Int J Thyroidol.  2017 Nov;10(2):102-106. 10.11106/ijt.2017.10.2.102.

Development of Graves' Ophthalmopathy after Radioactive Iodine Ablation Using Recombinant Human Thyrotropin for Incidentally Discovered Papillary Thyroid Carcinoma

• Park JS

• KMID: 2396814
• DOI: http://doi.org/10.11106/ijt.2017.10.2.102

Abstract

Several studies have revealed an association between radioactive iodine (RAI) therapy for Graves' disease and new or worsening Graves' ophthalmopathy. In the present case, thyroid papillary cancer was incidentally detected in a 43-year-old woman who was receiving medication for Graves' disease. This patient had undergone RAI ablation using recombinant human thyrotropin (rhTSH) after total thyroidectomy. The patient subsequently complained of a unilateral eyelid abnormality at approximately 6 months after the RAI ablation, and was diagnosed with bilateral Graves' ophthalmopathy after a thorough ophthalmological examination. I report this case for its interesting clinical features, rarity of occurrence and to highlight the importance of careful observation for appropriate management of Graves' ophthalmopathy developing or worsening after RAI ablation in differentiated thyroid cancer patients.

Keyword

Graves' ophthalmopathy; Thyroid cancer; Recombinant human thyrotropin; Radioactive iodine

MeSH Terms

Adult
Eyelids
Female
Graves Disease
Humans*
Iodine*
Thyroid Gland*
Thyroid Neoplasms*
Thyroidectomy
Thyrotropin*
Iodine
Thyrotropin

Figure

• 

  Fig. 1 Whole body planar I-123 scanning (A) and subsequent neck single photon emission computed tomography/computed tomography (B, C) reveal remnant thyroid tissue in the left thyroid bed.

• 

  Fig. 2 Sagittal (A), axial (B) and coronal computed tomography of the orbits reveal enlargement of the bilateral extraocular muscles.

Reference

1. Iyer S, Bahn R. Immunopathogenesis of Graves' ophthalmopathy: the role of the TSH receptor. Best Pract Res Clin Endocrinol Metab. 2012; 26(3):281–289.

2. Hiromatsu Y, Eguchi H, Tani J, Kasaoka M, Teshima Y. Graves' ophthalmopathy: epidemiology and natural history. Intern Med. 2014; 53(5):353–360.

3. Bahn RS. Graves' ophthalmopathy. N Engl J Med. 2010; 362(8):726–738.

4. Wiersinga WM, Bartalena L. Epidemiology and prevention of Graves' ophthalmopathy. Thyroid. 2002; 12(10):855–860.

5. Chong K. Thyroid eye disease: a comprehensive review. Hong Kong Fed Med Soc. 2010; 15:4–8.

6. Acharya SH, Avenell A, Philip S, Burr J, Bevan JS, Abraham P. Radioiodine therapy (RAI) for Graves' disease (GD) and the effect on ophthalmopathy: a systematic review. Clin Endocrinol (Oxf). 2008; 69(6):943–950.

7. Bartalena L, Marcocci C, Bogazzi F, Manetti L, Tanda ML, Dell'Unto E, et al. Relation between therapy for hyperthyroidism and the course of Graves' ophthalmopathy. N Engl J Med. 1998; 338(2):73–78.

8. Louvet C, De Bellis A, Pereira B, Bournaud C, Kelly A, Maqdasy S, et al. Time course of Graves' orbitopathy after total thyroidectomy and radioiodine therapy for thyroid cancer. Medicine (Baltimore). 2016; 95(48):e5474.

9. Tallstedt L, Lundell G, Torring O, Wallin G, Ljunggren JG, Blomgren H, et al. Occurrence of ophthalmopathy after treatment for Graves' hyperthyroidism. The Thyroid Study Group. N Engl J Med. 1992; 326(26):1733–1738.

10. Traisk F, Tallstedt L, Abraham-Nordling M, Andersson T, Berg G, Calissendorff J, et al. Thyroid-associated ophthalmopathy after treatment for Graves' hyperthyroidism with antithyroid drugs or iodine-131. J Clin Endocrinol Metab. 2009; 94(10):3700–3707.

11. Menconi F, Marino M, Pinchera A, Rocchi R, Mazzi B, Nardi M, et al. Effects of total thyroid ablation versus near-total thyroidectomy alone on mild to moderate Graves' orbitopathy treated with intravenous glucocorticoids. J Clin Endocrinol Metab. 2007; 92(5):1653–1658.

12. Moleti M, Violi MA, Montanini D, Trombetta C, Di Bella B, Sturniolo G, et al. Radioiodine ablation of postsurgical thyroid remnants after treatment with recombinant human TSH (rhTSH) in patients with moderate-to-severe graves' orbitopathy (GO): a prospective, randomized, single-blind clinical trial. J Clin Endocrinol Metab. 2014; 99(5):1783–1789.

13. Moleti M, Mattina F, Salamone I, Violi MA, Nucera C, Baldari S, et al. Effects of thyroidectomy alone or followed by radioiodine ablation of thyroid remnants on the outcome of graves' ophthalmopathy. Thyroid. 2003; 13(7):653–658.

14. Leo M, Marcocci C, Pinchera A, Nardi M, Megna L, Rocchi R, et al. Outcome of Graves' orbitopathy after total thyroid ablation and glucocorticoid treatment: follow-up of a randomized clinical trial. J Clin Endocrinol Metab. 2012; 97(1):E44–E48.

15. Stan MN, Bahn RS. Risk factors for development or deterioration of Graves' ophthalmopathy. Thyroid. 2010; 20(7):777–783.

16. Ergin AB, Saralaya S, Olansky L. Incidental papillary thyroid carcinoma: clinical characteristics and prognostic factors among patients with Graves' disease and euthyroid goiter, Cleveland Clinic experience. Am J Otolaryngol. 2014; 35(6):784–790.

17. Belfiore A, Russo D, Vigneri R, Filetti S. Graves' disease, thyroid nodules and thyroid cancer. Clin Endocrinol (Oxf). 2001; 55(6):711–718.

18. Kim SH, Jung SL, Moon WJ, Park MS, Kim YS, Lee HJ, et al. The prevalence of thyroid nodules and thyroid cancers in the Koreans: the nationwide data analysis of thyroid ultrasonography in 2004. J Korean Thyroid Assoc. 2009; 2(1):33–37.

19. van Zeijl CJ, Fliers E, van Koppen CJ, Surovtseva OV, de Gooyer ME, Mourits MP, et al. Thyrotropin receptor-stimulating Graves' disease immunoglobulins induce hyaluronan synthesis by differentiated orbital fibroblasts from patients with Graves' ophthalmopathy not only via cyclic adenosine monophosphate signaling pathways. Thyroid. 2011; 21(2):169–176.

20. Daumerie C, Boschi A, Perros P. Is recombinant human TSH a trigger for Graves' orbitopathy? Eur Thyroid J. 2012; 1(2):105–109.