Somatostatin receptor scintigraphy and octreotide treatment in patients with thyroid eye disease

Octreotide inhibits secretion of IGF-1 from orbital fibroblasts in patients with thyroid-associated ophthalmopathy via inhibition of the NF-κB pathway

PURPOSE

We investigated the effect of octreotide, a long-acting somatostatin (SST) analogue, on IGF-1 secretion and its possible mechanism of action in orbital fibroblasts (OFs) from patients with thyroid-associated ophthalmopathy (TAO).

MATERIALS AND METHODS

OFs were isolated from the orbital fat of patients with TAO or healthy individuals. The expression level of insulin-like growth factor (IGF)-1, at the protein and mRNA level, was determined with ELISA and quantitative RT-PCR, respectively. The expression pattern of somatostatin receptor (SSTR) 2, which has the highest affinity for octreotide, was examined by flow cytometry. The activity of NF-κB pathway was determined by examining the levels of phosphorylation of IKKα/β and p65, and degradation of IκB via western blot analysis, and by measuring the activity of NF-kB-dependent luciferase via transfection with plasmids containing luciferase and NF-κB binding site.

RESULTS

OFs from patients with TAO showed significantly higher levels of IGF-1 secretion and NF-κB activity even in the absence of stimulation, compared to those from controls. Treatment with octreotide reduced the level of IGF-1 secretion in OFs from patients with TAO, but not in OFs from controls. OFs from patients with TAO expressed higher levels of SSTR2 on the cell surface, compared to controls. In addition, the expression of IGF-1 at the protein and mRNA level was dependent on the activity of NF-κB pathway in OFs from patients with TAO. Furthermore, treatment with octreotide reduced on the activity of NF-κB pathway in OFs from patients with TAO.

CONCLUSION

OFs from patients with TAO showed significantly higher levels of IGF-1 secretion via up-regulation of NF-κB activity. Treatment with octreotide inhibited the secretion of IGF-1 by reducing the NF-κB pathway in OFs, which expressed higher levels of SSRT2 on the cell surface, from patients with TAO.

Somatostatin Analogs in Clinical Practice: a Review

Somatostatin analogs are an invaluable therapeutic option in the diagnosis and treatment of somatotropinomas, thyrotropinomas, and functioning and non-functioning gastroenteropancreatic neuroendocrine tumors. They should also be considered an effective and safe therapeutic alternative to corticotropinomas, gonadotropinomas, and prolactinomas resistant to dopamine agonists. Somatostatin analogs have also shown to be useful in the treatment of other endocrine diseases (congenital hyperinsulinism, Graves’ orbitopathy, diabetic retinopathy, diabetic macular edema), non-endocrine tumors (breast, colon, prostate, lung, and hepatocellular), and digestive diseases (chronic refractory diarrhea, hepatorenal polycystosis, gastrointestinal hemorrhage, dumping syndrome, and intestinal fistula).

Somatostatin receptor imaging by SPECT and PET in patients with chronic inflammatory disorders: a systematic review

OBJECTIVE

To review the literature on the clinical application of radiolabeled somatostatin receptor scintigraphy (SRS) by SPECT and PET in adults with chronic inflammatory diseases.

RESEARCH DESIGN

Systematic review of published observational studies between 1993 and 2017.

DATA COLLECTION AND ANALYSIS

The Cochrane Central Register of Controlled Trials, MedLine, EMBASE, PubMed, Google Scholar, OVID, EBSCO, Scopus, and Web of Science were used to search for studies on the use of SRS in adults with chronic inflammatory diseases. A team of reviewers independently screened for eligible studies. Quality of evidence was assessed by QUADAS approach.

RESULTS

Eligible papers included 38 studies. Studied populations were heterogeneous, and patients were classified according to the diagnosed disease: endothelial inflammation, rheumatoid arthritis, cardiac allograft rejection, granulomatous diseases, small vessel vasculitis, idiopathic pulmonary fibrosis, sarcoidosis, and thyroid exophthalmopathy. Because of many quality differences between studies, it was not possible to pool data, and a narrative synthesis is reported.

CONCLUSION

Results highlight the value of SRS to detect active inflammation in several chronic inflammatory conditions, despite the bias related to the index test, showing lack of standardization of the scintigraphic technique and high variability of methods used to clinically evaluate inflammatory condition.

Color Doppler imaging in thyroid eye disease and its correlation to disease activity

Purpose: To evaluate alterations in orbital color Doppler imaging (CDI) parameters and their correlation to disease activity and severity in patients with thyroid eye disease (TED). Methods: Seventy-six orbits of 45 TED patients and 40 orbits of 40 normal controls were enrolled in this cross-sectional study. According to clinical activity score (CAS), patients were categorized to active (CAS ≥ 3) or inactive disease (CAS < 3). Patients were also classified as having mild, moderate or severe disease. Peak systolic velocity (PSV), end diastolic velocity (EDV), and resistance index (RI) in ophthalmic artery and central retinal artery, and maximum and minimum velocity in superior ophthalmic vein and central retinal vein were determined in all subjects. Results: There was a significant difference in maximum velocity of superior ophthalmic vein and EDV and RI of ophthalmic artery between patients with TED and normal subjects. Superior ophthalmic vein maximum and minimum velocity and ophthalmic artery RI were significantly higher in patients with active disease than inactive cases. Disease severity did not affect the blood flow parameters independently. A cutoff point of 3.99 cm/s in superior ophthalmic vein maximum velocity yielded a sensitivity of 91.2% and specificity of 81.2% in detecting active disease. Conclusion: Retrobulbar blood flow is altered in TED and is related to disease activity. Superior ophthalmic vein maximum velocity could be helpful in differentiation of active and inactive cases.

New SPECT and PET Radiopharmaceuticals for Imaging Inflammatory Diseases: A Meta-analysis of the Last 10 Years

Modern molecular nuclear medicine is rapidly developing in the field of imaging of chronic inflammatory diseases, and many new radiopharmaceuticals have been recently described and tested in animals and man. These can detect early pathophysiological changes before the development of anatomical changes and, often, before clinical onset of symptoms. This field includes new radiopharmaceuticals for SPECT and PET use to define new strategies for imaging immune cells as well as tissue modifications induced by the inflammatory process. In this review, we present the results of a meta-analysis based on radiopharmaceuticals (for SPECT or PET) that are not commercially available and that have been used, at least once, in humans in the last 10 years.

Advances in the management of thyroid eye diseases: An overview

INTRODUCTION

Thyroid eye disease (TED) remains a notorious ailment for both patients and the treating ophthalmologists. Recent years have witnessed considerable research in the immunopathogenic mechanism of TED that has resulted in an expansion and modification of the available management options.

AIM

Purpose of this review is to summarise the advances in the management of thyroid ophthalmopathy.

MATERIAL AND METHOD

A thorough literature search and of the past 10 years web search with words Thyroid ophthalmopathy, recent, advances.

RESULTS

Recent VISA classification and new serum markers seem to have potential to give diagnostic as well as therapeutic guidance, gauge treatment response and even identify risk of disease progression. Majority of TED patients can be managed conservatively due to its self-limiting nature but if indicated, still steroids are the preferable medical therapy; however, there is an increasing consensus towards the use of parenteral form as compared to the oral one on account of greater efficacy with lesser side effects. Steroid sparing medications, for example, rituximab, infliximab, etanercept, adalimumab, teprotumumab, tocilizumab, tanshinone, are showing encouraging results and form an area of active research.

CONCLUSION

Radiation therapy remains as an adjunctive modality in active diseases as a nonmedical treatment for TED with some promising data. Surgical intervention may be required in vision threatening conditions or to counteract the sequel of inflammatory phase. Advances in surgical techniques like stereotactic image-guided balanced orbital decompression with endoscopic approach ensure meticulous dissection with minimal trauma.

99Tcm-octreotide scintigraphy and serum eye muscle antibodies in evaluation of active thyroid-associated ophthalmopathy

PurposeAs an autoimmune inflammatory disorder, active thyroid-associated ophthalmopathy (TAO) is managed optimally by immunosuppression. In this study, we aimed to evaluate octreotide scintigraphy and the level of serum extraocular muscle antibodies in TAO activity.Patients and methodsThis prospective study comprised 304 patients with active TAO (the clinical activity score; CAS≥3), 73 with inactive TAO (CAS<3), 128 with Graves' disease (GD) without ophthalmopathy, and 100 healthy subjects. Moderate-to-severe active TAO patients (CAS≥5) received intravenous injection of methylprednisolone; mild active patients (3≤CAS≤4) received periocular injection of triamcinolone acetonide. ⁹⁹Tc^m-octreotide scintigraphy and serum levels of calsequestrin, uveal auto-antigen with coiled-coil domains and ankyrin repeats (UACA) and G2s antibodies were detected before and after treatment.Results⁹⁹Tc^m-octreotide scintigraphy was positive in active TAO patients (97%) with elevated uptake ratio (UR) (P<0.05), and showed a significant correlation with CAS (r=0.816, P<0.01). After treatment both UR and CAS decreased significantly (P<0.05). The receiving operator characteristic curve (ROC) showed that the best UR threshold for discriminating active and inactive TAO was 1.34 (sensitivity, 100%; specificity, 89.4%). The level of serum calsequestrin antibody was higher in active TAO (P<0.05), showed a significant correlation with CAS (r=0.738, P<0.05), and also decreased after treatment (P<0.05). The best serum calsequestrin antibody threshold of the ROC curve was 138 ng/l (sensitivity, 88.4%; specificity, 89.2%). The UACA antibody was elevated in both TAO and GD patients (P<0.05), with no significant difference (P>0.05). As to G2s, no significant difference was found between all groups (P>0.05). Moreover, six GD patients (4.69%) with elevated calsequestrin developed active TAO 12 weeks later.Conclusion⁹⁹Tc^m-octreotide scintigraphy played a critical role in the evaluation of the clinical activity and therapeutic efficacy of TAO. Autoimmunity against calsequestrin in the pathogenesis of the eye muscle components may provide further objective evidence of myopathy in active TAO. Furthermore, calsequestrin antibody may predict myopathy in active TAO.

Advances in the pharmacological treatment of Graves' orbitopathy

Graves' orbitopathy has a deteriorating effect on patients' appearance and vision, thus significantly decreases their quality of life. A multidisciplinary team of endocrinologists, ophthalmologists, head and neck surgeons, nuclear medicine physicians, radiologists, and psychologists should constitute a standard health care team for those patients. It is vital that the therapy is based on an individual approach, with patients being well informed and involved in the decision-making process. Generally, traditional therapies include immunosuppression with steroids, orbital irradiation and surgical decompression. Novel treatment modalities include: biological agents, somatostatin analogs, antioxidants, methotrexate. Better insight into pathogenesis of Graves' orbitopathy is the only chance for targeted therapy development.

The impact of octreotide in experimental proliferative vitreoretinopathy

AIMS

This study aims to investigate the effects of intravitreal octreotide on the growth factors, which have significant roles in the pathogenesis of proliferative vitreoretinopathy (PVR).

SETTINGS AND DESIGN

An experimental trial.

MATERIALS AND METHODS

21 guinea pigs were randomly assigned to form 3 groups each including 7 animals. In group 1 (the control group), 0.2 ml saline solution was applied intravitreally in a location of 1.5 mm behind the limbus. In group 2 (the sham group), 0.07 IU dispase in 0.1 ml and 0.1 ml saline solution were applied via the same route. The guinea pigs in group 3 (the treatment group) were applied 0.07 IU dispase in 0.1 ml and 1 mg octreotide in 0.1 ml via the same route. Octreotide injection was applied twice during the period of 10 weeks of the experiment. At the end of the 10 weeks, eyes were enucleated and retinal homogenates were prepared. The platelet derivated growth factor (PDGF), insulin-like growth factor (IGF 1) and transforming growth factor (TGF ß) levels in homogenized retina tissue were measured by Enzyme Linked-Immuno-Sorbent Assay (ELISA) method.

STATISTICAL ANALYSIS USED

Kruskal-Wallis variance analysis and Mann-Whitney U test.

RESULTS

In the treatment group, a significant decrease was observed in retinal PDGF levels (P < 0.01) while decreases in TGF ß and IGF 1 levels were not found to be significant (P > 0.05).

CONCLUSIONS

Intravitreally applied octreotide at a dose of 1 mg has a highly strong effect on PDGF. This study suggests that intravitreal octreotide may suppress PVR development and that octreotide may merit investigation for PVR prophylaxis.

Update on advanced imaging options for thyroid-associated orbitopathy

Thyroid-associated orbitopathy (TAO) is a diverse spectrum of signs and symptoms that appears to have immunologic and pathologic causative factors as diverse as its clinical presentations. Lymphocytes, hormones, and cytokines affect orbital fibroblasts and other similar cells, which exert their effects on orbital tissues, including the extraocular muscles, orbital fat, and optic nerve. This complicated inflammatory cascade and the myriad of clinical findings that result contributes to the active phase of TAO. The distinction between the active and inactive phases of TAO is an important one, as the proper treatment will depend on the disease phase and degree thereof. Several clinical grading scales and scores have been established to help qualify and quantify the disease severity. Aiding clinical exam and acumen, proper and reproducible imaging of the orbit and ocular adnexa is incredibly important to the management of TAO. Orbital ultrasound, computed tomography, magnetic resonance imaging, and scintigraphy each have unique abilities, including quantifying orbital changes, assessing disease activity, correlating orbital findings with clinical changes, guiding appropriate treatment, and monitoring therapeutic responses. Further, study ease, accessibility, cost, sensitivity, specificity, reproducibility, and risks are all important considerations in picking the right test with which to diagnose and follow TAO. This analysis will provide a review of orbital imaging for TAO, including the mechanism of each imaging technique as well as their rationales, advantages, disadvantages, and utilities.

The impact of 99mTc-DTPA orbital SPECT in patient selection for external radiation therapy in Graves' ophthalmopathy

OBJECTIVE

In Graves' ophthalmopathy (GO), there is a demand to differentiate the immunologically active disease state, when immunosuppressive therapy is necessary, from the inactive state, when the patient would not benefit from it. We measured the inflammatory activity in the retrobulbar region using Tc-diethylene triamine pentaacetic acid (DTPA) SPECT before and after external radiation to determine whether this method is suitable for predicting the effectiveness of this therapy.

MATERIALS AND METHODS

Thirty-two patients with suspected active GO were involved in this retrospective study. The initial image, DTPA uptake value (UV) and its change after therapy were assessed to monitor the effect of the therapy and investigate whether a pretreatment scan is capable of predicting the outcome.

RESULTS

Depending on the change in DTPA UV after radiotherapy, three patient groups were formed: decreased, increased or minimally changed (less than 1×10 injected dose (ID)/ml). The initial DTPA UVs of these groups were significantly different (P<0.001). Improvement was observed mainly in patients with higher initial values. When comparing the groups with low (<12×10 ID/ml) versus high (≥12×10 ID/ml) initial uptake, an unexpected increase was observed in the first group after therapy (mean: +2.89±2.66×10 ID/ml), whereas the average change in the DTPA UV was negative in the latter group as anticipated (-2.24±4.47×10 ID/ml, P<0.00001).

CONCLUSION

We found that in GO patients a high DTPA UV may predict the response to orbital radiation therapy. DTPA orbital SPECT may be a suitable technique for the selection of GO patients for radiation therapy.

The role of intravenous methylprednisolone immunosuppression in the management of active thyroid eye disease

PURPOSE

To analyze the efficacy of intravenous methylprednisolone (IVMP) immunosuppression in the management of active thyroid eye disease (TED).

METHODS

This is a consecutive case series of 36 patients treated with 1 g of IVMP over 3 days, between January 2000 and January 2008. The indications for this treatment were moderate to severe active TED with or without optic nerve compression.

RESULTS

There were 32 hyperthyroid, 2 hypothyroid, and 2 euthyroid patients in this series. Nine patients presented with optic nerve compromise, 3 had severe active TED and 24 had moderately active TED. Twenty-seven patients received one course of IVMP and nine patients received two courses. All patients had tapering oral prednisolone over 1 month following the IVMP. The mean improvement in proptosis was 1.31 mm (range = 0-3 mm). Optic nerve function improved in seven of nine patients (77.8%). Extra ocular muscle movement improved in 18 patients (50%). Overall benefit from IVMP was seen at 1/12 in 27 patients (75%) and at 3/12 in 30 patients (83%). After IVMP one patient underwent radiotherapy and three patients had nonsteroidal immunosuppression.

CONCLUSIONS

 IVMP immunosuppression is effective in 83% of patients. The effect lasts from 3 months to 8 years, with a mean of 15 months in 30.5%. It remains a useful modality of treatment especially when the optic nerve or cornea is threatened because of moderate to severe active TED. We encountered no severe side effects of pulsed IVMP and 3 g over 3 days is a safe dose.

Modulation of expression of somatostatin receptor subtypes in Graves' ophthalmopathy orbits: relevance to novel analogs

Apart from evaluating orbital inflammation in Graves' ophthalmopathy (GO), somatostatin (SST) analogs have been proposed as a therapy, but recent trials were disappointing. We aimed to measure somatostatin receptor (SSTR) expression in orbital tissues ex vivo and determine whether the new broad-affinity analog SOM230 might be of therapeutic use. Orbital adipose/connective tissues from 29 GO patients and 10 normal individuals were analyzed. Transcripts were quantified using SYBR Green and a light cycler. In vitro models were used to investigate whether thyrotropin receptor activation (as occurs via thyroid stimulating antibodies) or adipogenesis affected SSTR expression in primary preadipocytes and to compare the biological activity of octreotide and SOM230 in their modulation. The expression of SSTR1 was significantly higher in GO patients than normal controls (P = 0.024). Although differences in the expression of SSTR2 were not significant, 39% of GO samples had levels above the 97th percentile of the controls. SSTR3, -4, and -5 were at or below the limit of detection (LOD). The lymphocyte contribution was minimal, since CD3alpha transcripts were at the LOD. TSH receptor activation did not modulate SSTR expression. An in vitro model of adipogenesis indicated upregulation of SSTR1 and SSTR2 during differentiation. SOM230 produced significantly greater inhibition of orbital preadipocyte proliferation than octreotide. Ex vivo analysis of orbital tissues reveals upregulation of SSTR1 and -2 in a group of GO patients. Adipogenesis, a process occurring in GO orbits, provides one possible explanation for some of the observed increase.

(99m)Tc-HYNIC-TOC scintigraphy in evaluation of active Graves' ophthalmopathy (GO)

OBJECTIVE

A promising radiopharmaceutical (99m)Tc-HYNIC-TOC ((99m)Tc-HYNIC-Octreotide) can be applied for somatostatin receptor scintigraphy with the potential to replace Indium-111 labeled somatostatin analogus. Here we evaluate whether orbital (99m)Tc-HYNIC-TOC scintigraphy can be used as a Graves' ophthalmopathy (GO) activity parameter to predict the retrobulbar irradiation response.

METHODS

Orbital (99m)Tc-HYNIC-TOC scintigraphy was performed on 14 consecutive patients demonstrating moderated to severe Graves' ophthalmopathy. The patients were treated with retrobulbar irradiation following the octreoscan and the response to this therapy was assessed at 3 months after the start of treatment. The orbital (99m)Tc-HYNIC-TOC uptake was calculated to assess the effects of treatment.

RESULTS

Among the 14 GO patients, eight (57.1%) responded to retrobulbar radiotherapy; six (42.9%) showed no change. We compared the eight responders and six non-responders in terms of orbital (99m)Tc-HYNIC-TOC uptake, using the orbital/occipital ratio. On the 4-h (99m)Tc-HYNIC-TOC scintigraphy, responders had a higher orbital/occipital uptake ratio than the no-responders (P = 0.001). A significant correlation was found between the orbital/occipital ratio and the clinical activity score (CAS) (P = 0.034). The Receiving-Operator-Characteristic curve showed the best threshold for discriminating active and inactive disease was 1.40 (sensitivity, 100%; specificity, 83.3%). In the responders group, all these eight patients had positive scintigraphy. While there were five patients who had negative scintigraphy in the non-responders group.

CONCLUSION

Orbital (99m)Tc-HYNIC-TOC scintigraphy can be a useful method for the estimation of disease activity and prediction the response to subsequent radiotherapy in GO patient. And the patients with positive octreoscan were more likely to respond to irradiation.

COX-2 and SCD, markers of inflammation and adipogenesis, are related to disease activity in Graves' ophthalmopathy

CONTEXT

Inflammation and adipogenesis are two parallel processes with increased activity in severe Graves' ophthalmopathy.

OBJECTIVE

The aim of this work was to define target genes for therapeutic intervention in adipogenesis and inflammation in Graves' ophthalmopathy.

DESIGN

Orbital tissue was obtained from patients with ophthalmopathy in acute or chronic phase undergoing orbital surgery to study gene expression followed by the study of potential intervention mechanisms in preadipocytes.

SETTING

Clinic of Endocrinology, University Hospital, Malmö, Sweden.

PARTICIPANTS

Patients in acute severe or in chronic phase of ophthalmopathy.

INTERVENTIONS

Lateral orbital decompression in acute phase and restorative surgery in chronic phase. In vitro treatment of preadipocytes with rosiglitazone and diclofenac.

MAIN OUTCOME MEASURE

Gene expression in intraorbital tissue or preadipocytes and differentiation of preadipocytes.

RESULTS

A marker of adipose tissue, stearoyl-coenzyme A desaturase (SCD), and the proinflammatory gene, cyclooxygenase-2 (COX-2), were overexpressed in patients in active phase compared to the chronic phase of ophthalmopathy. In growth-arrested preadipocytes stimulated with rosiglitazone, COX-2 expression increased temporarily within 1 hour and decreased to undetectable levels after 48 hours. In contrast, SCD and peroxisome proliferator-activated receptor-gamma (PPAR-gamma) expression increased continuously from day 2 to day 7 during adipogenesis. Diclofenac, an inhibitor of cyclooxygenases with antagonistic effects on PPAR-gamma, reduced the number of mature adipocytes by approximately 50%.

CONCLUSION

We conclude that inflammation and adipogenesis decrease with a decrease in activity of ophthalmopathy and that the nonsteroidal antiinflammatory drug diclofenac inhibits adipogenesis. This may represent a putative future treatment of endocrine ophthalmopathy.

Slow-release lanreotide in Graves' ophthalmopathy: A double-blind randomized, placebo-controlled clinical trial

SS analogs are an attractive alternative in treating Graves' ophthalmopathy (GO). Most of the previous studies were uncontrolled and enrolled few patients. The present study was conducted as a larger scale, prospective, randomized controlled study to determine the effectiveness of a slow-release formulation of lanreotide in GO. Sixty patients with active GO received an im injection every two weeks of either lanreotide 30 mg or placebo for 12 weeks. They were then followed and further treated in the traditional way if necessary. The Clinical Activity Score (CAS) was the primary efficacy criterion. Proptosis, diplopia, corneal erosion or ulcer, visual acuity, extraocular muscle movement and intraocular pressure were also evaluated. At the end of the 12 weeks, the mean CAS was not significantly decreased in the lanreotide group compared to the placebo group. The overall mean difference of proptosis between these two groups also did not reach significance at 12 weeks. Only diplopia at downward gaze had significant improvement for the lanreotide- treated group vs placebo group (p = 0.03). No differences were observed between the two groups compared to other outcome measures. During the 24-month follow-up after the clinical trial, 14 patients received eye surgery in the placebo group compared with 10 patients in the lanreotide group (p = 0.29). Six patients received methylprednisolone pulse therapy in the placebo group and two patients in the lanreotide group (p = 0.25). In conclusion, lanreotide treatment had no significant effects on GO compared with placebo.

Graves' ophthalmopathy: comparison of the Doppler sonography parameters with the clinical activity score

PURPOSE

Our aim was to compare the Doppler ultrasonography (US) parameters with clinical activity score (CAS) in patients with Graves' ophthalmopathy.

METHODS

Blood flow parameters in the ophthalmic artery (OA), superior ophthalmic vein (SOV), central retinal artery (CRA) and central retinal vein (CRV) were measured by Doppler US in 118 patients with Graves' disease in 3 groups (A, B, and C) and 20 control subjects. Group A included 25 patients with CAS value "0"; group B 55 patients with CAS value "1 or 2"; group C 38 patients with CAS value "3 or above."

RESULTS

Peak systolic velocities (PSV) and end-diastolic velocities (EDV) in the OA, PSV, and in the CRA calculated for group C were significantly higher than for group A, group B, and the control group. Resistance index in the OA and maximal velocity (MV) in the SOV calculated for group C were significantly lower than those calculated for group A, group B, and the control group.

CONCLUSION

Doppler parameters of MV in SOV, PSV and EDV in OA, and PSV in CRA seem to be helpful in the differentiation of active and inactive phases of Graves' ophthalmopathy.

Imaging of disease activity in Graves' orbitopathy with different methods: comparison of (99m)Tc-DTPA and (99m)Tc-depreotide single photon emission tomography, magnetic resonance imaging and clinical activity scores

BACKGROUND

The immunosuppressive treatment of Graves' orbitopathy (GO) influences the course of the disease in the early, active, retrobulbar inflammatory phase (active GO), which cannot be detected by direct clinical examination.

AIM

To evaluate the clinical effectiveness of a newly developed method for the detection of intraorbital inflammatory activity in patients suffering from Graves' orbitopathy, utilizing a four-headed single photon emission tomograph (SPET) camera and (99m)Tc-diethylenetriamine pentaacetic acid (Tc-DTPA).

METHODS

The magnetic resonance imaging (MRI) T2 relaxation time score, as a measure of ongoing orbital inflammation (reference method), was compared with the uptake activities (UA) of (99m)Tc-DTPA orbital SPET and the more specific (99m)Tc-Neospect ((99m)Tc-depreotide) SPET, as well as the clinical activity scores (CAS), in 21 patients (42 orbits).

RESULTS

By visual inspection, the 'eye SPET' frames of patients suffering from active GO could be easily distinguished from those with inactive GO. Although the distributions of the two radiopharmaceuticals were mildly different, the information obtained was essentially the same. The MRI activity scores correlated well with both (99m)Tc-DTPA and Tc-depreotide UA. The mean (99m)Tc-DTPA UA value of 25 inactive GO orbits was (6.55 +/- 1.4) x 10(-6) ID x cm3 (where ID is the injected dose); the values of the active GO orbits (12 orbits with an MRI score of 1 and five orbits with an MRI score of 2) were significantly higher: (8.87 +/- 1.63) x 10(-6) and (10.36 +/- 1.60) x 10(-6) ID x cm3, respectively. Similar differences were observed for the (99m)Tc-depreotide UA values: the averages in the inactive and active groups with MRI scores of 1 and 2 were (5.23 +/- 1.23) x 10(-6), (7.69+/-2.24) x 10 and (10.92 +/- 3.85) x 10(-6) ID x cm3, respectively. The (99m)Tc-DTPA accumulation pattern in the orbital region of active GO patients was similar to that of the more specific (99m)Tc-depreotide. There was a good correlation (r = 0.71, P<0.001) between the UA values of the two radiopharmaceuticals, but CAS did not correlate with either of the UA values.

CONCLUSIONS

(99m)Tc-DTPA eye SPET is a potentially useful method, allowing rapid imaging at an acceptable cost. It provides essential supplementary information to traditional CAS in assessing disease activity in Graves' orbitopathy.

The clinicopathologic basis of Graves' ophthalmopathy: a review

PURPOSE

Graves' ophthalmopathy (GO) is a controversial disease, with disagreement within the medical community regarding its pathogenesis, diagnosis, and treatment.

METHODS

We reviewed recent literature on clinical and pathological aspects of GO from both the endocrinologist's and ophthalmologist's perspective.

RESULTS

Investigations into the pathogenesis of GO have included possible antigenic targets, orbital cell types, and development of animal models. Diagnosis has been improved recently with new tools and grading systems, but can be complicated by conditions that may simulate one or more of the findings of GO. The new findings of clinical studies also compel practitioners to reassess commonly used GO treatments such as orbital irradiation.

CONCLUSIONS

Improved understanding of the pathogenic mechanisms of GO should hopefully lead to new diagnostic and therapeutic approaches to this problematic condition.

[Grave's ophthalmopathy: therapeutic strategy. Review of 30 patients]

BACKGROUND

Graves' ophthalmopathy is the primary etiology for exophthalmos in adults. It is a complex orbital disease whose pathophysiology remains controversial. Since its initial description more than 150 years ago, its heterogeneous clinical manifestations and poorly understood links with thyroid pathology remain unresolved issues. Disease activity is the main determinant for the management of Graves' ophthalmopathy, but treatments are often symptomatic, aiming at decreasing orbital inflammation.

MATERIAL AND METHODS

We report a retrospective analysis of 30 patients diagnosed with Graves' ophthalmopathy followed in our department between 1991 and 2002. Following a phase of medical management of their disease, all patients underwent surgical orbital decompression.

RESULTS

Medical and surgical care provided as well as results are presented with a mean follow-up of 23 months.

DISCUSSION

Based on our clinical experience, new concepts in the field of Graves' ophthalmopathy are discussed. Disease activity, evaluated through various means, appears to be the primary guide for therapeutic management. Moreover, the importance of a multidisciplinary approach is highlighted, in order to improve the management of this difficult disorder.

Measuring disease activity to predict therapeutic outcome in Graves' ophthalmopathy

OBJECTIVE

The concept of disease activity in Graves' ophthalmopathy (GO) might explain why as many as one-third of patients do not respond to immunosuppressive treatment, because only patients in the active stage of disease are expected to respond. The hypothesis was adopted that a parameter used to measure disease activity should be able to predict a response to immunosuppressive treatment. The aim of this study was to develop a multivariate prediction model in which all previous tested activity parameters are integrated.

DESIGN AND PATIENTS

We included 66 consecutive patients with untreated moderately severe GO who had been euthyroid for at least 2 months. All patients were treated with radiotherapy. Measurements Treatment efficacy after 6 months follow-up was used as the primary outcome measure. Disease severity and 15 different disease activity parameters were assessed before treatment. Univariate and multivariate logistic regression models were used to predict response (model 1) or no change (model 2).

RESULTS

In multivariate analyses, we found that duration of GO, soft tissue involvement, elevation, soluble interleukin-2 receptor (sIL-2R), soluble CD30 (sCD30), eye muscle reflectivity and octreotide uptake ratio were significant predictors of a response to radiotherapy. Gender, duration of GO, soft tissue involvement, eye muscle reflectivity, IL-6 and urinary glycosaminoglycan (GAG) excretion were significant predictors of no change upon radiotherapy. Prognostic score charts were developed for use in clinical practice to calculate the probability of response (model 1) and the probability of no change (model 2) for each new patient. Finally we used a combination of both models to define a recommended treatment modality for each individual patient, based on both the predicted probabilities of response and no change. We were able to identify the correct treatment (based on a comparison with the observed response) in 89% of the patients.

CONCLUSIONS

Although we strongly recommend that our results should be confirmed in other studies, our findings are the first evidence for the idea that disease (in)activity should determine which kind of treatment should be used.

Receptor-Mediated Tumor Targeting with Radiopeptides. Part 1. General Concepts and Methods: Applications to Somatostatin Receptor-Expressing Tumors

Radiolabeled peptides have become important tools in nuclear oncology, both as diagnostics and more recently also as therapeutics. They represent a distinct sector of the molecular targeting approach, which in many areas of therapy will implement the old "magic bullet" concept by specifically directing the therapeutic agent to the site of action. In this three-part review, we present a comprehensive overview of the literature on receptor-mediated tumor targeting with the different radiopeptides currently studied. Part I summarizes the general concepts and methods of targeting, the selection of radioisotopes, chelators, and the criteria of peptide ligand development. Then, the >400 studies on the application to somatostatin/somatostatin-release inhibiting factor receptor-mediated tumor localization and treatment will be reviewed, demonstrating that peptide radiopharmaceuticals have gained an important position in clinical medicine.

The cost of immunosuppressive therapies currently used in patients with thyroid eye disease

Thyroid eye disease (TED) is an inflammatory condition of the orbit occurring in patients with autoimmune disease. In patients with mild TED, the most important therapeutic measure is reassurance. In severe cases, immunosuppressive therapy is the mainstay of treatment and around 10 immunosuppressive regimens have been suggested and used in such patients so far. The efficacy of these regimens varies according to the number of studies that have addressed these issues. "Response" to the treatment is also variably defined. However, to the best of our knowledge, no study has reported on the cost of immunosuppressive therapy in such patients. The aim of this study was mainly to provide information concerning the cost of different immunosuppressive regimens that patients with active thyroid ophthalmopathy undergo in different European countries. We have shown that the cheapest treatment is oral glucocorticoids (GC) and the most expensive is iv immunoglobulins. Cyclosporine is the second cheapest treatment. Radiotherapy plus oral GC have a cost between 850-3200 Euro; while SS analogues (SS-a) are expensive with a cost between 5000-10000 Euro. However, it is worth noting that the patients studied so far in this group were only few and most of them selected on a basis of a positive octreoscan, the cost of which has to be considered when choosing this type of treatment. Germany is by far the most expensive country as regards the costs of the main remedies, whereas Greece is the cheapest. Denmark is the most expensive country concerning radiotherapy, while Germany is the cheapest.

Recent developments in Graves' ophthalmopathy imaging

Orbital ultrasound, computed tomography, and magnetic resonance are commonly used as imaging techniques to demonstrate pathological changes in ocular adnexa of patients with Graves' ophthalmopathy. Low cost, short time of investigation, and lack of radiation characterize ultrasound. Nevertheless, a clear differentiation regarding disease activity is not possible, nor is the evaluation of orbital tissue precise enough. Short investigation time, precise imaging of the orbital apex and moderate costs are advantages of tomography. This method delivers a significant radiation dose to the lens, which if repeated constitutes a risk for cataract development. For this reason, magnetic resonance imaging is preferable, particularly if repeated scans are required to assess response to treatment. Precise tissue differentiation and lack of ionizing radiation uniquely suit magnetic resonance for eye studies. Although sensitive in demonstrating interstitial edema within the rectos muscles in active disease, as well as providing a good predictive value with respect to immunosuppressive therapy, quantitative magnetic resonance imaging is an expensive method and is non-specific for the orbital changes in ophthalmopathy. Because of a favorable target to background ratio, octreoscan carries a high sensitivity and may be regarded as a semi-objective tool in the evaluation of patients with Graves' ophthalmopathy, both at initial stages as well as during treatment. A positive orbital octreoscan indicates a clinically active disease in which immunosuppressive treatment might be of therapeutic benefit. However, it is an expensive method with a non-negligible radiation burden. Also, it is neither specific nor does it offer detailed orbital imaging. In summary, in unclear cases of proptosis or recently developed diplopia, prior to orbital decompression surgery, or if imaging is needed in subjects with ophthalmopathy, magnetic resonance actually is the imaging method of choice.

Somatostatin analogs: a new tool for the management of Graves' ophthalmopathy

Somatostatin (SM), a peptide inhibiting the release of GH, is present and plays an inhibitory role in the regulation of several organ systems in men and other species. Various SM analogs (SM-As) have been developed and used in clinical practice because the short half-life of SM makes it unsuitable for routine treatment. Recently it has been shown that SM-As might be of therapeutic value in the treatment of active thyroid ophthalmopathy. So far, 61 patients have been treated with octreotide and the results have been published in the literature. It was found that in 41 patients the drug had a beneficial effect. Ten patients were given lanreotide and 8 of those had a positive response, while 23 patients were treated with long-acting release octreotide and 16 improved. The exact mechanism of action of SM-As has not yet been fully clarified. One possible mechanism could be a direct inhibition of insulin-like growth factor (IGF)-I mediated effects. A second mechanism could be an inhibition of the release of lymphokines and inflammatory mediators from T-lympocytes. Finally, SM-As may act directly on target cells through specific cell surface receptors. With the introduction from Novartis of SOM-230, a compound which binds with high affinity to SM-receptors (SM-Rs) subtypes 1, 2, 3 and 5, with lower affinity to SM-Rs 4, and which has a very favorable T1/2 of nearly 24 h, a much better therapeutic outcome is expected. Thus, SM-As may provide a well-tolerated therapeutic alternative to corticosteroids. However, prospective placebo-controlled studies with large numbers of patients are needed before their role in the treatment of Graves' opthalmopathy is definitely established.

Novel aspects of immunosuppressive and radiotherapy management of Graves' ophthalmopathy

Treatment of severe Graves' ophthalmopathy (GO) is a complex therapeutic challenge and, in spite of any efforts, about one third of patients are disappointed with the outcome of treatment. Glucocorticoids (GC), orbital radiotherapy (RT), or a combination of both, are most frequently used for their immunosuppressive effects. Novel immunosuppressive treatment procedures (or novel modalities of established treatments) are reviewed in the present article. GC has recently been used by the i.v. route and this treatment modality has been shown to be more effective and better tolerated than the oral route. Promising preliminary results have been reported by some authors with somatostatin analogs, octreotide and lanreotide. The number of patients treated so far is limited, most of the results have been obtained in nonrandomized or uncontrolled studies, and comparison with other validated methods of treatment is also needed. Because of the pathogenic role of cytokines, cytokine antagonists, currently evaluated in other autoimmune diseases, have been tested with positive results also in a small series of GO patients. The use of antioxidants might also be envisioned in the future, since in vitro studies have shown that oxygen free radicals might be involved in GO. Based on the shared antigen(s) theory, total thyroid ablation, by removing the bulk of shared antigens(s), might be beneficial for the course of GO. New data on recently performed placebo-controlled studies on orbital radiotherapy are discussed, together with studies on long-term safety of orbital radiotherapy.

Lack of effect of long-term octreotide therapy in severe thyroid-associated dermopathy

Severe thyroid associated dermopathy (TAD), a rare complication of Graves' disease, currently lacks effective treatment. Mediators of growth and inflammation, including insulin-like growth factor-1 (IGF-1) and somatostatin (SST) have been implicated in its pathogenesis. Octreotide, a potent SST analogue, has been used in TAD with anecdotal success. Therefore, we evaluated the efficacy of long-term octreotide therapy in moderate to severe TAD. Three obese women with TAD were studied. Baseline treatment included levothyroxine, methimazole, fluocinonide ointment under occlusive dressing, and physiotherapy for lymphedema. After establishing baseline clinical status, octreotide was started (300 microg subcutaneously daily) for 10 to 28 months. Studies obtained at baseline and every 3 months included: leg circumference, skin examination, clinical photography, self-reported clinical status, body mass index (BMI), serum thyrotropin (TSH) and free thyroxine, titers of antithyroidal and anti-TSH receptor antibodies. Minimal changes in the edema, erythema, skin texture and size of nodules were observed. The minor changes seen followed significant decreases in the patients' BMI, and hence, cannot be specifically attributed to octreotide administration. No clinically significant benefit from long-term octreotide therapy was demonstrated in three patients with moderate to severe TAD. Weight loss and measures such as compression bandaging and topical corticosteroid application still remain the most cost effective treatment modalities for TAD.

SPECT using 99mTc-DTPA for the assessment of disease activity in Graves' ophthalmopathy: a comparison with the results from MRI

Currently available methods for the estimation of disease activity in the orbits of patients with Graves' ophthalmopathy (GO) have the disadvantages of being either expensive or time consuming. The aim of this study was to develop a quick, reliable method using Tc labelled diethylenetriaminepentaacetic acid (DTPA) and four-headed single photon emission computed tomography (SPECT) for this purpose. The theoretical basis of the method is that the high capillarization and oedema in the orbit may be reflected on Tc-DTPA images in GO. SPECT data of 28 orbits of 14 patients with GO were compared with magnetic resonance imaging (MRI) T2 relaxation time scores. Based on the number of 'active' muscles with T2 relaxation times of more than 70 ms in a given orbit, an MRI score of 0 (no active muscle) to 4 (all rectus muscles active) was assigned to the orbit. With MRI, 18 orbits were inactive, and 10 were active. Thirty minutes after the intravenous administration of 7 MBq.kg Tc-DTPA, 128 projections were acquired by a four-headed SPECT. On the sum of six transaxial slices containing the entire bulbar region of the skull, a triangle-like region of interest (ROI) was drawn (OR ROI). This ROI was 'slipped' to the right temporal region of the brain as reference site (B ROI). The count ratios of OR/B were calculated and compared to MRI score values. In the group of 18 inactive orbits (an MRI score of zero on both sides), in the transaxial plane, the mean OR/B value was 6.4+/-1.17, and in the group of 10 active orbits (an MRI score of 1-3) 8.30+/-2.08, the difference being significant (P <0.05). Tc-DTPA orbital SPECT is a promising method for the estimation of disease activity in the orbits of patients with Graves' ophthalmopathy.

Somatostatin receptor imaging

[(111)In-DTPA(0)]octreotide is a radiopharmaceutical with a great potential for the visualization of somatostatin receptor-positive tumors. The overall sensitivity of Somatostatin Receptor Imaging (SRI) to localize neuroendocrine tumors is high. In a number of neuroendocrine tumor types, as well as in Hodgkin's disease, inclusion of SRI in the localization or staging procedure may be very rewarding, either in terms of cost-effectiveness, patient management, or quality of life. The value of SRI in patients with other tumors, like breast cancer, or in patients with granulomatous diseases, has to be established. The development of Peptide Receptor Radionuclide Therapy (PRRT) is expected to stimulate peptide receptor imaging.

Medical treatment for thyroid-associated ophthalmopathy

The medical management of thyroid-associated ophthalmopathy has been, and remains a clinical challenge. Several drugs have been used. Systemic steroids seem to be beneficial in patients with active disease. The evidence for the remaining drugs reported to be potentially useful, is unconvincing.

Octreoscan in thyroid-associated ophthalmopathy

Until recently, there was no imaging technique available that could be considered as a reliable measure of inflammation in thyroid-associated opthalmopathy (TAO). Pentetreotide (a synthetic derivative of somatostatin) labeled with 111In has been used to visualize somatostatin receptors in endocrine-related tumours in vivo. It has also been used to measure the orbital uptake in patients with TAO. An increased uptake in the orbit was found in patients with active disease. It was suggested that it is caused by the expression of somatostatin receptors on activated T-lymphocytes. Thus, a positive orbital octreoscan indicates clinically active eye disease in which immunosuppressive treatment might be of therapeutic benefit, in contrast to the fibrotic end stage. Indeed, successful immunosuppression with prednisone, orbital irradiation, or very recently with somatostatin analogues, has been demonstrated in patients with TAO and positive octreoscan. It is inferred that an orbital octreoscan is mainly indicated to select patients with TAO who will benefit from immunosuppression. However, limitations such as cost, nonnegligible radiation burden, nonspecific examination for TAO, and finally, lack of evaluation of eye muscle swelling restrict the widespread use of this technique. It remains to be seen if orbital octreoscan will become a widely available tool in the management of patients with TAO.

[Therapy with somatostatin analogs in patient with orbitopathy and positive Octreoscan]

We prospectively evaluated 28 persons with active endocrine ophthalmopathy and positive sonographic criteria (A-mode) on extraocular eye muscles. To evaluate somatostatin-receptor status SPECT of the orbits was performed with a double-headed rotating gamma camera after application of 110 MBq 111-In-Pentreotide. 9 patients (12/56 eyes respectively) showed a marked uptake ratio (> 2 in circular ROIs by semiquantitative calculation) and were selected for lanreotide (30 mg i.m. every 14 d) treatment. 5 individuals had control scan after clinical progression which became positive in two of them. All but one tolerated modest side-effects of lanreotide treatment (diarrhea). Therapy was discontinued after 3-10 months when thyroid eye disease had lead to fibrotic stage. This subgroup, with the exception of two women, who received corticosteroids additionally, presented stable disease. One of those had to be sent to surgery because of endangered optical nerve. Clinical ophthalmological control showed promising results in patients receiving somatostatin analogues at early stage when positive on octreo-scan.

Serum levels of tumor necrosis factor-alpha, soluble intercellular adhesion molecule-1, soluble vascular cell adhesion molecule-1, and soluble interleukin-1 receptor antagonist in patients with thyroid eye disease undergoing treatment with somatostatin analogues

The aim of this prospective, randomized study was to investigate the serum levels of tumor necrosis factor-alpha (TNF-alpha), soluble intercellular adhesion molecule-1 (sICAM-1), soluble vascular cell adhesion molecule-1 (sVCAM-1), and soluble interleukin-1 receptor antagonist (sIL-1RA) in patients with thyroid eye disease (TED) before and 1 and 3 months after treatment with somatostatin analogues (SM-a). Thirty patients, all with signs and symptoms of TED, were studied. Twenty-two patients (13 females) had active eye disease with a clinical activity score (CAS) > or = 4 (patients with active disease [PA]) and 8 patients (5 females) had inactive TED with CAS < or = 3 (patients with inactive disease [PI]). All PA patients had a positive orbital octreoscan, whereas PI patients had a negative one. Fifteen patients from the PA group were selected randomly and received SM-a (PA-S subgroup), while the remaining 7 patients were used as control subgroup (PA-C), received neither therapy, nor placebo. From the 15 patients who received SM-a (PA-S), 6 received octreotide (OCT) and 9 lanreotide (LRT). TED was reevaluated using the CAS 1 and 3 months after the initiation of SM-a treatment. Ten healthy individuals (6 females) were used as controls (group C). We found an increase in the basal levels of TNF-alpha (14.2 +/- 7.1 pg/mL), sICAM-1 (809.1 +/- 167.0 ng/mL), and sIL-1RA (542.1 +/- 259.0 pg/mL) in PA patients as a total group compared with the PI (1.6 +/- 1.9, 676.8 +/- 73.4, 267.6 +/- 152.8, respectively) group and C (1.9 +/- 1.4, 598.0 +/- 126.2, 258.6 +/- 155.1, respectively). The basal levels of TNF-alpha (13.3 +/- 8.3 pg/mL) and sIL-1RA (533.7 +/- 308.9 pg/mL) in PA-S as well as in PA-C (16.0 +/- 2.9, 560.2 +/- 107.3, respectively) subgroups were also increased compared with PI patients and C (1.9 +/- 1.4 and 258.6 +/- 155.1, respectively). The same was true for sICAM-1 when baseline levels compared with C (817.1 +/- 187.3 and 791.9 +/- 123.5, respectively vs. 598.0 +/- 126.2 ng/mL). After SM-a, serum levels of sICAM-1 and sVCAM-1 were decreased significantly 1 (781.2 +/- 205.9, 1,193.5 +/- 511.8 ng/mL) and 3 months (786.8 +/- 199.6, 1,122.1 +/- 225.3 ng/mL) after the initiation of treatment. In conclusion, serum levels of TNF-a, sICAM-1, and sIL-1RA were elevated in patients with active TED compared to controls. Furthermore, sICAM-1 and sVICAM-1 levels declined during the treatment with SM-a in patients with active TED.

Somatostatin-receptor scintigraphy in Graves' disease: reproducibility and variance of orbital activity

Somatostatin-receptor (SSTR) scintigraphy using the single photon emission computed tomography (SPECT) technique allows the assessment of orbital inflammation in patients with Graves' disease. Previous studies showed differences in orbital octreotide uptake already 4 hr after injection. In this study, analysis of inter-/intra-observer variance and reproducibility in the evaluation of orbital SPECT images was performed. First, SPECT data of one representative female patient with clinically active Graves' ophthalmopathy (GO), obtained 4 hr after intravenous injection of 110 MBq 111In-pentetreotide and processed by filtered backprojection, were analyzed. Transverse SPECT images were reconstructed, an optimal orbital image was selected and predetermined regions of interests (ROIs) for both orbits were positioned by three independent observers 15 to 19 times each. In a second step, SPECT data of 8 different patients with GO were evaluated in the same manner by four independent observers 3 to 4 times each. Variance component partitioning was used to compare the order of intra- and inter-observer variation. For the right and the left orbit, the inter-observer variance proportion was 90% and 79%, whereas intra-observer variance partition was 10% and 21%, respectively. The corresponding ratios 0.11 and 0.27 summarize the comparison of sources of variance. The overall reliability was 84%, representing the patients influence on the total variance. Intra-observer reliability for both orbits was 88%, 89%, 97% and 98% (mean over orbits), respectively for observers I to IV. Using the Spearman Brown prophecy formula it follows that two replications per patient are sufficient to ensure a minimum reproducibility of 90%, which is also confirmed by the low intra-observer variation. Furthermore, intra-class correlation as a measure of (multiple) observer reproducibility was 94%. In conclusion, due to the increased inter-observer variance proportion and the high variation in intra-observer reliability, evaluations of orbital SSTR scintigraphy have to be done by the same and experienced observer leading to comparable data. But an automatic and quantitative computerized technique for evaluation of these SPECT data should be exactly reproducible and probably lead to more accurate and representative results.

An evidence-based approach to the treatment of Graves' ophthalmopathy

A recent survey demonstrated considerable controversy about the therapeutic approach to a patient with Graves' ophthalmopathy. Among various reasons for this disagreement is the lack of an accepted way to assess the outcome of a given therapeutic intervention. An evidence-based approach requires an objective and meaningful assessment of therapeutic outcomes in prospective, randomized studies in which confounding factors (e.g., smoking, disease activity, and state of the thyroid) are accounted for and controlled. On the basis of the available studies, a treatment approach can be selected.

Assessment of disease activity in Graves' ophthalmopathy by orbital ultrasonography and clinical parameters

OBJECTIVE

To study if A-mode ultrasonography (US) in combination with the Clinical Activity Score (CAS) and duration of Graves' ophthalmopathy (GO) could predict the response to immunosuppression in Graves' ophthalmopathy.

DESIGN

A prospective clinical study.

PATIENTS AND METHODS

Fifty-six consecutive patients with moderately severe GO were treated with retrobulbar irradiation (10 fractions of 2 Gy). Before treatment the internal reflectivity in the extraocular eye muscles, the CAS, and the duration of Graves' ophthalmopathy were assessed and related to the therapeutic outcome 26 weeks after irradiation.

RESULTS

Twenty-eight (50%) of the patients responded favourably to radiotherapy (four patients became worse, and 24 did not change), and the eye muscle echogenecity indeed tended to be lower in the responders than in the non-responders (P = 0.09). From a receiver operator characteristics curve, a cut-off value of 30% yielded a good positive predictive value of 85%, but the negative predictive value was only 60%. The CAS (>/= 4/10) had a positive predictive value of 65%, and a negative predictive value of 56%. When combining the ultrasound with the CAS, the positive predictive value increased to 74% and the negative predictive value to 72%. Adding the duration of eye symptoms (cut-off 18 months), the prediction of response further improved: positive predictive value 79%, and negative predictive value 89%.

CONCLUSIONS

A-mode ultrasonography has a rather good positive predictive value, but its poor negative predictive value precludes its use as sole activity parameter. By adding the Clinical Activity Score and duration of Graves' ophthalmopathy, the negative predictive value increased considerably. By using this combination, inactive disease can be identified more precise, permitting rehabilitative surgery at an earlier stage in these patients.

Radiotherapy for Graves' orbitopathy: randomised placebo-controlled study

BACKGROUND

The best treatment (steroids, irradiation, or both) for moderately severe Graves' orbitopathy, a self-limiting disease is not known. We tested the efficacy of external beam irradiation compared with sham-irradiation.

METHODS

In a double-blind randomised clinical trial, 30 patients with moderately severe Graves' orbitopathy had radiotherapy (20 Gy in ten fractions), and 30 were assigned sham-irradiation (ten fractions of 0 Gy). Treatment outcome was measured qualitatively by changes in major and minor criteria and quantitatively in several ophthalmic and other variables, such as eyelid aperture, proptosis, eye movements, subjective eye score, and clinical-activity score at 24 weeks.

FINDINGS

The qualitative treatment outcome was successful in 18 of 30 (60%) irradiated patients versus nine of 29 (31%) sham-irradiated patients at week 24 (relative risk [RR]=1.9 [95% CI 1.0-3.6], p=0.04). This difference was caused by improvements in diplopia grade, but not by reduction of proptosis, nor of eyelid swelling. Quantitatively, elevation improved significantly in the radiotherapy group, whereas all other variables remained unchanged. The field of binocular single vision was enlarged in 11 of 17 patients after irradiation compared with two of 15 after sham-irradiation. Nevertheless, only 25% of the irradiated patients were spared from additional strabismus surgery.

INTERPRETATION

In these patients with moderately severe Graves' orbitopathy, radiotherapy should be used only to treat motility impairment.

Management of Graves' ophthalmopathy: reality and perspectives

Graves' ophthalmopathy is an debilitating disease impairing the quality of life of affected individuals. Despite recent progress in the understanding of its pathogenesis, treatment is often not satisfactory. In mild cases, local therapeutic measures (artificial tears and ointments, sunglasses, nocturnal taping of the eyes, prisms) can control symptoms and signs. In severe forms of the disease (3-5%), aggressive measures are required. If the disease is active, high-dose glucocorticoids and/or orbital radiotherapy, or orbital decompression represent the mainstay of treatment. If the disease is severe but inactive, orbital decompression is preferred. Novel treatments such as somatostatin analogs or intravenous immunoglobulins are under evaluation. Rehabilitative (extraocular muscle or eyelid) surgery is often needed after treatment and inactivation of eye disease. Correction of both hyper- and hypothyroidism is crucial for the ophthalmopathy. Antithyroid drugs and thyroidectomy do not influence the course of the ophthalmopathy, whereas radioiodine treatment may cause the progression of preexisting ophthalmopathy, especially in smokers. The exacerbation, however, is prevented by glucocorticoids. In addition, thyroid ablation may prove beneficial for the ophthalmopathy in view of the pathogenetic model relating eye disease to autoimmune reactions directed against antigens shared by the thyroid and the orbit.