CT texture analysis in evaluating the activity of thyroid-associated ophthalmopathy (TAO) . This retrospective study examined 115 TAO patients from a single institution as an internal cohort and 58 TAO patients from another institution as an external validation set. Patients in the internal cohort were randomly divided into training (n = 81) and internal validation sets (n = 34). Radiomics signatures were constructed with the minimal redundancy maximal relevance and least absolute shrinkage and selection operator algorithms in training set. Multivariate logistic regression analysis was used to develop a clinical model and a combined clinical-radiomics model. Diagnostic performance of models was evaluated using receiver operating characteristic curve analysis, calibration curves and decision curve analysis. Compared with CT and SPECT radiomics models, Rad-scoreSPECT/CT demonstrated the best performance with areas under the receiver operating characteristic curve of 0.94 and 0.91 in the training and test sets, respectively. The combined clinical-radiomics model exhibited significantly better performance in evaluating TAO activity. Our results demonstrate the validity of a multimodal radiomic model of 99mTc-DTPA-SPECT/CT to assess TAO activity. The combined clinical-radiomics model exhibited significantly better diagnostic performance than the clinical model.

New Multi-Parameters Combination of Technetium-99m-Diethylene-Triamine-Pentaacetate Orbital Single-Photon Emission Computed Tomography/Computed Tomography for the Evaluation of Graves' Orbitopathy Activity

PURPOSE

This study investigates the new combined parameters of 99mTc-DTPA orbital single-photon emission computed tomography/computed tomography (SPECT/CT) for the evaluation of Graves' orbitopathy (GO) activity.

METHODS

A retrospective analysis was performed on 41 patients. All the patients undergone the 99mTc-DTPA orbital SPECT/CT and were categorized into active and inactive group based on the standard combined by the clinical active score (CAS), magnet resonance imaging (MRI) and/or follow-up results. Quantitative parameters of lacrimal gland (LG) including the protruding degree of lacrimal gland herniation (LGH) and uptake ratios (URs) of region of interest (ROI) drawn on lacrimal gland and occipital bone. SPECT/CT reading results were based on visual analysis. Parameters were compared between the two groups and the diagnostic value on discrimination of GO activity was also evaluated.

RESULTS

All parameters of SPECT/CT for active GO groups were significantly higher than those of the inactive groups (p<.05). There were notable linear positive correlations between the assumption standard and readings as well as combination models 2 and 3 (r = .794, r = .772, r = .760, respectively). ROC analysis indicated that model 2 provided the highest diagnostic performance, exhibiting an area under the curve (AUC) of .947, a sensitivity of 92.7%, and a specificity of 88.6%.

CONCLUSIONS

The combined use of SPECT/CT reading results and DTPA uptake parameters of LG offers a more objective and precise evaluation of active GO. This study further recommends 99mTc-DTPA SPECT/CT might be serving as a supplementary beneficial approach for CAS in evaluating GO activity.

Thyroid Accumulation of 99m Tc-DTPA in Graves Disease

ABSTRACT

99m Tc-DTPA dynamic renal scintigraphy for evaluating glomerular filtration rate was performed in a 29-year-old woman with hyperuricemia and Graves disease. Subsequently, 99m Tc-DTPA orbital scintigraphy was conducted to determine the activity of Graves ophthalmopathy. Thyroid accumulation of 99m Tc-DTPA was incidentally identified. This should be cautiously distinguished from 99m Tc-pertechnetate uptake, considering that the salivary glands, oral cavity, and stomach were not visualized. Our case demonstrates that augmentation of blood supply, enhancement of capillary permeability, and accumulation of inflammatory exudate may be involved in the pathological process of Graves disease.

Deep learning-based diagnosis of disease activity in patients with Graves' orbitopathy using orbital SPECT/CT

PURPOSE

Orbital [99mTc]TcDTPA orbital single-photon emission computed tomography (SPECT)/CT is an important method for assessing inflammatory activity in patients with Graves' orbitopathy (GO). However, interpreting the results requires substantial physician workload. We aim to propose an automated method called GO-Net to detect inflammatory activity in patients with GO.

MATERIALS AND METHODS

GO-Net had two stages: (1) a semantic V-Net segmentation network (SV-Net) that extracts extraocular muscles (EOMs) in orbital CT images and (2) a convolutional neural network (CNN) that uses SPECT/CT images and the segmentation results to classify inflammatory activity. A total of 956 eyes from 478 patients with GO (active: 475; inactive: 481) at Xiangya Hospital of Central South University were investigated. For the segmentation task, five-fold cross-validation with 194 eyes was used for training and internal validation. For the classification task, 80% of the eye data were used for training and internal fivefold cross-validation, and the remaining 20% of the eye data were used for testing. The EOM regions of interest (ROIs) were manually drawn by two readers and reviewed by an experienced physician as ground truth for segmentation GO activity was diagnosed according to clinical activity scores (CASs) and the SPECT/CT images. Furthermore, results are interpreted and visualized using gradient-weighted class activation mapping (Grad-CAM).

RESULTS

The GO-Net model combining CT, SPECT, and EOM masks achieved a sensitivity of 84.63%, a specificity of 83.87%, and an area under the receiver operating curve (AUC) of 0.89 (p < 0.01) on the test set for distinguishing active and inactive GO. Compared with the CT-only model, the GO-Net model showed superior diagnostic performance. Moreover, Grad-CAM demonstrated that the GO-Net model placed focus on the GO-active regions. For EOM segmentation, our segmentation model achieved a mean intersection over union (IOU) of 0.82.

CONCLUSION

The proposed Go-Net model accurately detected GO activity and has great potential in the diagnosis of GO.

Monitoring and Predicting Treatment Response of Extraocular Muscles in Grave's Orbitopathy by 99mTc-DTPA SPECT/CT

Objective: To investigate single-photon emission computed tomography/computed tomography (SPECT/CT) for assessing inflammation in the extraocular muscles (EOMs) and predicting the therapeutic efficacy of periocular glucocorticoid therapy (PGT) for Grave's ophthalmopathy (GO). Materials and Methods: A total of 412 eyes from 206 patients with GO referred for 99mTc-DTPA orbital SPECT/CT were enrolled. Fourteen age- and gender-matched healthy controls (28 eyes) were included. The thickness and uptake ratio (UR) of four EOMs were derived from SPECT/CT. Eighty-six eyes from patients with GO patients received PGT. Changes in SPECT/CT parameters were evaluated between the pre- and post-treatment. Results: 195 eyes and 217 eyes were classified as active and inactive stages by clinical activity score (CAS). Values of the thickness and UR of each EOM, Tmax, and Umax were all significantly higher in the active GO than in the inactive GO and controls (p < 0.01). Among the 86 eyes (48 GO patients) included in the efficacy analysis, 56 eyes and 30 eyes were classified as responders and non-responders. Values of thicknesses and UR of each EOM, the maximum thickness (Tmax), and the maximum UR (Umax) all dropped following PGT in the responders (p < 0.01). Logistic regression analysis identified the Umax as an independent predictor for the responders (p < 0.01). Moreover, the Umax demonstrated incremental predictive value over clinical characters and CAS, as evidenced by the improved area under the curve (0.85 vs. 0.78) and global chi-square (34.12 vs. 18.1). Conclusion: 99mTc-DTPA SPECT/CT has the potential to assess inflammatory activity by detecting the involvement of EOMs in GO. Pre-treatment UR provides independent and incremental values for the prediction of PGT treatment response.

Current Knowledge on Graves' Orbitopathy

(1) Background: Graves' orbitopathy (GO) is an autoimmune inflammation of the orbital tissues and the most common extra-thyroid symptom of Graves' disease (GD). Mild cases of GO are often misdiagnosed, which prolongs the diagnostic and therapeutic process, leading to exacerbation of the disease. A severe course of GO may cause permanent vision loss. (2) Methods: The article presents an analysis of GO-its etiopathogenesis, diagnostics, current treatment and potential future therapeutic options based on a review of the currently available literature of the subject. (3) Results: Current treatment of the active GO consists predominantly in intravenous glucocorticoids (GCs) administration in combination with orbital radiotherapy. The growing knowledge on the pathogenesis of the disease has contributed to multiple trials of the use of immunosuppressive drugs and monoclonal antibodies which may be potentially effective in the treatment of GO. Immunosuppressive treatment is not effective in patients in whom a chronic inflammatory process has caused fibrous changes in the orbits. In such cases surgical treatment is performed-including orbital decompression, adipose tissue removal, oculomotor muscle surgery, eyelid alignment and blepharoplasty. (4) Conclusions: Management of GO is difficult and requires interdisciplinary cooperation in endocrinology; ophthalmology, radiation oncology and surgery. The possibilities of undertaking a reliable assessment and comparison of the efficacy and safety of the therapeutic strategies are limited due to the heterogeneity of the available studies conducted mostly on small group of patients, with no comparison with classic systemic steroid therapy. The registration by FDA of Teprotumumab, an IGF1-R antagonist, in January 2020 may be a milestone in future management of active GO. However, many clinical questions require to be investigated first.