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Verrienti M, Gagliardi I, Valente L, Stefanelli A, Borgatti L, Franco E, Galiè M, Bondanelli M, Zatelli MC, Ambrosio MR. Late orbital radiotherapy combined with intravenous methylprednisolone in the management of long-lasting active graves' orbitopathy: a case report and literature review. Endocrine 2024; 85:576-583. [PMID: 38517640 PMCID: PMC11291534 DOI: 10.1007/s12020-024-03788-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 03/15/2024] [Indexed: 03/24/2024]
Abstract
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.
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Affiliation(s)
- Martina Verrienti
- Section of Endocrinology, Geriatrics & Internal Medicine, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Irene Gagliardi
- Section of Endocrinology, Geriatrics & Internal Medicine, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Luisa Valente
- Unit of Cranio Maxillo Facial Surgery, Center for Craniofacial Deformities & Orbital Surgery-Reference Center for Rare Disease, St. Anna University Hospital of Ferrara, Ferrara, Italy
| | - Antonio Stefanelli
- Department of Radiation Oncology, St. Anna University Hospital of Ferrara, Ferrara, Italy
| | - Luca Borgatti
- Neuroradiology Unit, Department of Neuroscience and Rehabilitation, St. Anna University Hospital of Ferrara, Ferrara, Italy
| | - Elena Franco
- Operational Unit of Ophthalmology, St. Anna University Hospital of Ferrara, Ferrara, Italy
| | - Manlio Galiè
- Unit of Cranio Maxillo Facial Surgery, Center for Craniofacial Deformities & Orbital Surgery-Reference Center for Rare Disease, St. Anna University Hospital of Ferrara, Ferrara, Italy
| | - Marta Bondanelli
- Section of Endocrinology, Geriatrics & Internal Medicine, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Maria Chiara Zatelli
- Section of Endocrinology, Geriatrics & Internal Medicine, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Maria Rosaria Ambrosio
- Section of Endocrinology, Geriatrics & Internal Medicine, Department of Medical Sciences, University of Ferrara, Ferrara, Italy.
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Stoynova MA, Shinkov AD, Novoselski MT, Petrova VV, Dimitrova ID, Yankova IA, Kovatcheva RD. Changes in therapeutic response, ocular manifestations of Graves' orbitopathy and quality of life during the first year after orbital radiotherapy. Int Ophthalmol 2023; 43:4305-4314. [PMID: 37561249 DOI: 10.1007/s10792-023-02842-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 07/27/2023] [Indexed: 08/11/2023]
Abstract
PURPOSE The aim of our study was to assess the changes in the therapeutic response, ocular manifestations of GO and quality of life during the first year after OR. METHODS The study involved 26 consecutive patients with active moderate-to-severe GO indicated for OR, 18 females, mean age 57 ± 12.5. At baseline, all patients underwent comprehensive ocular examination and thyroid hormone and antibody testing. Then, OR was performed with a total dose of 20 Gy, divided into 10 sessions of 2 Gy each with concomitant oral intake of low-dose glucocorticoids. Therapeutic response and individual ocular manifestations were evaluated 1, 3, 6 and 12 months after OR, and QoL-at 3, 6 and 12 months by a disease-specific questionnaire. RESULTS One month after OR, 61.6% of patients had a therapeutic response (full or partial). During the follow-up, the proportion of full-responders gradually increased up to 57.5% at 12 months, while that of non-responders gradually decreased, reaching 11.5% at 12 months. All individual ocular manifestations improved significantly 1-3 months after OR. QoL related to visual functioning increased significantly at 6 months, whereas QoL related to appearance improved significantly at 12 months. CONCLUSIONS The vast majority of our patients with active moderate-to-severe GO exhibited full or partial therapeutic response after OR. The initial effect on the therapeutic response and individual ocular parameters was evident as soon as 1-3 months after the procedure. OR also has a beneficial effect on patients' QoL. TRIAL REGISTRATION NUMBER NCT05775185/07.03.2023, retrospectively registered.
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Affiliation(s)
- Mariya Asenova Stoynova
- Department of Endocrinology, Medical University of Sofia, University Hospital of Endocrinology, 2 Zdrave Str., 1431, Sofia, Bulgaria.
| | - Alexander Dimitrov Shinkov
- Department of Endocrinology, Medical University of Sofia, University Hospital of Endocrinology, 2 Zdrave Str., 1431, Sofia, Bulgaria
| | - Miroslav Todorov Novoselski
- Department of Radiooncology, Medical University of Sofia, University Hospital "Tsaritsa Yoanna", Sofia, Bulgaria
| | | | - Inna Dimitrova Dimitrova
- Department of Endocrinology, Medical University of Sofia, University Hospital of Endocrinology, 2 Zdrave Str., 1431, Sofia, Bulgaria
| | - Inna Angelova Yankova
- Department of Endocrinology, Medical University of Sofia, University Hospital of Endocrinology, 2 Zdrave Str., 1431, Sofia, Bulgaria
| | - Roussanka Dimitrova Kovatcheva
- Department of Endocrinology, Medical University of Sofia, University Hospital of Endocrinology, 2 Zdrave Str., 1431, Sofia, Bulgaria
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Lu TJ, Amarikwa L, Sears CM, Kossler AL. Advances in the Treatment of Thyroid Eye Disease Associated Extraocular Muscle Myopathy and Optic Neuropathy. Curr Neurol Neurosci Rep 2022; 22:313-325. [PMID: 35614367 PMCID: PMC10812872 DOI: 10.1007/s11910-022-01194-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2022] [Indexed: 11/03/2022]
Abstract
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.
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Affiliation(s)
- Tracy J Lu
- Department of Ophthalmology, Byers Eye Institute, Stanford University School of Medicine, 2452 Watson Court, Palo Alto, CA, 94303, USA
| | - Linus Amarikwa
- Department of Ophthalmology, Byers Eye Institute, Stanford University School of Medicine, 2452 Watson Court, Palo Alto, CA, 94303, USA
| | - Connie M Sears
- Department of Ophthalmology, Byers Eye Institute, Stanford University School of Medicine, 2452 Watson Court, Palo Alto, CA, 94303, USA
| | - Andrea L Kossler
- Department of Ophthalmology, Byers Eye Institute, Stanford University School of Medicine, 2452 Watson Court, Palo Alto, CA, 94303, USA.
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Jiang C, Deng Z, Huang J, Deng H, Tan J, Li X, Zhao M. Monitoring and Predicting Treatment Response of Extraocular Muscles in Grave's Orbitopathy by 99mTc-DTPA SPECT/CT. Front Med (Lausanne) 2021; 8:791131. [PMID: 34977092 PMCID: PMC8716578 DOI: 10.3389/fmed.2021.791131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 11/15/2021] [Indexed: 11/30/2022] Open
Abstract
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.
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Affiliation(s)
- Chengzhi Jiang
- Department of Nuclear Medicine, Xiangya Hospital, Central South University, Changsha, China
- Department of PET-CT Center, Hunan Cancer Hospital/The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
| | - Zilong Deng
- Department of Nuclear Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Jin Huang
- Department of Nuclear Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Haoyu Deng
- Department of Nuclear Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Jia Tan
- Department of Ophthalmology, Xiangya Hospital, Central South University, Changsha, China
| | - Xinhui Li
- Department of Nuclear Medicine, Xiangya Hospital, Central South University, Changsha, China
- *Correspondence: Xinhui Li
| | - Min Zhao
- Department of Nuclear Medicine, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center of Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
- Min Zhao
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Sobel RK, Aakalu VK, Vagefi MR, Foster JA, Tao JP, Freitag SK, Wladis EJ, McCulley TJ, Yen MT. Orbital Radiation for Thyroid Eye Disease: A Report by the American Academy of Ophthalmology. Ophthalmology 2021; 129:450-455. [PMID: 34895729 DOI: 10.1016/j.ophtha.2021.10.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 10/27/2021] [Accepted: 10/29/2021] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To review the current literature on the safety and efficacy of orbital radiation for the management of thyroid eye disease (TED). METHODS A literature search was conducted last in February 2021 of the PubMed database to identify all articles published in the English language on original research that assessed the effect of orbital radiation on TED. The search identified 55 articles, and 18 met the inclusion criteria for this assessment. A panel methodologist then assigned a level of evidence rating for each study, and all of them were rated level III. RESULTS Two large retrospective studies demonstrated the efficacy of radiation treatment, with or without corticosteroid use, in preventing or treating compressive optic neuropathy (CON). Three studies highlighted the role of orbital radiation therapy (RT) to facilitate the tapering of corticosteroids. Several other studies showed a possible role for RT to improve diplopia and soft tissue signs. CONCLUSIONS Although no level I or level II evidence exists, the best available evidence suggests that orbital radiation, used with or without corticosteroids, is efficacious in preventing CON, improving motility restriction, and decreasing clinical activity in TED. Orbital radiation also may facilitate a corticosteroid taper. Together, these studies show that RT seems to modify the active phase of TED. Short-term risks of orbital radiation are minor, but long-term outcome data are lacking.
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Affiliation(s)
- Rachel K Sobel
- Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Vinay K Aakalu
- Illinois Eye and Ear Infirmary, University of Illinois College of Medicine at Chicago, Chicago, Illinois
| | - M Reza Vagefi
- Department of Ophthalmology, University of California San Francisco, San Francisco, California
| | - Jill A Foster
- Ophthalmic Surgeons and Consultants of Ohio, Columbus, Ohio
| | - Jeremiah P Tao
- Gavin Herbert Eye Institute, University of California, Irvine School of Medicine, Irvine, California
| | - Suzanne K Freitag
- Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts
| | - Edward J Wladis
- Ophthalmic Plastic Surgery, Lions Eye Institute, Department of Ophthalmology, Albany Medical Center, Albany (Slingerlands), New York
| | - Timothy J McCulley
- Ruiz Department of Ophthalmology and Visual Sciences, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Texas
| | - Michael T Yen
- Cullen Eye Institute, Baylor College of Medicine, Houston, Texas
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