Thyroid Associated Orbitopathy

1. 10thAsia and Oceania Thyroid Association Congress October 21-23, 2012 Thyroid Associated Orbitopathy Yuji Hiromatsu, M.D., Ph.D. Division of Endocrinology and Metabolism, Department of Medicine, Kurume University School of Medicine, Kurume, Japan 1

2. 10thAsia and Oceania Thyroid Association Congress October 21-23, 2012 Thyroid Associated Orbitopathy • Pathogenesis • Role of MRI • Treatment Yuji Hiromatsu, M.D., Ph.D. Division of Endocrinology and Metabolism, Department of Medicine, Kurume University School of Medicine, Kurume, Japan 2

3. Secondary impairment Site Primary Müller’s muscle Eyelid 上眼瞼挙筋 Lev palpebrae sup 上眼瞼挙筋 Conj. Lid retraction Abnormal Secretion of Lacrimal fluid Extra- ocular Muscle Lacrimalgland 涙腺 Cornea Optic Nerve Retina 脂肪組織 Orbital connectivetissue Proptosis ExtraocularMuscle 外眼筋 外眼筋

4. Morbus Basedow Graves’ disease Genetic factor Enviromental factor Breakdown of immunological tolerance Robert James Graves TRAb (1796~1853) Carl von Basedow 25~50% (1799~1854) 80~90% Hyperthyroidism Graves’ ophthalmopathy Pretibial myxedema (Thyroid associated orbitopathy)

5. Enlargement of eye muscle Increase of orbital fat tissue P < 0.05 P < 0.05 P < 0.05 1400 2500 P < 0.05 1200 2000 1000 Enlargement of eye muscles（mm2) 1500 800 Orbital fat volume (mm2) 600 1000 400 500 200 0 0 ー ＋ ー ＋ ー ＋ ー ＋ IL-4 IL-6 IL-10 TNFαgene expression in eye muscle tissue Cytokine gene expression in orbital fat tissue （Hiromatsu et al.： JCEM 85:1194, 2000）

6. Expression of TSH-R mRNA in the orbit RT-PCR TSH-R （1.2kb） TSH-R (296 bp) In situ hybridization sense anti-sense (Hiromatsu et al. Thyroid 6: 553, 1996)

7. Gene Array Studies sFRP-1 (secreted frizzled related protein-1) (Kumar et al.: JCEM 90:4730, 2005)

8. sFRP-1 (100 nM)induced adiponectin mRNA (A), leptin mRNA (B), and TSHr mRNA (C)expression on orbital fibroblasts sFRP-1 (secreted frizzled related protein-1) (Kumar, S. et al. J Clin Endocrinol Metab 2005;90:4730-4735) sFRP-1 induces adipogenesis and expression of TSHR on orbital fibroblasts.

9. Peroxisome Proliferator-Activated Receptor-g in Thyroid Eye Disease: Contraindicaiton for Thiazolidinedion Use? (Starkey et al: J Clin Endocrinol Metab 88: 55-59, 2003) 57 yr-old male, 8-yr history of type 2 DM Pioglitazone30mg/d for 3 months 6wk pre 3m on 3m stop Proptosis rt 19mm 21 20 lt 20 23 22 Conj. Redness (-) mild (-) Lid swelling Mild Severe Severe Diplopia (-) Intermittent (-) CAS 6 2

10. Thiazolidinedione induced Graves’ ophthalmopathy • Starkey K, Heufelder A, Baker G, Joba W, Evans M, Davies S, Ludgate M.： Peroxisome proliferator-activated receptor-gamma in thyroid eye disease: contraindication for thiazolidinedione use? J Clin Endocrinol Metab.2003;88:55–9. • Levin F, Kazim M, Smith TJ, Marcovici E.： Rosiglitazone-induced proptosis. Arch Ophthalmol.2005;123:119–21. • Dorkhan M, Lantz M, Frid A, Groop L, Hallengren B.： Treatment with a thiazolidinedione increases eye protrusion in a subgroup of patients with type 2 diabetes. Clin Endocrinol (Oxf).2006;65:35–9. • Lee S, et al.： Thiazolidinedione induced thyroid associated orbitopathy. BMC Ophthalmol.2007; 7: 8.

11. Orbital fibroblasts CD34+ fibrocytes TSHR Ab IGF-1R Ab serum + IL-1b IFNg TGFb TNFa Adipogenesis Glycosaminoglycans short chain hyaluronan long chain hyaluronan ＋ IL-6 IL-8 TSHR Ab IGF-1R Ab PPARg _ TGFb TNFa TSHR↑ IGF-1R↑ proliferation CD34+OF preadipocytes CD34-OF IL-16 RANTES CXCL10 HLA B7 CD40 CD40L Orbit IL-1a IL-8 COX-2 CXCL12 T cell IL-6 TNFa T cell CXCR4 TCR Cytokine Th1, Th2 B cell activation Migration of T cells Th1-：Leukoregulin,TNFα, IL-1β, INFβ, INFγ, IL-2, IL-12 Th2-：IL-4, IL-5, IL-10 Macrophages IL-1 TNFa TGFb Antibody IGF-1R Ab TSHR Ab

12. CD90 (Thy-1)+ orbital fibroblasts may differentiate into myofibroblasts, that participate in the development of fibrosis in late stages of the disease. Thy-1+ OF TGF-β Myofibroblast Expanded Adipose tissues Bahn R.S: N Engl J Med 2010; 362:726-738. Extraocular muscle enlargement Elevated TRAb Fibrosis

13. Relationships between anti-TSH receptor antibidies and GO • TRAB ( 1st generation; TBII) • TRAb (2nd generation; hTRAb; TRAb-CT) • TRAb (3rd generation; M22) • TSAb • TSI [Mc4; chimeric TSH-R (amino acid residues 262-335 of human TSH-R replaced by rat LH-R)]

14. Anti-TSH receptorAntibodies • At the first visit, there is no difference in the prevalence of TRAb between GO and GD without ophthalmopathy. TSH-Rantibodies GO（＋） GO（ー） Normal TBII 67%85%0% TSAb 59%83%0% • In GO patients there are significant correlation between TRAb and the enlargement of eye muscle. T S A Enlargement of EM b TBII Enlargement of EM (Nishikawa et al., Acta Endocrinol 129: 213, 1993) (Hiromatsu et al., Thyroid 6: 553, 1996)

15. Anti-TSHreceptor antibody in GO Mild GO Severe GO

16. The novel chimeric(Mc4) TSH-R (amino acid residues 262-335 of human TSH-R replaced by rat LH-R)

17. A novel thyroid stimulating immunoglobulin assay chimeric (Mc4) TSH-R (amino acid residues 262-335 of human TSH-R replaced by rat LH-R) TSI level of GO was greater than that of Graves’ disease without ophthalmopathy. Majority of patients with GD had undergone antithyroid treatment and were rendered euthyroid at the time of blood sampling.

18. Correlation of the thyroid stimulating lgs in GO with clinical disease activity.

19. Greves’ ophthalmopathy Enviromental factors Genetic factors EM antigens G2s HLATNFa ICAM-1 NFkB1 FOXP3 CTLA-4 CD40 PTPN22 Inflammation / fibrosis 1D Anti-EM Ab smoking SDH Severe Calsequestrin Th1, Th2 cytokines Collagen XIII Breakdown of immune tolerance IGF-1R Ab IGF-1receptor↑ Mild adipogenesis TSH receptor ↑ sFRP-1, CYR61 Tg TSI Anti-TSH receptor Abs G2s TSH receptor 1D Hyperthyroidism (Graves’ disease) Th2 thyroiditis Tg Shared antigens Between thyroid and orbit

20. TNF-α gene polymorphism (T-1031C) and GO （日本人） genotype Allele frequency n TT TC CC T COR GO GD w/o oph 62 111 28 (45.2) 81 (73.0) 29 (46.7) 30 (27.0) 5 (8.1) 0 (0) 85 (68.5) 192 (86.5) 39* (31.5) 30 (13.5) 2.9 ＊P=0.0001 The C allele frequency is higher in GO patients. （Kamizono et al. Clin Endocrinol 2000; 52:759-764.)

21. ICAM-1 gene polymorphism Ｋ４６９Ｅ (1405 A→G) Genotype frequency Allele frequency ATA class ＡＡ ４６ ７２ （％） （４９） （３６） ＧＡ ３６ ９９ （％） （３９） （４９） ＧＧ １１ ３０ （％） （１２） （１５） 　Ａ　（％） １２８（６９） ２４３（６０）　 　Ｇ　（％） 　５８（３１） １５９（４０） OR 1.44 ｃｌａｓｓ ⅢーⅥ ｃｌａｓｓ ０－Ⅱ χ2=4.925 P=0.0852 χ2=3.825 P=0.0505 OR 1.75 GA + GG　（％） 　４７（５１） １２９（６４） （％） （４９） （３６） ＡＡ ４６ ７２ ｃｌａｓｓ ⅢーⅥ ｃｌａｓｓ ０－Ⅱ χ2=4.643 P=0.0312 The ＡＡ genotype frequency is higher in severe GO .

22. NFkB1 gene polymorphism（-94del ATTG） Genotype frequency Allele frequency ATA class N Del (%) Hetero (%) Ins (%) Del (%) Ins (%) ５９（４８％） ３９（３２％） Ⅲ～Ⅵ １２３ ２５（２０％） １３７（５６％） １０９（４４％） ０～Ⅱ ３０１ ３８（１３％） １３２（４４％） １３１（４３％） ２０８（３５％） ３９４（６５％） χ2=7.103 P=0.0077 OR 1.51 χ2=6.853 P=0.0325 OR 1.76 The -94delATTG polymorphism of the NFkB1 gene is higher in severe GO.

23. PPARγ （Pro12Ala)gene polymorphism Genotype Allele ATA class N ＣＣ (%) ＣＧ (%) GG (%) Ｃ (%) Ｇ (%) 　３（１３％） 　０（０％） Ⅲ～Ⅵ １２３ １２０（３１％） 　３（１１％） ２４３（３０％） ２９４ ２７１（６９％） ２１（８７％） ２（100％） ５６３（７０％） ２５（８９％） ０～Ⅱ Χ２＝4.439 P = 0.1087 Fisher’s exact probability test P = 0.0328 OR 3.59 Χ２＝4.430 P = 0.0381 OR 3.39 Patients with ＣＣ genotypefrequently have severe ophthalmopathy.

24. Summary (1) TSH receptor is a primary autoantigen in GO. Recent study suggests the presence of GO specific TRAb (Mc4)? The increase of TSH receptor expression through adipogenesis is important in the pathogenesis of GO. 3. CD34+ fibroblasts, which are derived from peripheral blood and expand in the orbit, express TSH receptor in high level.

25. 4. The increase of IGF-1 receptor expression in the orbital fibroblasts may also be important. Activation of IGF-1R leads secretion of IL-16 and RANTES on CD34-fibroblasts, which enhance recruitment of activated T lymphocytes. CD90 (Thy-1)+ orbital fibroblasts may differentiate into myofibroblasts that participate in the development of fibrosis in late stages of the disease. Gene polymorphisms of the immunomodulator genes (such as TNFa, ICAM-1, NFkB, PPARg and FOXP3 etc) have been proposed as the susceptibility genes for GO. The significance of the presence of anti-eye muscle antibodies, such as SDH, CASQ needs to be confirmed.

26. Thyroid Associated Orbitopathy • Pathogenesis • Role of MRI • Treatment

27. NOSPECS classification of eye changes of Graves’ disease (Thyroid 2:235, 1992)

28. NOSPECS classification of eye changes of Graves’ disease (Thyroid 2:235, 1992) 50~75% of patients with Graves’ disease do not have any signs or symptoms of GO. MRI 70%

29. Occult Thyroid Eye Disease Occult thyroid eye disease Case 1 Case 2 No physical signs or symptoms Enlargement of extra-occular muscles

30. 2000 eyes (%) Inoue et al. MRI

31. Dalrymple sign (lid retraction) Case 3 Case 4

32. Ｒ Ｌ Ｒ Ｌ von Graefe’s sign Case 5 Case 6

33. Ｒ Ｌ Ｒ Ｌ Unilateral lid retraction Case 7 Case 8

34. 2000 eyes (%) Inoue et al. MRI

35. Swelling of upper and lower eyelid Case 9

36. Untreated Graves’ disease Symptoms 24.2% Hertelexophthalmometer mild 39% total 57% moderate　１3% severe 5% GO patients (4598 eyes) total 85% mild 39% moderate 33% severe 13% Proptosis alone 18.5% + lid lag 46.2% + lid swelling 19.0% + lid lag and lid swelling 16.3% Male 444 eyes female 1556 eyes Japanese MRI

37. Proptosis R) 17.0 mm L) 17.0 mm R) 13.0 mm L) 13.0 mm R) 19.0 mm L) 19.0 mm R) 28.5 mm L) 30.5 mm

38. Proptosis 18mm~<21mm Proptosis ≥21mm Case 11 Case 13 + lid swelling Case 12 Case 14 + lid swelling + lid retraction

39. 2000 eyes (%) Inoue et al. MRI

40. Diplopia Case 15 Restriction of motion in upward gaze Vertical deviation of right eye Enlargement of right inferior rectus muscle

41. Papilledema Papillitis Optic disc atrophy 2000 eyes (%) Inoue et al. MRI

42. He complains orbital ache and decreased visual acuity. Eyelid swelling Eyelid eythema Conjunctival redness Proptosis Case 17 MRI:The enlargement of superior, inferior, medial and lateral rectus muscles may compress optic nerve. T2 immage: The increased T2 relaxation time indicates that GO is in active state.

43. Summary (2) MRI is useful for the assessment of GO. useful for planning of the management of GO. We strongly recommend MRI for management of GO.

44. Thyroid Associated Orbitopathy • Pathogenesis • Role of MRI • Treatment

45. Treatment of Graves’ ophthalmopathy All patients with GO NOSPECSClass0 NOSPECS ClassI~VI Restore euthyroid(avoid hypothyroidism) Urge smoking withdrawal Wait and see Occult thyroid eye disease Specialized center Ophtalmological examination, CAS, QOL Mild Moderate to severe Sight-threatening (DON） MRI MRI MRI i.v. GCs(±OR) Local measures Wait and see Progression Inactive Active Poor response (2 weeks) Inflammation of eye muscles Inflammation of Upper eyelids prompt decompression Stable & inactive i.v. GCs(±OR) Local injection of GCs or Botulinum toxin Still active Stable & inactive intractable Rehabilitative surgery (if needed) Rehabilitative surgery (if needed) Iv GCs (±OR) Rehabilitative surgery Immuno-suppressant , Decompression Stable & inactive

46. Sight-threating GO (DON) Dysthyroid optic neuropathy（DON）and/or Corneal breakdown Sight-threating GO (DTN) MRI i.v. Glucocorticoids Pulse therapy Poor response (2 weeks) methylpredonisolone 1g/d 3days3 cycles Prompt decompression Still active Stable and inactive 1w i.v. Glucocorticoids ( orbital radiation) Rehabilitative surgery

47. Pulse therapy Before After 3 cycles

48. Transantral orbital decompression for Papilledema（dysthyroid optic neuropathy) Papilledema pre 6 months after the surgery post

49. Moderately to severe GO MRI active inactive i.v. Glucocorticoids ( orbital radiation) Rehabilitative surgery Stable and inactive

50. Prediction of outcome of Immunosuppressive treatment Rehabilitative therapy Immunosuppressive therapy Immunosuppressive therapy Activity Activity Severity Severity Outcome Outcome