The efficacy of intensity modulated radiation therapy in treating thyroid-associated ophthalmopathy and predictive factors for treatment response

Radiation Therapy for Graves' Ophthalmopathy: When Is the Optimal Timing of Treatment and Evaluation

PURPOSE

Despite the decades of using radiation therapy (RT) for Graves' ophthalmopathy, the effects and optimal timing remain unclear. We retrospectively analyzed to evaluate the overall efficacy and response, predictive factors, and the effective timing of RT by assessing steroid requirement after RT in patients without prior surgery.

METHODS AND MATERIALS

Between 2008 and 2022, we analyzed 74 patients with Graves' ophthalmopathy who received RT to both orbits. Concurrent steroid therapy was administered to 51 patients. Symptoms were evaluated using a modified clinical activity score (CAS), defining responders as those with a ≥2 score improvement in CAS, diplopia, or a significant reduction in exophthalmos asymmetry. Common symptoms included eye swelling (81.1%), and conjunctival edema (81.1%). Diplopia observed in 48 patients (64.9%).

RESULTS

Median follow-up was 44.5 months (range, 4.8-169.6). CAS significantly improved in the early-immediate phase, 1 month after RT (P < .001). However, diplopia showed significant improvement at a relatively late phase, 4 months after RT (P = .039). Patients treated with steroids concurrently showed a faster response compared to those without steroids. Initiating RT within 12 months of symptom onset resulted in a shorter duration of steroid use after RT compared with later initiation (65 vs 286 days, P = .011).

CONCLUSIONS

Our study suggests an evaluation period of at least 4 months after RT regardless of concurrent steroid treatment, recognizing the prolonged improvement timeline for diplopia. Additionally, for reducing steroid use after RT, our study suggests optimal timing of RT within 12 months of symptom onset.

A curative effect evaluation of intensity-modulated radiation therapy combined with periorbital triamcinolone acetonide injection in treating thyroid eye disease patients with active extraocular muscle but low CAS

The purpose of this study is to evaluate the effectiveness of intensity-modulated radiation therapy (IMRT) combined with periorbital triamcinolone acetonide injection in treating thyroid eye disease (TED) patients with active extraocular muscle but low CAS. The retrospective observational study was conducted. A total of 156 eligible patients were selected from the TED patient database of the Ophthalmology Department of West China Hospital of Sichuan University. The patient's relevant medical history was recorded, including gender, age of initial onset, onset eye, the interval between onset and the first visit to our hospital, extraocular muscle condition, smoking status, CAS, NOSPECS, thyroid function, symptoms and signs, and the condition of the affected extraocular muscle. We found that IMRT combined with periorbital triamcinolone acetonide injection has a good therapeutic effect on TED patients with low CAS but significant active extraocular muscles, and there is a significant improvement at 3 months after treatment. Thyroid function and CAS can affect the curative effect of IMRT. Patients with hyperthyroidism had worse effect than those with normal thyroid function. The higher the CAS, the better the effect.

Late orbital radiotherapy combined with intravenous methylprednisolone in the management of long-lasting active graves' orbitopathy: a case report and literature review

PURPOSE

To present a case and review the literature on Orbital Radiotherapy (OR) combined with intravenous methylprednisolone, focusing on its late application in patients with long-lasting active Graves' Orbitopathy (GO). Additionally, we suggest emerging perspective for future research in this context.

METHOD

Relevant literature (randomized controlled studies, retrospective studies and reviews) was explored on PubMed from January 1973 to January 2024, searching "orbital radiotherapy" & "Graves disease".

RESULTS

OR is a well-established second-line treatment for moderate-to-severe active GO, providing response rates comparable to glucocorticoids. Its anti-inflammatory effect makes OR particularly suitable for early active GO, and when combined with glucocorticoids, outcomes are synergistically improved. The emergence of the new Volumetric Modulated Arc Image-Guided Radiation Therapy (VMAT-IGRT) technique enables precise radiation delivery to the target, significantly reducing associated toxicity. This technological advancement enhances the feasibility of radiotherapy in benign diseases like GO. A retrospective study indicated that late OR in patients with long-lasting active GO may improve diplopia and visual acuity, decreasing disease activity. Our case report supports this conclusion.

CONCLUSIONS

This report and literature review underscores the importance of considering late OR combined with intravenous methylprednisolone as a viable treatment option for GO patients with prolonged disease activity, emphasizing the crucial role of personalized therapy in managing GO. However, further investigations are warranted to validate this approach in cases of long-lasting active GO.

Predictive markers for anti-inflammatory treatment response in thyroid eye disease

Anti-inflammatory treatment is the primary and vital therapeutic approach for active, moderate-to-severe thyroid eye disease (TED). Accurate pretreatment prediction of treatment response is of paramount importance for the prognosis of patients. However, relying solely on the clinical activity score asa determinant of activity has led to unsatisfactory treatment outcomes. In recent years, significant advancements have been made in identifying predictive markers for anti-inflammatory treatment response in TED, clinical markers, body fluid biomarkers and imaging biomarkers. Several clinical studies have developed prediction models based on these markers. However, there is still a lack of comprehensive elucidation or comparison between the different markers. Therefore, this review aims to provide a detailed analysis of the definition, characteristics, and application of predictive markers for anti-inflammatory treatment response in TED. Through detailed literature search, 26 articles applying anti-inflammatory treatment effect prediction with a total of 1948 TED patients were used for analysis and discussion. By gaining a better understanding of the current research on predictive markers, we can accelerate and guide the exploration of treatment prediction strategies, leading us towards an era of precise therapy for TED.

Advances in the Treatment of Thyroid Eye Disease Associated Extraocular Muscle Myopathy and Optic Neuropathy

PURPOSE OF REVIEW

To review emerging treatments for thyroid eye disease (TED) associated extraocular muscle myopathy and dysthyroid optic neuropathy (DON).

RECENT FINDINGS

Emerging targeted biologic therapies may alter the disease course in TED. Teprotumumab, a type I insulin-like growth factor receptor inhibitor, is the most recent addition to the treatments available for TED-associated extraocular muscle myopathy causing diplopia. Small studies also suggest a potential therapeutic benefit for DON. Various recent studies have also expanded our knowledge on conventional TED therapies. The therapeutic landscape of TED and its sequelae has evolved in recent years. New targeted therapies have the potential to reduce the extraocular muscle and orbital volume expansion which can lead to diplopia and vision loss from optic nerve compression. Longer term efficacy and durability data is needed to determine the role biologics, such as teprotumumab, should play in the treatment of TED patients compared to the current standard of care.

Deep Neural Network with Structural Similarity Difference and Orientation-based Loss for Position Error Classification in The Radiotherapy of Graves' Ophthalmopathy Patients

Identifying position errors for Graves' ophthalmopathy (GO) patients using electronic portal imaging device (EPID) transmission fluence maps is helpful in monitoring treatment.} However, most of the existing models only extract features from dose difference maps computed from EPID images, which do not fully characterize all information of the positional errors. In addition, the position error has a three-dimensional spatial nature, which has never been explored in previous work. To address the above problems, a deep neural network (DNN) model with structural similarity difference and orientation-based loss is proposed in this paper, which consists of a feature extraction network and a feature enhancement network. To capture more information, three types of Structural SIMilarity (SSIM) sub-index maps are computed to enhance the luminance, contrast, and structural features of EPID images, respectively. These maps and the dose difference maps are fed into different networks to extract radiomic features. To acquire spatial features of the position errors, an orientation-based loss function is proposed for optimal training. It makes the data distribution more consistent with the realistic 3D space by integrating the error deviations of the predicted values in the left-right, superior-inferior, anterior-posterior directions. Experimental results on a constructed dataset demonstrate the effectiveness of the proposed model, compared with other related models and existing state-of-the-art methods.

PRL-1 overexpressed placenta-derived mesenchymal stem cells suppress adipogenesis in Graves' ophthalmopathy through SREBP2/HMGCR pathway

Background

Graves’ ophthalmopathy (GO) is a disorder, in which orbital connective tissues get in inflammation and increase in volume. Stimulants such as thyroid-stimulating hormone (TSH), insulin-like growth factor 1(IGF-1), IL-1, interferon γ, and platelet-derived growth factor cause differentiation into adipocytes of orbital fibroblasts (OFs) in the orbital fat and extraocular muscles. Human placental mesenchymal stem cells (hPMSCs) are known to have immune modulation effects on disease pathogenesis. Some reports suggest that hPMSCs can elicit therapeutic effects, but to date, research on this has been insufficient. In this study, we constructed PRL-1 overexpressed hPMSCs (hPMSCs^PRL-1) in an attempt to enhance the suppressive function of adipogenesis in GO animal models.

Methods

In order to investigate the anti-adipogenic effects, primary OFs were incubated with differentiation medium for 10 days. After co-culturing with hPMSCs^PRL-1, the characteristics of the OFs were analyzed using Nile red stain and quantitative real-time polymerase chain reaction. We then examined the in vivo regulatory effectiveness of hPMSCs^PRL-1 in a GO mouse model that immunized by leg muscle electroporation of pTriEx1.1Neo-hTSHR A-subunit plasmid. Human PMSCs^PRL-1 injection was performed in left orbit. We also analyzed the anti-adipogenic effects of hPMSCs^PRL-1 in the GO model.

Results

We found that hPMSCs^PRL-1 inhibited adipogenic activation factors, specifically PPARγ, C/EBPα, FABP4, SREBP2, and HMGCR, by 75.1%, 50%, 79.6%, 81.8%, and 87%, respectively, compared with naïve hPMSCs in adipogenesis-induced primary OFs from GO. Moreover, hPMSCs^PRL-1 more effectively inhibited adipogenic factors ADIPONECTIN and HMGCR by 53.2% and 31.7%, respectively, than hPMSCs, compared with 15.8% and 29.8% using steroids in the orbital fat of the GO animal model.

Conclusion

Our findings suggest that hPMSCs^PRL-1 would restore inflammation and adipogenesis of GO model and demonstrate that they could be applied as a novel treatment for GO patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13287-021-02337-2.

Efficacy of orbital radiotherapy in moderate-to-severe active graves' orbitopathy including long-lasting disease: a retrospective analysis

Background

We aimed to explore the efficacy of orbital radiotherapy (RT) in patients with moderate-to-severe active Graves’ orbitopathy (GO), including long-lasting disease, and to determine the predictive factors associated with treatment response.

Methods

This was a retrospective study of 62 moderate-to-severe active GO patients treated with RT. Demographic data and ophthalmic findings prior to RT and at 3 and 6 months afterward were analyzed. Computed tomography was performed before and after RT to compare orbital volume change. We used logistic regression to determine the predictive factors for treatment response. Subjects were divided into early- and late-active phase groups based on GO duration of 24 months and treatment outcomes were compared with each other to observe the effects of RT timing on treatment response.

Results

Forty (64.5%) and forty-six (74.1%) patients experienced improvements in GO at 3 and 6 months after radiotherapy, respectively. Ocular parameters such as clinical activity score (CAS), proptosis, extraocular muscle (EOM) limitation, and compressive optic neuropathy (CON) were improved by RT. Volumes of EOM significantly decreased after RT. The enlargement of EOMs and EOM limitation were predictive factors for a good response to RT. At 6 months after RT, 22 (68.8%) patients of late-active phase group exhibited improvement in GO, which is comparable to the number of 24 (80.0%) patients of early-active phase group. In the late-active phase group, CAS, diplopia, and visual acuity were improved significantly, but there was no change in EOM limitation.

Conclusions

In moderate-to-severe active GO patients, orbital RT may help improve high CAS, proptosis, EOM limitation, and CON. The orbital RT in long-lasting active GO patients may be considered as treatments for the relief of symptoms including high CAS and poor visual acuity.

Quantitative analysis of extraocular muscle volume and exophthalmos reduction after radiation therapy to treat Graves' ophthalmopathy: A pilot study

PURPOSE

The aim of this study was to provide radiological information on the inherent response of Graves' ophthalmopathy after radiation therapy.

METHODS

Quantitative analysis of extraocular muscle volume was performed on 96 involved extraocular muscles in a total of 16 patients. A total of 48 computed tomography images were analyzed. Exophthalmos was also measured. The percentage reductions in extraocular muscle volume and exophthalmos length were determined and compared to the pre-radiation therapy values at 6-, 12-, and 24-month follow-up.

RESULTS

The median follow-up time was 21.5 months (range: 7.2-29.4 months). The mean reduction in relative tumor volume compared to the pre-radiation therapy extraocular muscle volume was 46.1% (range: 33.3%-58.8%). The mean relative extraocular muscle volumes were 71.5% at 6 months, 59.2% at 12 months, and 54.3% at 24 months after radiation therapy. The volume of the involved extraocular muscles decreased rapidly within the first 12 months of follow-up. The mean pre-radiation therapy length of exophthalmos was 21.7 mm (range: 17.6-26.1 mm). The mean percentages of exophthalmos length by comparison with the pre-radiation therapy length were 96.7% at 6 months, 92.3% at 12 months, and 88.5% at 24 months after radiation therapy. Exophthalmos decreased slowly and steadily during the follow-up period.

CONCLUSION

Quantitative volumetric analysis of the pattern of extraocular muscle volume reduction and exophthalmos length reduction in response to radiation therapy will allow clinicians to better understand the effect of radiotherapy on Graves' ophthalmopathy.

Human placenta-derived mesenchymal stem cells ameliorate orbital adipogenesis in female mice models of Graves' ophthalmopathy

Background

Graves’ ophthalmopathy (GO) is a complication of Graves’ disease (GD), in which orbital connective tissues become inflamed and increase in volume and orbital fibroblasts within the orbital fat and extraocular muscles differentiate into adipocytes in vitro when stimulated by hormones, several cytokines, and growth factors including TSH, IGF-1, IL-1, interferon γ, and platelet-derived growth factor. Human placental mesenchymal stem cells (hPMSCs) have immunomodulatory effects in disease pathogenesis. Although a number of studies have reported that hPMSCs can elicit therapeutic effects, these are not sufficient. Therefore, we constructed a GO animal model in order to find out the hPMSCs recovery effect.

Methods

We investigated their anti-adipogenic effects in in vitro cultures of orbital fibroblasts established from GO patients. Primary orbital fibroblasts were exposed to differentiation medium for 10 days. After being co-cultured with hPMSCs, the characteristics of orbital fibroblast were determined by Oil Red O stain and real-time PCR. Then, we explored the in vivo regulatory effects of hPMSCs in an experimental mouse model of GO. We developed the GO mouse model using immunization by leg muscle electroporation of pTriEx1.1Neo-hTSHR A-subunit plasmid. Human PMSC injection was performed into the left orbit. We also analyzed the effects of hPMSCs in the GO animal model.

Result

We found that hPMSCs inhibited a lipid accumulation and activated factors, such as ADIPONECTIN, PPARγ, C/EBPα, and TGFβ2 genes in adipogenesis-induced primary orbital fibroblasts from GO patients. Moreover, hPMSCs were highly effective at ameliorating adipogenesis in the orbital tissue of the model.

Conclusion

These data indicate that hPMSCs recover pathogenic activation of orbital fibroblasts in animals undergoing experimental GO and confirm the feasibility of applying hPMSCs as a novel treatment for GO patients.