de Keizer, Bart

Kalmann, Rachel

Laban, Kamil G

Utrecht University Repository

IMAGE OF THE MONTHZirconium-89 labelled rituximab PET-CT imagingof Graves’ orbitopathyBart de Keizer1 & Kamil G. Laban2,3 & Rachel Kalmann2Received: 21 August 2019 /Accepted: 4 November 2019 /Published online: 18 November 2019# The Author(s) 2019Zirconium-89 labelled rituximab PET-CTimaging of Graves’ orbitopathyGraves’ orbitopathy (GO) is the main extrathyroidal manifes-tation of Graves’ disease. A proportion of patients have mod-erate to severe orbital inflammation, with corneal ulceration,intense pain or even compressive optic neuropathy [1]. High-dose glucocorticoids (GCs) are the first-line treatment in thesepatients. When high-dose GCs fail to reduce the inflamma-tion, shared decision-making is recommended for selecting asecond-line treatment. Options for treatment include a secondcourse of intravenous GCs, oral GCs combined with orbitalradiotherapy, rituximab or watchful waiting [2]. Rituximabtreatment is not yet approved for clinical use in GO and rough-ly 50% do not have significant improvement 1 year after treat-ment [3]. In rheumatoid arthritis, zirconium-89-labelled ritux-imab (89Zr-rituximab) PET-CTshows promising clinical valuewith higher rates of response to therapy in patients with higher89Zr-rituximab uptake in responders than in non-responders[4]. 89Zr-rituximab PET scanning is approved by Dutch au-thorities to select patients for rituximab treatment and is usedin our hospital to select patients with orbital inflammatorydisease (including GO) that might benefit from rituximabtreatment. In a recent retrospective study, we showed that of4 patients with intense 89Zr-rituximab uptake in orbital inflam-matory disease, 3 patients responded well to rituximab treat-ment [5]. Here, we present a patient with GO refractory tointravenous GCs. PET-CT performed 3 days after 74 MBq89Zr-rituximab showed high uptake in orbital musculature.89Zr-rituximab binding more than in normal bone marrowand comparable to binding in normal lymph nodes was ob-served in thickened medial rectus muscle of the left eye(SUVmax 5.9) and the superior rectus muscle of the righteye (SUVmax 5.2) (Figure 1 A coronal CT reconstruction, Bcoronal PET-CT reconstruction, C axial PET-CT reconstruc-tion of right superior rectus muscle and D axial PET-CT re-construction of left medial rectus muscle). Because of high89Zr-rituximab uptake, rituximab treatment was initiated.This article is part of the Topical Collection on Image of the month.* Bart de Keizerb.dekeizer@umcutrecht.nl1 Department of Radiology and Nuclear Medicine, University MedicalCenter Utrecht, University Utrecht, Heidelberglaan 100, 3584, CXUtrecht, The Netherlands2 Department of Ophthalmology, University Medical Center Utrecht,University Utrecht, Utrecht, The Netherlands3 Laboratory of Translational Immunology, University Medical CenterUtrecht, University Utrecht, Utrecht, The NetherlandsEuropean Journal of Nuclear Medicine and Molecular Imaging (2020) 47:738–739https://doi.org/10.1007/s00259-019-04599-8Compliance with Ethical Standards The authors declare thatthey have no conflicts of interest.All procedures performed in studies involving human participantswere in accordance with the ethical standards of the institutional and/ornational research committee and with the 1964 Helsinki declaration andits later amendments or comparable ethical standards.Informed consent was obtained from the participant included in thestudy.2. Bartalena L, Baldeschi L, Boboridis K, Eckstein A, Kahaly GJ,Marcocci C, et al. The 2016 European Thyroid Association/European Group on Graves’ Orbitopathy Guidelines for theManagement of Graves’ Orbitopathy. Eur Thyroid J [Internet].2016;5:9–26 Available from: https://www.karger.com/Article/FullText/443828.3. Stan MN, Garrity JA, Leon BGC, Prabin T, Bradley EA, Bahn RS.Randomized controlled trial of rituximab in patients with Graves’orbitopathy. J Clin Endocrinol Metab. 2015;100:432–41.4. Bruijnen S, Tsang-A-SjoeM, Raterman H, Ramwadhdoebe T, VugtsD, van Dongen G, et al. B-cell imaging with zirconium-89 labelledrituximab PET-CTat baseline is associated with therapeutic response24 weeks after initiation of rituximab treatment in rheumatoid arthri-tis patients. Arthritis Res Ther. 2016:18 Available from: http://www.ncbi.nlm.nih.gov/pubmed/27863504.5. Laban KG, Kalmann R, Leguit RJ, de Keizer B. Zirconium-89-labelled rituximab PET-CT in orbital inflammatory disease.EJNMMI Res. 2019;9:69. https://doi.org/10.1186/s13550-019-0530-9.Publisher’s note Springer Nature remains neutral with regard to jurisdic-tional claims in published maps and institutional affiliations.Figure 1Eur J Nucl Med Mol Imaging (2020) 47:738–739 739Open Access This article is distributed under the terms of the CreativeCommons At t r ibut ion 4 .0 In te rna t ional License (h t tp : / /creativecommons.org/licenses/by/4.0/), which permits unrestricted use,distribution, and reproduction in any medium, provided you give appro-priate credit to the original author(s) and the source, provide a link to theCreative Commons license, and indicate if changes were made.References1. Bahn RS. Graves’ ophthalmopathy. N Engl J Med [Internet].2010;362:726–38 Available from: http://www.ncbi.nlm.nih.gov/pubmed/20181974.

Zirconium-89 labelled rituximab PET-CT imaging of Graves' orbitopathy

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Zirconium-89 labelled rituximab PET-CT imaging of Graves' orbitopathy

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