1

Peter Hirschi
Clinical Practicum I
March 27, 2015
Radiation Treatment for Graves Ophthalmopathy
HISTORY OF PRESENT ILLNESS: Mr. T is a 63 year old gentleman with a history of
hyperthyroidism and Graves' Ophthalmopathy (GO) disease. GO is a benign condition that is
seen in patients with hyperthyroidism and is characterized by exophthalmos secondary to
swelling of the muscles in the orbit.1 GO is historically treated with corticoids and then followed
by surgical decompression or radiation therapy, if needed.2 Mr. T was previously treated with
radioactive iodine ablation receiving 20 mCi for his hyperthyroidism. He has a history of more
or less 3-5 months of involuntary weight loss of almost 35 pounds associated with polyphagia.
He refers he has very low energy and generalized weakness, but denies insomnia, problems with
concentration or memory, changes in vision, or gynecomastia. He was told his thyroid function
tests were abnormal, but was never started on treatment while waiting for evaluation. He had
initially burning sensation on his neck, but never dysphagia, odynophagia, or hoarseness. He
refers he is extremely tired and he needs to get treated for this condition. He also has a history of
type I diabetes and COPD. The patient has been having difficulties with his vision for over a
year. They have tried to treat this with medication with little response. He also underwent a
decompression surgery in the fall of 2014. He states that this did decrease the bulging of his
eyes, but continues to experince double vision. The patient was referred to the department for
consideration of radiation treatment of Graves' ophthalmopathy.
PAST MEDICAL HISTORY: diabetes, COPD, and thyroid disease.
PAST SURGICAL HISTORY: Open heart surgery for septal myectomy for hypertrophic
cardiomyopathy2008 and elastoma removal 2011 /surgery and tonsils/adenoids removed.
RADIATION/CHEMOTHERAPY: Patient denies previous radiation or chemotherapy.
SOCIAL HISTORY: He smokes half a pack per day, since age 13. Patient has positive history
of alcohol abuse in the past. He lives in Mesquite. He works as a car salesman. Has a sister at 36
years old with a history of thyroid cancer, diabetes mellitus type 2 on his father and grandfathers
side.
MEDICATIONS: Allergy, Levemir, Levothyroxine Sodium, Metoprolol Tartrate, NovoLOG.

Diagnostic Imaging: A CT scan of the head in March 2014 did show diffusely enlarged
extraocular muscles consistent with thyroid ophthalmopathy.
The Plan (Prescription): Unfortunately, Mr. Ts ophthalmopathy has not responded to medical
therapy or a decompression surgery. There have been several trials looking at the utility of
radiation treatment of the Graves' or thyroid ophthalmopathy. A study done between 1968 and
1988 on 311 patients with progressive Graves opthalmopathy were treated with megavoltage
orbital radiotherapy, found that 80% of patients showed improvement or complete resolution of
soft tissue symptoms.3 A two week course of daily radiation treatment delivering 2,000 cGy in 10
fractions was prescribed. This treatment is to be delivered using opposed lateral fields directed
at the posterior orbit and extra ocular muscles. The physician explained the possible risks and
side effects associated with such a course including, but not limited to; vision changes, dry eye,
irritation of the eye, pain, fatigue, and 2nd malignancy. The prescribed dose is considered lower
than the threshold dose of the retina or optic nerve, therefore the risk for long-term nerve injury
is low.
Patient Setup/Immobilization: The patient was placed on an S-frame with a head only
aquaplast mask. A B headrest was placed under his head. BBs were placed near the orbits.
Anatomic Contouring: The following structures were contoured; body, brain, left eye, left lens,
left optic nerve, right eye, right lens, and the right optic nerve. The physician created a gross
tumor volume as well as a clinical tumor volume. The dosimetrist then added a 0.5cm margin to
the CTV to create a planning treatment volume.
Beam Isocenter/Arrangement: The patient was treated on a Varian LINAC. Two lateral
opposed beams were used to deliver 10 fractions of 200cGy to the PTV. The left lateral field was
turned slightly passed 90 to 92 degrees in order to superimpose the eyes over each other in the
beams eye view so a conformal dose could be delivered while keeping dose to the orbits as low
as possible. The left lateral delivered 135 monitors units (MU), using 6mv energy and a dose rate
of 600. A 15 degree electronic dynamic wedge (EDW) was used with the heel placed anteriorly
to help dose conformity because the anterior portion of the patients head has less separation than
the posterior. The right lateral field was directly opposed to the left. It also utilized 6mv energy,
600 dose rate, and delivered 136 MU. It also used a 15 degree EDW with the heel anteriorly.
Treatment Planning: The Eclipse treatment planning system was used to create the lateral
opposed fields plan. The orbital muscles posterior to the orbits were defined as the GTV by the

physician. The PTV included the posterior aspect of the orbits, some bone, small amount of the
superior aspect of maxillary sinus, and a small amount of frontal lobe of the brain. The physician
listed the lens of the eyes and the brain as two critical structures. The DVH shown below
indicates that the max dose to the lenses was 300 cGy, which is below the lenses threshold for
toxicity. The hot spot of the plan is 111.6% and is in soft tissue on the left side of the patient. The
DVH also shows the brain is receiving minimal dose. The mean dose to both optic nerves is
104.5cGy and the mean dose to the eye orbits average is 73.7cGy. Most importantly, the PTV is
covered well. 99% of the PTV is receiving 96.5% of the prescribed dose. 95% of the PTV is
receiving 98.5% of the prescribed dose. 100% of the CTV is receiving 99.2% of the prescribed
dose. Because the muscles posterior to the orbit are the target tissue and not a malignant disease,
the coverage just mentioned should be more than adequate to produce a good patient outcome.
Quality Assurance Check: The MU calculations done by the Eclipse planning system for both
lateral opposed fields were verified by the third party software, IMsure. The results were as
follows:
Field
Eclipse MU
IMsure MU
Percent Diff

Right Lateral
136.1
136.8
-0.5%

Left Lateral
134.9
134.5
0.3%

Conclusion: The color wash plan in figure one shows a nice uniform dose that covers the
posterior orbital muscles very well. Notice the field edge ends half way through orbit in order to
spare the lenses of the eye, yet cover any swollen muscle tissue that may be near the
posterior/lateral aspect of the orbit. Obviously if the prescription was any higher than the 30Gy
prescribed, this plan would be much more difficult. The 30Gy prescription is below the
tolerances of nearby critical organs with the exception of the lens of the eye.

Figure 1 Treatment plan with color wash.

Figure 2 DVH

References
1. Bentel GC. Radiation Therapy Planning. 2nd ed. New York, NY: McGraw-Hill; 1996:
2. Prummel MF, Wiersinga WM. Immunomodulatory treatment of Graves opthalmopathy.
Thyroid 1998;8(6):545-548. doi:10.1089/thy.1996.6.381.
3. Petersen IA, Kriss JP, Mcdougall IR, et al. Prognostic factors in the radiotherapy of
Graves ophthalmopathy. Int J Radiat Oncol Biol Phys 1990;19(2):259-264. DOI
10.1186/1748-717X-6-46