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AML risk is doubled in low-risk thyroid cancer patients unnecessarily given radioactive iodine therapy
MADRID – Radioactive iodine treatment is associated with nearly twice the risk of developing acute myeloid leukemia (AML) in patients with well-differentiated thyroid cancer, based on data from the Surveillance Epidemiology and End Results (SEER) registry.
Up to 40% of patients in Europe and North America with well-differentiated thyroid cancer still receive radioactive iodine treatment “even though RAI has no proven benefit in this population,” Remco Molenaar, MD, PhD, of the University of Amsterdam reported at the European Society of Medical Oncology Congress.
Of 148,215 patients treated for well-differentiated thyroid cancer between 1973 and 2014, 55% had surgery only and 45% received surgery plus radioactive iodine treatment. After a median 4.3 years of follow-up, 44 patients developed AML. When cases in those exposed to RAI were cross-referenced to those who were not, the relative risk was increased more than fivefold. When the analysis controlled for an extensive list of potentially confounding variables, the hazard ratio of 1.79 remained statistically significant (P = .03).
“There is a nearly twofold increased risk even though radioactive iodine treatment is not indicated in this population,” Dr. Molenaar said. Moreover, AML following treatment for well-differentiated thyroid cancer was associated with a substantial reduction in expected overall survival, falling from a median 24.4 years to 7.5 years.
Compared with other AML patients, “those who develop AML after RAI also have a worse prognosis,” added Dr. Molenaar, noting the difference in overall survival is highly statistically significant (1.2 vs. 3.5 years; P = .004).
The ESMO-invited discussant, Tim Somervaille, MD, senior group leader of the Leukemia Biology Laboratory at the Cancer Research UK Manchester Institute, called this analysis “a more thorough and detailed study” than previous retrospective analyses, but he added a note of caution: Despite the almost twofold increase in risk, AML remains a rare iatrogenic event in thyroid cancer patients even if it is avoidable by withholding RAI therapy.
“These data do suggest that the risk is measurable and will further provide some downward pressure on the numbers of patients having unnecessary RAI therapy for well-differentiated thyroid cancer,” he said.
In the discussion that followed the presentation, one audience member suggested that telling patients they have a twofold increased risk of AML after RAI therapy is misleading. It was emphasized that a twofold increase of a very small number is still a very small number, but Dr. Molenaar suggested that this misses the point.
“I don’t think this is something that you need to discuss with patients, because you should not be giving RAI therapy to thyroid cancer patients with low- or intermediate-risk disease,” he said. Any AML case caused “by a therapy with no proven benefit is one too many,” especially since unnecessary RAI adds inconvenience and cost to treatment.
MADRID – Radioactive iodine treatment is associated with nearly twice the risk of developing acute myeloid leukemia (AML) in patients with well-differentiated thyroid cancer, based on data from the Surveillance Epidemiology and End Results (SEER) registry.
Up to 40% of patients in Europe and North America with well-differentiated thyroid cancer still receive radioactive iodine treatment “even though RAI has no proven benefit in this population,” Remco Molenaar, MD, PhD, of the University of Amsterdam reported at the European Society of Medical Oncology Congress.
Of 148,215 patients treated for well-differentiated thyroid cancer between 1973 and 2014, 55% had surgery only and 45% received surgery plus radioactive iodine treatment. After a median 4.3 years of follow-up, 44 patients developed AML. When cases in those exposed to RAI were cross-referenced to those who were not, the relative risk was increased more than fivefold. When the analysis controlled for an extensive list of potentially confounding variables, the hazard ratio of 1.79 remained statistically significant (P = .03).
“There is a nearly twofold increased risk even though radioactive iodine treatment is not indicated in this population,” Dr. Molenaar said. Moreover, AML following treatment for well-differentiated thyroid cancer was associated with a substantial reduction in expected overall survival, falling from a median 24.4 years to 7.5 years.
Compared with other AML patients, “those who develop AML after RAI also have a worse prognosis,” added Dr. Molenaar, noting the difference in overall survival is highly statistically significant (1.2 vs. 3.5 years; P = .004).
The ESMO-invited discussant, Tim Somervaille, MD, senior group leader of the Leukemia Biology Laboratory at the Cancer Research UK Manchester Institute, called this analysis “a more thorough and detailed study” than previous retrospective analyses, but he added a note of caution: Despite the almost twofold increase in risk, AML remains a rare iatrogenic event in thyroid cancer patients even if it is avoidable by withholding RAI therapy.
“These data do suggest that the risk is measurable and will further provide some downward pressure on the numbers of patients having unnecessary RAI therapy for well-differentiated thyroid cancer,” he said.
In the discussion that followed the presentation, one audience member suggested that telling patients they have a twofold increased risk of AML after RAI therapy is misleading. It was emphasized that a twofold increase of a very small number is still a very small number, but Dr. Molenaar suggested that this misses the point.
“I don’t think this is something that you need to discuss with patients, because you should not be giving RAI therapy to thyroid cancer patients with low- or intermediate-risk disease,” he said. Any AML case caused “by a therapy with no proven benefit is one too many,” especially since unnecessary RAI adds inconvenience and cost to treatment.
MADRID – Radioactive iodine treatment is associated with nearly twice the risk of developing acute myeloid leukemia (AML) in patients with well-differentiated thyroid cancer, based on data from the Surveillance Epidemiology and End Results (SEER) registry.
Up to 40% of patients in Europe and North America with well-differentiated thyroid cancer still receive radioactive iodine treatment “even though RAI has no proven benefit in this population,” Remco Molenaar, MD, PhD, of the University of Amsterdam reported at the European Society of Medical Oncology Congress.
Of 148,215 patients treated for well-differentiated thyroid cancer between 1973 and 2014, 55% had surgery only and 45% received surgery plus radioactive iodine treatment. After a median 4.3 years of follow-up, 44 patients developed AML. When cases in those exposed to RAI were cross-referenced to those who were not, the relative risk was increased more than fivefold. When the analysis controlled for an extensive list of potentially confounding variables, the hazard ratio of 1.79 remained statistically significant (P = .03).
“There is a nearly twofold increased risk even though radioactive iodine treatment is not indicated in this population,” Dr. Molenaar said. Moreover, AML following treatment for well-differentiated thyroid cancer was associated with a substantial reduction in expected overall survival, falling from a median 24.4 years to 7.5 years.
Compared with other AML patients, “those who develop AML after RAI also have a worse prognosis,” added Dr. Molenaar, noting the difference in overall survival is highly statistically significant (1.2 vs. 3.5 years; P = .004).
The ESMO-invited discussant, Tim Somervaille, MD, senior group leader of the Leukemia Biology Laboratory at the Cancer Research UK Manchester Institute, called this analysis “a more thorough and detailed study” than previous retrospective analyses, but he added a note of caution: Despite the almost twofold increase in risk, AML remains a rare iatrogenic event in thyroid cancer patients even if it is avoidable by withholding RAI therapy.
“These data do suggest that the risk is measurable and will further provide some downward pressure on the numbers of patients having unnecessary RAI therapy for well-differentiated thyroid cancer,” he said.
In the discussion that followed the presentation, one audience member suggested that telling patients they have a twofold increased risk of AML after RAI therapy is misleading. It was emphasized that a twofold increase of a very small number is still a very small number, but Dr. Molenaar suggested that this misses the point.
“I don’t think this is something that you need to discuss with patients, because you should not be giving RAI therapy to thyroid cancer patients with low- or intermediate-risk disease,” he said. Any AML case caused “by a therapy with no proven benefit is one too many,” especially since unnecessary RAI adds inconvenience and cost to treatment.
AT ESMO 2017
Key clinical point:
Major finding: The hazard ratio for AML after RAI therapy in well-differentiated thyroid cancer patients is almost doubled (HR = 1.79).
Data source: Population-based, retrospective study of 148,215 patients treated for well-differentiated thyroid cancer between 1973 and 2014.
Disclosures: Dr. Molenaar reported that he had no relevant financial relationships to disclose.
Study reveals limits of 4-D CT scanning for parathyroid disease
Preoperative four-dimensional computed tomography imaging and intraoperative findings for parathyroid disease are not always in agreement, a retrospective study has found.
Among patients with primary hyperparathyroidism who underwent preoperative four-dimensional computed tomography (4-D CT) followed by parathyroidectomy, multigland disease was the most strongly associated with discordance between the scan and the intraoperative findings, according to the study.
“Parathyroid 4-D CTs have emerged as one of the most accurate preoperative imaging modalities to localize abnormal parathyroid glands,” wrote researchers led by Shonan Sho, MD (JAMA Surg. 2017 Aug 9. doi: 10.1001/jamasurg.2017.2649). “Despite this use, missed lesions and incorrect localization still occur.”
In what is believed to be the first study of its kind, Dr. Sho of the section of endocrine surgery at the University of California, Los Angeles, and his associates prospectively evaluated factors associated with discordance between preoperative four-dimensional computed tomographic scans and intraoperative findings. They examined data from 411 patients with primary hyperparathyroidism who underwent 4-D CTs followed by parathyroidectomy at UCLA from Sept. 1, 2011, through Oct. 31, 2016. The mean age of patients was 59, 79% were female, and 30% had discordance between preoperative 4-D CTs and intraoperative findings.
When the researchers compared concordant cases with discordant cases, they found that discordant cases had higher frequencies of multigland disease (24.3% vs. 66.7%, respectively; P less than .001) and multinodular goiter or thyroid nodule (29.2% vs. 40.7%; P = .02). “Thyroid nodules can mimic parathyroid adenomas because they can occur in similar locations and appear oval or round, and they can have enhancement characteristics similar to those of parathyroid adenomas,” Dr. Sho and his associates wrote. “The addition of ultrasound may enable correct identification of abnormal parathyroid glands in a patient with thyroid nodules.”
The investigators also found that missed parathyroid lesions tended to be smaller than 10 mm in size and were more likely to be in the inferior position.
Multivariable analysis revealed the analysis risk factors for discordant 4-D CT findings: multigland disease (odds ratio, 7.63), parathyroid lesion in the inferior position (OR, 6.82), parathyroid lesion size of 10 mm or less (OR, 4.37), and multinodular goiter or thyroid nodule (OR, 1.82). The researchers concluded, “In the case of a negative 4-D CT, the surgeon may elect to allot additional operative time for what may be a more difficult case. Or, after considering the likelihood of MGD [multigland disease] based on biochemical values and the 4-D CT result, the surgeon may consider having a more detailed discussion with the patient regarding the potential need for subtotal parathyroidectomy. During surgery, if the surgeon is not finding the culprit glands or if the PTH [parathyroid hormone] level is not dropping, he or she should recall that discordance between intraoperative findings and the 4-D CT results is likely to be explained by MGD, an inferior gland that is flattened against the surface of the thyroid gland, or, less commonly, an intrathyroidal gland.”
They acknowledged certain limitations of the study, including its single-center, retrospective design; the fact that calcium levels were not available in all patients; and the fact that the 4-D CT technique remains novel.
The investigators reported having no relevant financial disclosures.
This study highlights the fact that no imaging for parathyroid disease is perfect. The diagnosis of hyperparathyroidism is based on laboratory testing, not on imaging studies. 
Dr. Rebecca S. Sippel is chief of endocrine surgery at the University of Wisconsin–Madison.
This study highlights the fact that no imaging for parathyroid disease is perfect. The diagnosis of hyperparathyroidism is based on laboratory testing, not on imaging studies.
Dr. Rebecca S. Sippel is chief of endocrine surgery at the University of Wisconsin–Madison.
This study highlights the fact that no imaging for parathyroid disease is perfect. The diagnosis of hyperparathyroidism is based on laboratory testing, not on imaging studies.
Dr. Rebecca S. Sippel is chief of endocrine surgery at the University of Wisconsin–Madison.
Preoperative four-dimensional computed tomography imaging and intraoperative findings for parathyroid disease are not always in agreement, a retrospective study has found.
Among patients with primary hyperparathyroidism who underwent preoperative four-dimensional computed tomography (4-D CT) followed by parathyroidectomy, multigland disease was the most strongly associated with discordance between the scan and the intraoperative findings, according to the study.
“Parathyroid 4-D CTs have emerged as one of the most accurate preoperative imaging modalities to localize abnormal parathyroid glands,” wrote researchers led by Shonan Sho, MD (JAMA Surg. 2017 Aug 9. doi: 10.1001/jamasurg.2017.2649). “Despite this use, missed lesions and incorrect localization still occur.”
In what is believed to be the first study of its kind, Dr. Sho of the section of endocrine surgery at the University of California, Los Angeles, and his associates prospectively evaluated factors associated with discordance between preoperative four-dimensional computed tomographic scans and intraoperative findings. They examined data from 411 patients with primary hyperparathyroidism who underwent 4-D CTs followed by parathyroidectomy at UCLA from Sept. 1, 2011, through Oct. 31, 2016. The mean age of patients was 59, 79% were female, and 30% had discordance between preoperative 4-D CTs and intraoperative findings.
When the researchers compared concordant cases with discordant cases, they found that discordant cases had higher frequencies of multigland disease (24.3% vs. 66.7%, respectively; P less than .001) and multinodular goiter or thyroid nodule (29.2% vs. 40.7%; P = .02). “Thyroid nodules can mimic parathyroid adenomas because they can occur in similar locations and appear oval or round, and they can have enhancement characteristics similar to those of parathyroid adenomas,” Dr. Sho and his associates wrote. “The addition of ultrasound may enable correct identification of abnormal parathyroid glands in a patient with thyroid nodules.”
The investigators also found that missed parathyroid lesions tended to be smaller than 10 mm in size and were more likely to be in the inferior position.
Multivariable analysis revealed the analysis risk factors for discordant 4-D CT findings: multigland disease (odds ratio, 7.63), parathyroid lesion in the inferior position (OR, 6.82), parathyroid lesion size of 10 mm or less (OR, 4.37), and multinodular goiter or thyroid nodule (OR, 1.82). The researchers concluded, “In the case of a negative 4-D CT, the surgeon may elect to allot additional operative time for what may be a more difficult case. Or, after considering the likelihood of MGD [multigland disease] based on biochemical values and the 4-D CT result, the surgeon may consider having a more detailed discussion with the patient regarding the potential need for subtotal parathyroidectomy. During surgery, if the surgeon is not finding the culprit glands or if the PTH [parathyroid hormone] level is not dropping, he or she should recall that discordance between intraoperative findings and the 4-D CT results is likely to be explained by MGD, an inferior gland that is flattened against the surface of the thyroid gland, or, less commonly, an intrathyroidal gland.”
They acknowledged certain limitations of the study, including its single-center, retrospective design; the fact that calcium levels were not available in all patients; and the fact that the 4-D CT technique remains novel.
The investigators reported having no relevant financial disclosures.
Preoperative four-dimensional computed tomography imaging and intraoperative findings for parathyroid disease are not always in agreement, a retrospective study has found.
Among patients with primary hyperparathyroidism who underwent preoperative four-dimensional computed tomography (4-D CT) followed by parathyroidectomy, multigland disease was the most strongly associated with discordance between the scan and the intraoperative findings, according to the study.
“Parathyroid 4-D CTs have emerged as one of the most accurate preoperative imaging modalities to localize abnormal parathyroid glands,” wrote researchers led by Shonan Sho, MD (JAMA Surg. 2017 Aug 9. doi: 10.1001/jamasurg.2017.2649). “Despite this use, missed lesions and incorrect localization still occur.”
In what is believed to be the first study of its kind, Dr. Sho of the section of endocrine surgery at the University of California, Los Angeles, and his associates prospectively evaluated factors associated with discordance between preoperative four-dimensional computed tomographic scans and intraoperative findings. They examined data from 411 patients with primary hyperparathyroidism who underwent 4-D CTs followed by parathyroidectomy at UCLA from Sept. 1, 2011, through Oct. 31, 2016. The mean age of patients was 59, 79% were female, and 30% had discordance between preoperative 4-D CTs and intraoperative findings.
When the researchers compared concordant cases with discordant cases, they found that discordant cases had higher frequencies of multigland disease (24.3% vs. 66.7%, respectively; P less than .001) and multinodular goiter or thyroid nodule (29.2% vs. 40.7%; P = .02). “Thyroid nodules can mimic parathyroid adenomas because they can occur in similar locations and appear oval or round, and they can have enhancement characteristics similar to those of parathyroid adenomas,” Dr. Sho and his associates wrote. “The addition of ultrasound may enable correct identification of abnormal parathyroid glands in a patient with thyroid nodules.”
The investigators also found that missed parathyroid lesions tended to be smaller than 10 mm in size and were more likely to be in the inferior position.
Multivariable analysis revealed the analysis risk factors for discordant 4-D CT findings: multigland disease (odds ratio, 7.63), parathyroid lesion in the inferior position (OR, 6.82), parathyroid lesion size of 10 mm or less (OR, 4.37), and multinodular goiter or thyroid nodule (OR, 1.82). The researchers concluded, “In the case of a negative 4-D CT, the surgeon may elect to allot additional operative time for what may be a more difficult case. Or, after considering the likelihood of MGD [multigland disease] based on biochemical values and the 4-D CT result, the surgeon may consider having a more detailed discussion with the patient regarding the potential need for subtotal parathyroidectomy. During surgery, if the surgeon is not finding the culprit glands or if the PTH [parathyroid hormone] level is not dropping, he or she should recall that discordance between intraoperative findings and the 4-D CT results is likely to be explained by MGD, an inferior gland that is flattened against the surface of the thyroid gland, or, less commonly, an intrathyroidal gland.”
They acknowledged certain limitations of the study, including its single-center, retrospective design; the fact that calcium levels were not available in all patients; and the fact that the 4-D CT technique remains novel.
The investigators reported having no relevant financial disclosures.
FROM JAMA SURGERY
Key clinical point:
Major finding: Compared with cases that showed concordance between the 4-D CT scan and the intraoperative findings, discordant cases had higher frequencies of multigland disease (24.3% vs. 66.7%, respectively; P less than .001) and multinodular goiter or thyroid nodule (29.2% vs. 40.7%; P = .02).
Data source: A retrospective analysis of 411 patients with primary hyperparathyroidism who underwent preoperative 4-D CT scans followed by parathyroidectomy.
Disclosures: The researchers reported having no relevant financial disclosures.
Big changes coming for thyroid cancer staging
BOSTON – When the American Joint Committee on Cancer’s Eighth Edition Cancer Staging Manual becomes effective for U.S. practice on Jan. 1, 2018, substantially more patients with thyroid cancer will meet the definition for stage I disease, but their survival prognosis will remain as good as it was for the smaller slice of patients defined with stage I thyroid cancer by the seventh edition, Bryan R. Haugen, MD, predicted during a talk at the World Congress on Thyroid Cancer.
Under current stage definitions in the seventh edition, roughly 60% of thyroid cancer patients have stage I disease, but this will kick up to about 80% under the eighth edition, said Dr. Haugen, professor of medicine and head of the division of endocrinology, metabolism, and diabetes at the University of Colorado in Aurora. Despite this influx of more patients, “survival rates in stage I patients haven’t changed,” with a disease-specific survival (DSS) of 98%-100% for stage I patients in the eighth edition compared with 97%-100% in the seventh edition, he noted.
Dr. Haugen credited this apparent paradox to the revised staging system’s superior discrimination among various grades of disease progression. “The eighth edition better separates patients based on their projected survival.” As more patients fit stage I classification with its highest level of projected survival, fewer patients will classify with more advanced disease and its worse projected survival.
For example, in the seventh edition patients with stage IV disease had a projected DSS rate of 50%-75%; in the eighth edition that rate is now less than 50%. The projected DSS rate for patients with stage II disease has down shifted from 97%-100% in the seventh edition to 85%-95% in the eighth. For patients with stage III thyroid cancer the DSS rate of 88%-95% in the seventh edition became 60%-70% in the eighth edition.
‘The new system will take some getting used to,” Dr. Haugen admitted, and it involves even more “big” changes, he warned. These include:
• Changing the cutpoint separating younger from older patients to 55 years of age in the eighth edition, a rise from the 45-year-old cutpoint in the seventh edition.
• Allowing tumors classified as stage I to be as large as 4 cm, up from the 2 cm or less defining stage I in the seventh edition.
• Reserving stage II designation for patients with tumors larger than 4 cm. In the seventh edition tumors had to be 2-4 cm in size.
• Expanding stage II disease to include not only patients with disease confined to their thyroid, but also patients with N1 lymph node spread or gross extrathyroidal extension. In the seventh edition tumor spread like this put patients into stage III.
• Specifying in the eighth edition that stage III disease must feature gross extrathyroidal extension into the larynx, trachea, esophagus, or recurrent laryngial nerve. To qualify for stage IV in the eighth edition, spread must extend into prevertebral fascia or encase major vessels, for stage IVA, or involve distant metastases for stage IVB.
• Paring down three stage IV subgroups, A, B, and C, in the seventh edition to just an A or B subgroup in the eighth edition.
Dr. Haugen coauthored a recent editorial that laid out an assessment of the eighth edition in greater detail (Thyroid. 2017 Jun;27[6]:751-6).
mzoler@frontlinemedcom.com
On Twitter @mitchelzoler
BOSTON – When the American Joint Committee on Cancer’s Eighth Edition Cancer Staging Manual becomes effective for U.S. practice on Jan. 1, 2018, substantially more patients with thyroid cancer will meet the definition for stage I disease, but their survival prognosis will remain as good as it was for the smaller slice of patients defined with stage I thyroid cancer by the seventh edition, Bryan R. Haugen, MD, predicted during a talk at the World Congress on Thyroid Cancer.
Under current stage definitions in the seventh edition, roughly 60% of thyroid cancer patients have stage I disease, but this will kick up to about 80% under the eighth edition, said Dr. Haugen, professor of medicine and head of the division of endocrinology, metabolism, and diabetes at the University of Colorado in Aurora. Despite this influx of more patients, “survival rates in stage I patients haven’t changed,” with a disease-specific survival (DSS) of 98%-100% for stage I patients in the eighth edition compared with 97%-100% in the seventh edition, he noted.
Dr. Haugen credited this apparent paradox to the revised staging system’s superior discrimination among various grades of disease progression. “The eighth edition better separates patients based on their projected survival.” As more patients fit stage I classification with its highest level of projected survival, fewer patients will classify with more advanced disease and its worse projected survival.
For example, in the seventh edition patients with stage IV disease had a projected DSS rate of 50%-75%; in the eighth edition that rate is now less than 50%. The projected DSS rate for patients with stage II disease has down shifted from 97%-100% in the seventh edition to 85%-95% in the eighth. For patients with stage III thyroid cancer the DSS rate of 88%-95% in the seventh edition became 60%-70% in the eighth edition.
‘The new system will take some getting used to,” Dr. Haugen admitted, and it involves even more “big” changes, he warned. These include:
• Changing the cutpoint separating younger from older patients to 55 years of age in the eighth edition, a rise from the 45-year-old cutpoint in the seventh edition.
• Allowing tumors classified as stage I to be as large as 4 cm, up from the 2 cm or less defining stage I in the seventh edition.
• Reserving stage II designation for patients with tumors larger than 4 cm. In the seventh edition tumors had to be 2-4 cm in size.
• Expanding stage II disease to include not only patients with disease confined to their thyroid, but also patients with N1 lymph node spread or gross extrathyroidal extension. In the seventh edition tumor spread like this put patients into stage III.
• Specifying in the eighth edition that stage III disease must feature gross extrathyroidal extension into the larynx, trachea, esophagus, or recurrent laryngial nerve. To qualify for stage IV in the eighth edition, spread must extend into prevertebral fascia or encase major vessels, for stage IVA, or involve distant metastases for stage IVB.
• Paring down three stage IV subgroups, A, B, and C, in the seventh edition to just an A or B subgroup in the eighth edition.
Dr. Haugen coauthored a recent editorial that laid out an assessment of the eighth edition in greater detail (Thyroid. 2017 Jun;27[6]:751-6).
mzoler@frontlinemedcom.com
On Twitter @mitchelzoler
BOSTON – When the American Joint Committee on Cancer’s Eighth Edition Cancer Staging Manual becomes effective for U.S. practice on Jan. 1, 2018, substantially more patients with thyroid cancer will meet the definition for stage I disease, but their survival prognosis will remain as good as it was for the smaller slice of patients defined with stage I thyroid cancer by the seventh edition, Bryan R. Haugen, MD, predicted during a talk at the World Congress on Thyroid Cancer.
Under current stage definitions in the seventh edition, roughly 60% of thyroid cancer patients have stage I disease, but this will kick up to about 80% under the eighth edition, said Dr. Haugen, professor of medicine and head of the division of endocrinology, metabolism, and diabetes at the University of Colorado in Aurora. Despite this influx of more patients, “survival rates in stage I patients haven’t changed,” with a disease-specific survival (DSS) of 98%-100% for stage I patients in the eighth edition compared with 97%-100% in the seventh edition, he noted.
Dr. Haugen credited this apparent paradox to the revised staging system’s superior discrimination among various grades of disease progression. “The eighth edition better separates patients based on their projected survival.” As more patients fit stage I classification with its highest level of projected survival, fewer patients will classify with more advanced disease and its worse projected survival.
For example, in the seventh edition patients with stage IV disease had a projected DSS rate of 50%-75%; in the eighth edition that rate is now less than 50%. The projected DSS rate for patients with stage II disease has down shifted from 97%-100% in the seventh edition to 85%-95% in the eighth. For patients with stage III thyroid cancer the DSS rate of 88%-95% in the seventh edition became 60%-70% in the eighth edition.
‘The new system will take some getting used to,” Dr. Haugen admitted, and it involves even more “big” changes, he warned. These include:
• Changing the cutpoint separating younger from older patients to 55 years of age in the eighth edition, a rise from the 45-year-old cutpoint in the seventh edition.
• Allowing tumors classified as stage I to be as large as 4 cm, up from the 2 cm or less defining stage I in the seventh edition.
• Reserving stage II designation for patients with tumors larger than 4 cm. In the seventh edition tumors had to be 2-4 cm in size.
• Expanding stage II disease to include not only patients with disease confined to their thyroid, but also patients with N1 lymph node spread or gross extrathyroidal extension. In the seventh edition tumor spread like this put patients into stage III.
• Specifying in the eighth edition that stage III disease must feature gross extrathyroidal extension into the larynx, trachea, esophagus, or recurrent laryngial nerve. To qualify for stage IV in the eighth edition, spread must extend into prevertebral fascia or encase major vessels, for stage IVA, or involve distant metastases for stage IVB.
• Paring down three stage IV subgroups, A, B, and C, in the seventh edition to just an A or B subgroup in the eighth edition.
Dr. Haugen coauthored a recent editorial that laid out an assessment of the eighth edition in greater detail (Thyroid. 2017 Jun;27[6]:751-6).
mzoler@frontlinemedcom.com
On Twitter @mitchelzoler
EXPERT ANALYSIS FROM WCTC 2017
Contralateral nodal thyroid metastases show slow progression
BOSTON – More than a third of 63 patients with unilateral papillary thyroid carcinoma and ipsilateral lymph node metastases also had occult, contralateral, lateral-neck lymph nodes with metastases, but the low reported rate of contralateral neck recurrence has raised the question of whether routine resection of these contralateral lymph nodes benefits patients.
“Prophylactic contralateral lateral-neck dissection may not be relevant for patients with unilateral N1b tumors,” Dana Hartl, MD, PhD, said at the World Congress on Thyroid Cancer.
She envisioned a more targeted approach to using surgical resection of contralateral, lateral-neck lymph nodes. “We would still do this surgery for patients with lots of big, bulky nodules; it just takes an additional 10-20 minutes. It’s not that long or morbid. For patients with lots of [affected] nodes, you’ve got to clear it out. But for a patient with a small, level III node on one side I will no longer do [prophylactic, contralateral, lateral-neck lymph node removal].”
Dr. Hartl and her associates reviewed records for 63 patients with unilateral, unifocal papillary thyroid carcinoma who underwent prophylactic, contralateral, lymph node removal during 1997-2016. They ranged from 11-84 years old, and 60% had extrathyroidal extension of their primary tumor. The patients averaged having four lymph nodes with metastatic cells in the ipsilateral lateral neck, an average of five affected lymph nodes in the ipsilateral central neck, and an average of two affected lymph nodes in the contralateral central neck.
Among the 63 patients, 23 (37%) had metastases-containing lymph nodes at levels III and IV in the contralateral lateral neck, with a range of 1-17 metastases per node. All nodes were less than 1 cm in diameter. Extracapsular spread had occurred in 11 of the 23 cases.
The relatively frequent presence of metastases in the contralateral, lateral-neck lymph nodes contrasted with the reported low 5%-15% rate of recurrence in these lymph nodes in patients with N1b disease, Dr. Hartl said.
The analysis identified two factors that significantly linked with having contralateral, lateral-neck metastases: having a bilateral tumor with contralateral microcancer, or having at least four lymph nodes positive for metastases in the ipsilateral central compartment, she reported. When patients had fewer than five positive lymph nodes in the ipsilateral central neck, their risk for occult metastases in contralateral lymph nodes was 26%.
“It’s not very strong data; we were a little disappointed” with the results, Dr. Hartl said.
mzoler@frontlinemedcom.com
On Twitter @mitchelzoler
The finding reported by Dr. Hartl is consistent with recent experience with other tumor types, like prostate cancer, that often show low aggressiveness. The need to routinely resect what may be indolent microscopic metastases remains a big open question.
The dilemma for thyroid cancer was nicely summarized by Gilbert Welch, MD, and his associates who highlighted the risk of overdiagnosing thyroid cancer with aggressive screening. In South Korea, this resulted in a 15-fold increase in thyroid cancer diagnoses between 1993 and 2011, which led to substantial increases in the rates of thyroidectomy including patients with tumors too small to warrant surgery (N Engl J Med. 2014 Nov 6;371[19]:1765-7).
Pamela Hartzband, MD , is an endocrinologist at Beth Israel Deaconess Medical Center in Boston. She had no disclosures. She made these comments in an interview.
The finding reported by Dr. Hartl is consistent with recent experience with other tumor types, like prostate cancer, that often show low aggressiveness. The need to routinely resect what may be indolent microscopic metastases remains a big open question.
The dilemma for thyroid cancer was nicely summarized by Gilbert Welch, MD, and his associates who highlighted the risk of overdiagnosing thyroid cancer with aggressive screening. In South Korea, this resulted in a 15-fold increase in thyroid cancer diagnoses between 1993 and 2011, which led to substantial increases in the rates of thyroidectomy including patients with tumors too small to warrant surgery (N Engl J Med. 2014 Nov 6;371[19]:1765-7).
Pamela Hartzband, MD , is an endocrinologist at Beth Israel Deaconess Medical Center in Boston. She had no disclosures. She made these comments in an interview.
The finding reported by Dr. Hartl is consistent with recent experience with other tumor types, like prostate cancer, that often show low aggressiveness. The need to routinely resect what may be indolent microscopic metastases remains a big open question.
The dilemma for thyroid cancer was nicely summarized by Gilbert Welch, MD, and his associates who highlighted the risk of overdiagnosing thyroid cancer with aggressive screening. In South Korea, this resulted in a 15-fold increase in thyroid cancer diagnoses between 1993 and 2011, which led to substantial increases in the rates of thyroidectomy including patients with tumors too small to warrant surgery (N Engl J Med. 2014 Nov 6;371[19]:1765-7).
Pamela Hartzband, MD , is an endocrinologist at Beth Israel Deaconess Medical Center in Boston. She had no disclosures. She made these comments in an interview.
BOSTON – More than a third of 63 patients with unilateral papillary thyroid carcinoma and ipsilateral lymph node metastases also had occult, contralateral, lateral-neck lymph nodes with metastases, but the low reported rate of contralateral neck recurrence has raised the question of whether routine resection of these contralateral lymph nodes benefits patients.
“Prophylactic contralateral lateral-neck dissection may not be relevant for patients with unilateral N1b tumors,” Dana Hartl, MD, PhD, said at the World Congress on Thyroid Cancer.
She envisioned a more targeted approach to using surgical resection of contralateral, lateral-neck lymph nodes. “We would still do this surgery for patients with lots of big, bulky nodules; it just takes an additional 10-20 minutes. It’s not that long or morbid. For patients with lots of [affected] nodes, you’ve got to clear it out. But for a patient with a small, level III node on one side I will no longer do [prophylactic, contralateral, lateral-neck lymph node removal].”
Dr. Hartl and her associates reviewed records for 63 patients with unilateral, unifocal papillary thyroid carcinoma who underwent prophylactic, contralateral, lymph node removal during 1997-2016. They ranged from 11-84 years old, and 60% had extrathyroidal extension of their primary tumor. The patients averaged having four lymph nodes with metastatic cells in the ipsilateral lateral neck, an average of five affected lymph nodes in the ipsilateral central neck, and an average of two affected lymph nodes in the contralateral central neck.
Among the 63 patients, 23 (37%) had metastases-containing lymph nodes at levels III and IV in the contralateral lateral neck, with a range of 1-17 metastases per node. All nodes were less than 1 cm in diameter. Extracapsular spread had occurred in 11 of the 23 cases.
The relatively frequent presence of metastases in the contralateral, lateral-neck lymph nodes contrasted with the reported low 5%-15% rate of recurrence in these lymph nodes in patients with N1b disease, Dr. Hartl said.
The analysis identified two factors that significantly linked with having contralateral, lateral-neck metastases: having a bilateral tumor with contralateral microcancer, or having at least four lymph nodes positive for metastases in the ipsilateral central compartment, she reported. When patients had fewer than five positive lymph nodes in the ipsilateral central neck, their risk for occult metastases in contralateral lymph nodes was 26%.
“It’s not very strong data; we were a little disappointed” with the results, Dr. Hartl said.
mzoler@frontlinemedcom.com
On Twitter @mitchelzoler
BOSTON – More than a third of 63 patients with unilateral papillary thyroid carcinoma and ipsilateral lymph node metastases also had occult, contralateral, lateral-neck lymph nodes with metastases, but the low reported rate of contralateral neck recurrence has raised the question of whether routine resection of these contralateral lymph nodes benefits patients.
“Prophylactic contralateral lateral-neck dissection may not be relevant for patients with unilateral N1b tumors,” Dana Hartl, MD, PhD, said at the World Congress on Thyroid Cancer.
She envisioned a more targeted approach to using surgical resection of contralateral, lateral-neck lymph nodes. “We would still do this surgery for patients with lots of big, bulky nodules; it just takes an additional 10-20 minutes. It’s not that long or morbid. For patients with lots of [affected] nodes, you’ve got to clear it out. But for a patient with a small, level III node on one side I will no longer do [prophylactic, contralateral, lateral-neck lymph node removal].”
Dr. Hartl and her associates reviewed records for 63 patients with unilateral, unifocal papillary thyroid carcinoma who underwent prophylactic, contralateral, lymph node removal during 1997-2016. They ranged from 11-84 years old, and 60% had extrathyroidal extension of their primary tumor. The patients averaged having four lymph nodes with metastatic cells in the ipsilateral lateral neck, an average of five affected lymph nodes in the ipsilateral central neck, and an average of two affected lymph nodes in the contralateral central neck.
Among the 63 patients, 23 (37%) had metastases-containing lymph nodes at levels III and IV in the contralateral lateral neck, with a range of 1-17 metastases per node. All nodes were less than 1 cm in diameter. Extracapsular spread had occurred in 11 of the 23 cases.
The relatively frequent presence of metastases in the contralateral, lateral-neck lymph nodes contrasted with the reported low 5%-15% rate of recurrence in these lymph nodes in patients with N1b disease, Dr. Hartl said.
The analysis identified two factors that significantly linked with having contralateral, lateral-neck metastases: having a bilateral tumor with contralateral microcancer, or having at least four lymph nodes positive for metastases in the ipsilateral central compartment, she reported. When patients had fewer than five positive lymph nodes in the ipsilateral central neck, their risk for occult metastases in contralateral lymph nodes was 26%.
“It’s not very strong data; we were a little disappointed” with the results, Dr. Hartl said.
mzoler@frontlinemedcom.com
On Twitter @mitchelzoler
AT WCTC 2017
Key clinical point:
Major finding: Thirty-seven percent of patients with unilateral N1b thyroid tumors also had metastases in their contralateral lateral-neck lymph nodes.
Data source: Review of 63 patients treated at a single French center during a 20-year period.
Disclosures: Dr. Hartl had no disclosures.
Thyroid-nodule size boosts serum thyroglobulin’s diagnostic value
BOSTON – Normalizing the serum thyroglobulin level by thyroid nodule size in patients surgically treated for a thyroid nodule produced a strongly significant link between the level of this marker and nodule malignancy in a review of nearly 200 patients treated at any of three Montreal centers.
After normalization, the serum thyroglobulin of patients with a malignant nodule averaged 51 mcg/L*cm, more than double the average 23 mcg/L*cm among patients with benign nodules, Neil Verma, MD, said at the World Congress on Thyroid Cancer.
But the senior investigator on the study said that, even if the MTNS+ gets a little more accurate by using a nodule size-normalized serum thyroglobulin level, the clinical utility of the MTNS+ will soon be completely eclipsed by widespread reliance on molecular tests, whereas the MTNS+ combines many clinical and conventional laboratory measures. It‘s only a matter of cost, said Richard J. Payne, MD, a head and neck surgeon at McGill.
Routine reimbursement for molecular diagnostic tests for the malignancy of thyroid nodules was discussed at a recent meeting of Canadian head and neck surgeons, who decided to lobby provincial governments to try to get it covered, according to Dr. Payne. “I’d be very surprised if we don’t have government coverage within 4-5 years,” in part because the cost for molecular testing will likely fall significantly in that time frame, he predicted.
The analysis reported by Dr. Verma included 196 patients with thyroid nodules who underwent a partial or total thyroidectomy at any of three McGill teaching hospitals during 2010-2015. He determined the benign or malignant status of their nodules based on their histology. The analysis he presented also showed that malignancy had no clear relationship to nodule size. Nodules that were less than 2 cm in diameter were about as likely to be malignant as were those that were 3 cm or larger in diameter, Dr. Verma reported.
Size-normalized serum thyroglobulin will now be incorporated into the MTNS+, which will be the fourth change to the original MTNS scoring system since it was developed more than a decade ago, noted Dr. Payne. But, while the MTNS+ allows better prediction of malignant potential than does the Bethesda system for evaluating nodule cytopathology in a fine-needle aspirate, it still falls short of molecular testing in its predictive accuracy, Dr. Payne said.
Dr. Verma and Dr. Payne had no disclosures.
mzoler@frontlinemedcom.com
On Twitter @mitchelzoler
BOSTON – Normalizing the serum thyroglobulin level by thyroid nodule size in patients surgically treated for a thyroid nodule produced a strongly significant link between the level of this marker and nodule malignancy in a review of nearly 200 patients treated at any of three Montreal centers.
After normalization, the serum thyroglobulin of patients with a malignant nodule averaged 51 mcg/L*cm, more than double the average 23 mcg/L*cm among patients with benign nodules, Neil Verma, MD, said at the World Congress on Thyroid Cancer.
But the senior investigator on the study said that, even if the MTNS+ gets a little more accurate by using a nodule size-normalized serum thyroglobulin level, the clinical utility of the MTNS+ will soon be completely eclipsed by widespread reliance on molecular tests, whereas the MTNS+ combines many clinical and conventional laboratory measures. It‘s only a matter of cost, said Richard J. Payne, MD, a head and neck surgeon at McGill.
Routine reimbursement for molecular diagnostic tests for the malignancy of thyroid nodules was discussed at a recent meeting of Canadian head and neck surgeons, who decided to lobby provincial governments to try to get it covered, according to Dr. Payne. “I’d be very surprised if we don’t have government coverage within 4-5 years,” in part because the cost for molecular testing will likely fall significantly in that time frame, he predicted.
The analysis reported by Dr. Verma included 196 patients with thyroid nodules who underwent a partial or total thyroidectomy at any of three McGill teaching hospitals during 2010-2015. He determined the benign or malignant status of their nodules based on their histology. The analysis he presented also showed that malignancy had no clear relationship to nodule size. Nodules that were less than 2 cm in diameter were about as likely to be malignant as were those that were 3 cm or larger in diameter, Dr. Verma reported.
Size-normalized serum thyroglobulin will now be incorporated into the MTNS+, which will be the fourth change to the original MTNS scoring system since it was developed more than a decade ago, noted Dr. Payne. But, while the MTNS+ allows better prediction of malignant potential than does the Bethesda system for evaluating nodule cytopathology in a fine-needle aspirate, it still falls short of molecular testing in its predictive accuracy, Dr. Payne said.
Dr. Verma and Dr. Payne had no disclosures.
mzoler@frontlinemedcom.com
On Twitter @mitchelzoler
BOSTON – Normalizing the serum thyroglobulin level by thyroid nodule size in patients surgically treated for a thyroid nodule produced a strongly significant link between the level of this marker and nodule malignancy in a review of nearly 200 patients treated at any of three Montreal centers.
After normalization, the serum thyroglobulin of patients with a malignant nodule averaged 51 mcg/L*cm, more than double the average 23 mcg/L*cm among patients with benign nodules, Neil Verma, MD, said at the World Congress on Thyroid Cancer.
But the senior investigator on the study said that, even if the MTNS+ gets a little more accurate by using a nodule size-normalized serum thyroglobulin level, the clinical utility of the MTNS+ will soon be completely eclipsed by widespread reliance on molecular tests, whereas the MTNS+ combines many clinical and conventional laboratory measures. It‘s only a matter of cost, said Richard J. Payne, MD, a head and neck surgeon at McGill.
Routine reimbursement for molecular diagnostic tests for the malignancy of thyroid nodules was discussed at a recent meeting of Canadian head and neck surgeons, who decided to lobby provincial governments to try to get it covered, according to Dr. Payne. “I’d be very surprised if we don’t have government coverage within 4-5 years,” in part because the cost for molecular testing will likely fall significantly in that time frame, he predicted.
The analysis reported by Dr. Verma included 196 patients with thyroid nodules who underwent a partial or total thyroidectomy at any of three McGill teaching hospitals during 2010-2015. He determined the benign or malignant status of their nodules based on their histology. The analysis he presented also showed that malignancy had no clear relationship to nodule size. Nodules that were less than 2 cm in diameter were about as likely to be malignant as were those that were 3 cm or larger in diameter, Dr. Verma reported.
Size-normalized serum thyroglobulin will now be incorporated into the MTNS+, which will be the fourth change to the original MTNS scoring system since it was developed more than a decade ago, noted Dr. Payne. But, while the MTNS+ allows better prediction of malignant potential than does the Bethesda system for evaluating nodule cytopathology in a fine-needle aspirate, it still falls short of molecular testing in its predictive accuracy, Dr. Payne said.
Dr. Verma and Dr. Payne had no disclosures.
mzoler@frontlinemedcom.com
On Twitter @mitchelzoler
AT WCTC 2017
Key clinical point:
Major finding: The average size-normalized serum thyroglobulin level was 51 mcg/L*cm in patients with malignant nodules and 23 mcg/L*cm with benign nodules.
Data source: Review of 196 patients who underwent partial or complete thyroidectomy at any of three Montreal centers.
Disclosures: Dr. Verma and Dr. Payne had no disclosures.
VIDEO: Less follow-up proposed for low-risk thyroid cancer
BOSTON – , Bryan R. Haugen, MD, suggested in a keynote lecture during the World Congress on Thyroid Cancer.
Traditionally, thyroid cancer specialists have monitored these patients for persistent or recurrent disease as often as every 6 or 12 months. “But what we’ve realized with recent assessments of response to treatment is that some patients do well without a recurrence over many years; so, the concept of doing less monitoring and less imaging, especially in patients with an excellent response [to their initial treatment], is being studied,” Dr. Haugen said in a video interview following his talk.
He estimated that perhaps two-thirds or as many as three-quarters of patients with differentiated thyroid cancer fall into the category of having low- or intermediate-risk disease with an excellent or good response to treatment, and hence they are potential candidates for eventually transitioning to less frequent follow-up.
During his talk, Dr. Haugen suggested that after several years with no sign of disease recurrence, lower-risk patients with an excellent treatment response may be able to stop undergoing regular monitoring, and those with a good treatment response may be able to safely have their monitoring intervals extended.
According to the most recent (2015) guidelines for differentiated thyroid cancer management from the American Thyroid Association, lower-risk patients with an excellent treatment response should have their serum thyroglobulin measured every 12-24 months and undergo an ultrasound examination every 3-5 years, while patients with a good response are targeted for serum thyroglobulin measurement annually with an ultrasound every 1-3 years (Thyroid. 2016 Jan;26[1]:1-133). Dr. Haugen chaired the expert panel that wrote these guidelines.
In another provocative suggestion, Dr. Haugen proposed that once well-responsive, lower-risk patients have remained disease free for several years, their less frequent follow-up monitoring could be continued by a primary care physician or another less specialized clinician.
At some time in the future, “a patient’s primary care physician could follow a simple tumor marker, thyroglobulin, maybe once every 5 years,” said Dr. Haugen, professor of medicine and head of the division of endocrinology, metabolism, and diabetes at the University of Colorado in Aurora. “At the University of Colorado, we use advanced-practice providers to do long-term follow-up” for lower-risk, treatment-responsive patients, he said.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @mitchelzoler
BOSTON – , Bryan R. Haugen, MD, suggested in a keynote lecture during the World Congress on Thyroid Cancer.
Traditionally, thyroid cancer specialists have monitored these patients for persistent or recurrent disease as often as every 6 or 12 months. “But what we’ve realized with recent assessments of response to treatment is that some patients do well without a recurrence over many years; so, the concept of doing less monitoring and less imaging, especially in patients with an excellent response [to their initial treatment], is being studied,” Dr. Haugen said in a video interview following his talk.
He estimated that perhaps two-thirds or as many as three-quarters of patients with differentiated thyroid cancer fall into the category of having low- or intermediate-risk disease with an excellent or good response to treatment, and hence they are potential candidates for eventually transitioning to less frequent follow-up.
During his talk, Dr. Haugen suggested that after several years with no sign of disease recurrence, lower-risk patients with an excellent treatment response may be able to stop undergoing regular monitoring, and those with a good treatment response may be able to safely have their monitoring intervals extended.
According to the most recent (2015) guidelines for differentiated thyroid cancer management from the American Thyroid Association, lower-risk patients with an excellent treatment response should have their serum thyroglobulin measured every 12-24 months and undergo an ultrasound examination every 3-5 years, while patients with a good response are targeted for serum thyroglobulin measurement annually with an ultrasound every 1-3 years (Thyroid. 2016 Jan;26[1]:1-133). Dr. Haugen chaired the expert panel that wrote these guidelines.
In another provocative suggestion, Dr. Haugen proposed that once well-responsive, lower-risk patients have remained disease free for several years, their less frequent follow-up monitoring could be continued by a primary care physician or another less specialized clinician.
At some time in the future, “a patient’s primary care physician could follow a simple tumor marker, thyroglobulin, maybe once every 5 years,” said Dr. Haugen, professor of medicine and head of the division of endocrinology, metabolism, and diabetes at the University of Colorado in Aurora. “At the University of Colorado, we use advanced-practice providers to do long-term follow-up” for lower-risk, treatment-responsive patients, he said.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @mitchelzoler
BOSTON – , Bryan R. Haugen, MD, suggested in a keynote lecture during the World Congress on Thyroid Cancer.
Traditionally, thyroid cancer specialists have monitored these patients for persistent or recurrent disease as often as every 6 or 12 months. “But what we’ve realized with recent assessments of response to treatment is that some patients do well without a recurrence over many years; so, the concept of doing less monitoring and less imaging, especially in patients with an excellent response [to their initial treatment], is being studied,” Dr. Haugen said in a video interview following his talk.
He estimated that perhaps two-thirds or as many as three-quarters of patients with differentiated thyroid cancer fall into the category of having low- or intermediate-risk disease with an excellent or good response to treatment, and hence they are potential candidates for eventually transitioning to less frequent follow-up.
During his talk, Dr. Haugen suggested that after several years with no sign of disease recurrence, lower-risk patients with an excellent treatment response may be able to stop undergoing regular monitoring, and those with a good treatment response may be able to safely have their monitoring intervals extended.
According to the most recent (2015) guidelines for differentiated thyroid cancer management from the American Thyroid Association, lower-risk patients with an excellent treatment response should have their serum thyroglobulin measured every 12-24 months and undergo an ultrasound examination every 3-5 years, while patients with a good response are targeted for serum thyroglobulin measurement annually with an ultrasound every 1-3 years (Thyroid. 2016 Jan;26[1]:1-133). Dr. Haugen chaired the expert panel that wrote these guidelines.
In another provocative suggestion, Dr. Haugen proposed that once well-responsive, lower-risk patients have remained disease free for several years, their less frequent follow-up monitoring could be continued by a primary care physician or another less specialized clinician.
At some time in the future, “a patient’s primary care physician could follow a simple tumor marker, thyroglobulin, maybe once every 5 years,” said Dr. Haugen, professor of medicine and head of the division of endocrinology, metabolism, and diabetes at the University of Colorado in Aurora. “At the University of Colorado, we use advanced-practice providers to do long-term follow-up” for lower-risk, treatment-responsive patients, he said.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @mitchelzoler
AT WCTC 2017
Is that thyroid nodule malignant?
ESTES PARK, COLO. – Before ordering any tests at all, an astute clinician can have a pretty good idea as to whether a palpable thyroid nodule is at higher or lower risk for being malignant based upon the patient’s history and physical examination, Michael T. McDermott, MD, said at a conference on internal medicine sponsored by the University of Colorado.
“The possibility of cancer is what scares people, and that’s what people want to know,” observed Dr. McDermott, professor of medicine and director of endocrinology and diabetes practice at University of Colorado Hospital.
This is a common clinical problem.
“If you felt the neck of every patient that you saw, 4%-7% would have a palpable thyroid nodule,” the endocrinologist said. 
Moreover, upon imaging the thyroid by ultrasound, CT, or MRI, the prevalence of a thyroid nodule is close to 40%. And because the prevalence increases with age, thyroid nodules are found at autopsy in 50%-60% of individuals.
Ninety percent of thyroid nodules are benign. And even when they are malignant, for the most part the prognosis is very good. Ten-year survival is in excess of 90% in patients with papillary, follicular, or Hurthle-cell thyroid cancer and greater than 60% in the 2%-5% of thyroid cancers classified as medullary. The one bad actor is anaplastic thyroid cancer, with a 1-year survival rate of less than 5%; however, only 2%-5% of thyroid cancers are of the anaplastic type.
The cancer risk of a palpable thyroid nodule is increased if it is 3 cm or larger in size, of a firm and fixed consistency, or cervical lymph nodes are palpable. Clues of increased risk from the patient history include a family history of papillary or medullary thyroid cancer, compressive symptoms such as a mass sensation or difficulty swallowing, or radiation therapy to the head and neck before age 20 years for treatment of acne, ringworm, or for tonsil/adenoid shrinkage, a fairly common practice in the 1950s and 1960s.
The first test to order in evaluating a thyroid nodule is always a serum TSH. If the level is low or undetectable, that’s a relief: It is not cancer. A mildly elevated free T4 and total T3 in conjunction with the low TSH indicate an autonomously functioning nodule.
In this situation, the next test to order is a radioactive iodine uptake and scan.
“Every nuclear medicine department in the country does these,” Dr. McDermott observed.
A normal radioactive iodine uptake value is 20%-40%; however, in the setting of suppressed serum TSH, there is no physiologic stimulation for uptake, so any uptake would be considered inappropriately high and constitutes confirmation that this is a patient with hyperthyroidism.
If the serum TSH is normal or high, there is no need to order a free T4 and total T3. Instead, the next test to order is a neck ultrasound; the size and features of the nodule upon imaging will determine the need for fine needle aspiration as a next step in the evaluation. Ultrasound findings suggestive of malignancy are a dark, hypoechoic nodule with irregular margins, microcalcifications, and/or increased blood flow upon Doppler imaging.
“Patterns and combinations of findings are more informative than any single finding,” he said.
Fine needle aspiration pathology results are reported as benign, malignant, or indeterminate. If the report is benign, there is still about a 2.5% chance of malignancy due to sampling error.
Molecular markers have a role in the 30% or more of fine needle aspiration results labeled indeterminate based upon a finding of atypia of unknown significance, a follicular lesion of unknown significance, or a follicular neoplasm. The Afirma gene expression classifier (Veracyte) has a high negative predictive value because it identifies patterns of mRNA expression consistent with benign tumors. The ThyroSeq oncogene panel (Interspace Diagnostics) has a moderate negative predictive value but a high positive predictive value. The tests each run about $1,200, but they spare patients with indeterminate aspiration biopsy findings from additional invasive diagnostic procedures – and the tests are covered by insurers.
“The gene expression classifier is a good test when you’re trying to avoid surgery, and the oncogene panel tells you when you really need surgery,” Dr. McDermott explained.
He recommends as a thyroid screen palpating the thyroid as part of a routine annual physical exam and ordering a serum TSH every 5 years starting at age 50. He is opposed to proactive ultrasound imaging of the thyroid as a means of screening for thyroid cancer because that practice picks up a huge number of nonharmful nodules.
Dr. McDermott cited the current American Thyroid Association guidelines on the evaluation and management of thyroid nodules as “one of the most important recent developments in the field.” The guidelines include detailed evidence-based recommendations regarding initial evaluation, criteria for fine-needle aspiration biopsy, interpretation of the biopsy results, use of molecular markers, and management of benign thyroid nodules. The guidelines also address the initial management of thyroid cancer and surveillance for recurrent disease.
Dr. McDermott reported having no financial conflicts regarding his presentation.
ESTES PARK, COLO. – Before ordering any tests at all, an astute clinician can have a pretty good idea as to whether a palpable thyroid nodule is at higher or lower risk for being malignant based upon the patient’s history and physical examination, Michael T. McDermott, MD, said at a conference on internal medicine sponsored by the University of Colorado.
“The possibility of cancer is what scares people, and that’s what people want to know,” observed Dr. McDermott, professor of medicine and director of endocrinology and diabetes practice at University of Colorado Hospital.
This is a common clinical problem.
“If you felt the neck of every patient that you saw, 4%-7% would have a palpable thyroid nodule,” the endocrinologist said.
Moreover, upon imaging the thyroid by ultrasound, CT, or MRI, the prevalence of a thyroid nodule is close to 40%. And because the prevalence increases with age, thyroid nodules are found at autopsy in 50%-60% of individuals.
Ninety percent of thyroid nodules are benign. And even when they are malignant, for the most part the prognosis is very good. Ten-year survival is in excess of 90% in patients with papillary, follicular, or Hurthle-cell thyroid cancer and greater than 60% in the 2%-5% of thyroid cancers classified as medullary. The one bad actor is anaplastic thyroid cancer, with a 1-year survival rate of less than 5%; however, only 2%-5% of thyroid cancers are of the anaplastic type.
The cancer risk of a palpable thyroid nodule is increased if it is 3 cm or larger in size, of a firm and fixed consistency, or cervical lymph nodes are palpable. Clues of increased risk from the patient history include a family history of papillary or medullary thyroid cancer, compressive symptoms such as a mass sensation or difficulty swallowing, or radiation therapy to the head and neck before age 20 years for treatment of acne, ringworm, or for tonsil/adenoid shrinkage, a fairly common practice in the 1950s and 1960s.
The first test to order in evaluating a thyroid nodule is always a serum TSH. If the level is low or undetectable, that’s a relief: It is not cancer. A mildly elevated free T4 and total T3 in conjunction with the low TSH indicate an autonomously functioning nodule.
In this situation, the next test to order is a radioactive iodine uptake and scan.
“Every nuclear medicine department in the country does these,” Dr. McDermott observed.
A normal radioactive iodine uptake value is 20%-40%; however, in the setting of suppressed serum TSH, there is no physiologic stimulation for uptake, so any uptake would be considered inappropriately high and constitutes confirmation that this is a patient with hyperthyroidism.
If the serum TSH is normal or high, there is no need to order a free T4 and total T3. Instead, the next test to order is a neck ultrasound; the size and features of the nodule upon imaging will determine the need for fine needle aspiration as a next step in the evaluation. Ultrasound findings suggestive of malignancy are a dark, hypoechoic nodule with irregular margins, microcalcifications, and/or increased blood flow upon Doppler imaging.
“Patterns and combinations of findings are more informative than any single finding,” he said.
Fine needle aspiration pathology results are reported as benign, malignant, or indeterminate. If the report is benign, there is still about a 2.5% chance of malignancy due to sampling error.
Molecular markers have a role in the 30% or more of fine needle aspiration results labeled indeterminate based upon a finding of atypia of unknown significance, a follicular lesion of unknown significance, or a follicular neoplasm. The Afirma gene expression classifier (Veracyte) has a high negative predictive value because it identifies patterns of mRNA expression consistent with benign tumors. The ThyroSeq oncogene panel (Interspace Diagnostics) has a moderate negative predictive value but a high positive predictive value. The tests each run about $1,200, but they spare patients with indeterminate aspiration biopsy findings from additional invasive diagnostic procedures – and the tests are covered by insurers.
“The gene expression classifier is a good test when you’re trying to avoid surgery, and the oncogene panel tells you when you really need surgery,” Dr. McDermott explained.
He recommends as a thyroid screen palpating the thyroid as part of a routine annual physical exam and ordering a serum TSH every 5 years starting at age 50. He is opposed to proactive ultrasound imaging of the thyroid as a means of screening for thyroid cancer because that practice picks up a huge number of nonharmful nodules.
Dr. McDermott cited the current American Thyroid Association guidelines on the evaluation and management of thyroid nodules as “one of the most important recent developments in the field.” The guidelines include detailed evidence-based recommendations regarding initial evaluation, criteria for fine-needle aspiration biopsy, interpretation of the biopsy results, use of molecular markers, and management of benign thyroid nodules. The guidelines also address the initial management of thyroid cancer and surveillance for recurrent disease.
Dr. McDermott reported having no financial conflicts regarding his presentation.
ESTES PARK, COLO. – Before ordering any tests at all, an astute clinician can have a pretty good idea as to whether a palpable thyroid nodule is at higher or lower risk for being malignant based upon the patient’s history and physical examination, Michael T. McDermott, MD, said at a conference on internal medicine sponsored by the University of Colorado.
“The possibility of cancer is what scares people, and that’s what people want to know,” observed Dr. McDermott, professor of medicine and director of endocrinology and diabetes practice at University of Colorado Hospital.
This is a common clinical problem.
“If you felt the neck of every patient that you saw, 4%-7% would have a palpable thyroid nodule,” the endocrinologist said.
Moreover, upon imaging the thyroid by ultrasound, CT, or MRI, the prevalence of a thyroid nodule is close to 40%. And because the prevalence increases with age, thyroid nodules are found at autopsy in 50%-60% of individuals.
Ninety percent of thyroid nodules are benign. And even when they are malignant, for the most part the prognosis is very good. Ten-year survival is in excess of 90% in patients with papillary, follicular, or Hurthle-cell thyroid cancer and greater than 60% in the 2%-5% of thyroid cancers classified as medullary. The one bad actor is anaplastic thyroid cancer, with a 1-year survival rate of less than 5%; however, only 2%-5% of thyroid cancers are of the anaplastic type.
The cancer risk of a palpable thyroid nodule is increased if it is 3 cm or larger in size, of a firm and fixed consistency, or cervical lymph nodes are palpable. Clues of increased risk from the patient history include a family history of papillary or medullary thyroid cancer, compressive symptoms such as a mass sensation or difficulty swallowing, or radiation therapy to the head and neck before age 20 years for treatment of acne, ringworm, or for tonsil/adenoid shrinkage, a fairly common practice in the 1950s and 1960s.
The first test to order in evaluating a thyroid nodule is always a serum TSH. If the level is low or undetectable, that’s a relief: It is not cancer. A mildly elevated free T4 and total T3 in conjunction with the low TSH indicate an autonomously functioning nodule.
In this situation, the next test to order is a radioactive iodine uptake and scan.
“Every nuclear medicine department in the country does these,” Dr. McDermott observed.
A normal radioactive iodine uptake value is 20%-40%; however, in the setting of suppressed serum TSH, there is no physiologic stimulation for uptake, so any uptake would be considered inappropriately high and constitutes confirmation that this is a patient with hyperthyroidism.
If the serum TSH is normal or high, there is no need to order a free T4 and total T3. Instead, the next test to order is a neck ultrasound; the size and features of the nodule upon imaging will determine the need for fine needle aspiration as a next step in the evaluation. Ultrasound findings suggestive of malignancy are a dark, hypoechoic nodule with irregular margins, microcalcifications, and/or increased blood flow upon Doppler imaging.
“Patterns and combinations of findings are more informative than any single finding,” he said.
Fine needle aspiration pathology results are reported as benign, malignant, or indeterminate. If the report is benign, there is still about a 2.5% chance of malignancy due to sampling error.
Molecular markers have a role in the 30% or more of fine needle aspiration results labeled indeterminate based upon a finding of atypia of unknown significance, a follicular lesion of unknown significance, or a follicular neoplasm. The Afirma gene expression classifier (Veracyte) has a high negative predictive value because it identifies patterns of mRNA expression consistent with benign tumors. The ThyroSeq oncogene panel (Interspace Diagnostics) has a moderate negative predictive value but a high positive predictive value. The tests each run about $1,200, but they spare patients with indeterminate aspiration biopsy findings from additional invasive diagnostic procedures – and the tests are covered by insurers.
“The gene expression classifier is a good test when you’re trying to avoid surgery, and the oncogene panel tells you when you really need surgery,” Dr. McDermott explained.
He recommends as a thyroid screen palpating the thyroid as part of a routine annual physical exam and ordering a serum TSH every 5 years starting at age 50. He is opposed to proactive ultrasound imaging of the thyroid as a means of screening for thyroid cancer because that practice picks up a huge number of nonharmful nodules.
Dr. McDermott cited the current American Thyroid Association guidelines on the evaluation and management of thyroid nodules as “one of the most important recent developments in the field.” The guidelines include detailed evidence-based recommendations regarding initial evaluation, criteria for fine-needle aspiration biopsy, interpretation of the biopsy results, use of molecular markers, and management of benign thyroid nodules. The guidelines also address the initial management of thyroid cancer and surveillance for recurrent disease.
Dr. McDermott reported having no financial conflicts regarding his presentation.
EXPERT ANALYSIS FROM THE ANNUAL INTERNAL MEDICINE PROGRAM
New trial shows thymectomy benefits myasthenia gravis
The effectiveness of thymectomy as a cure for myasthenia gravis has long been debated, but the publication of Myasthenia Gravis Thymectomy Treatment (MGTX) trial results, showing that thymectomy improved outcomes over 3 years in patients with nonthymomatous myasthenia gravis, has gone a long way toward settling the debate, Joshua R. Sonett, MD, and his coauthors noted in a feature expert opinion (J Thorac Cardiovasc Surg. 2017;154:306-9).
The MGTX trial randomized patients with nonthymomatous MG into two treatment groups: medical therapy alone or thymectomy with medical therapy (N Engl J Med. 2016;375:511-22). For uniformity, the study mandated one type of thymectomy, an extended transsternal approach. The study was 12 years in the making, with 6 years of patient accrual followed by 3 years of surveillance, Dr. Sonett and his coauthors noted.
Those markers include an average quantitative myasthenia score of 6.15 for the thymectomy group vs. 8.99 for the medical therapy group (P less than .0001); a lower dose of prednisone to attain improved neurologic status (44 mg vs. 60 mg; P less than .001); time-weighted average score on the Myasthenia Gravis Activities of Daily Living scale (2.24 vs. 3.41; P = .008); azathioprine use (17% vs. 48%; P less than .001); percentage of patients who had minimal-manifestation status at month 36 (67% vs. 47%; P = .03); and hospitalization for myasthenia-related symptoms (9% vs. 37%). “Interestingly,” the researchers wrote, “despite these quantitative results, no difference was seen in the quality of life measured surveys.”
An ancillary study, Bio-MGTX, was performed simultaneously to investigate pathologic and serum markers. “Many questions still need to be answered in regard to the role of thymectomy in MG,” Dr. Sonett and his coauthors maintained. They include an analysis of radiologic predictors of success with thymectomy, and the role of thymectomy in seronegative MG, ocular MG and elderly patients.
“Future studies may be directed at achieving a more rapid and consistent time to a complete symptom response,” they said.
The MGTX trial does support the use of high-dose prednisone induction combined with thymectomy to achieve higher complete early remission rates, but Bio-MGTX data may help to refine induction protocols. “The debate will likely continue in regard to widespread adoption of extended transsternal maximal thymectomy,” the researchers wrote. “What was categorically measured in this trial was the effect of maximal thymectomy, as sternotomy offers no particular independent therapeutic benefit.”
The structure of the MGTX trial despite its small cohort (126) “enabled the medical and surgical community to definitively answer an important question,” they noted. Nonetheless, further investigation of the role of thymectomy in MG is “sorely needed.”
Patients may need up to 3 years to achieve an optimal response, and complete cure in a shorter time frame should be the goal for each patient. Multimodal therapy should be the basis of MG treatment. “Continued progress in the management of MG will require diligent, multidisciplinary teams designing and completing prospective studies like the MGTX,” the researchers wrote.
Dr. Sonett and his coauthors had no financial relationships to disclose. The MGTX trial was funded by the U.S. National Institute of Neurological Disorders and Stroke. There was no commercial support for the trial.
In the MGTX trial, patients in the thymectomy group still needed a high average dose of prednisone, and the rates of remission may decrease over time, Michael K. Hsin, MD, of Queen Mary Hospital, Hong Kong, wrote in his invited commentary (J Thorac Cardiovasc Surg. 2017;154:310-1). But he added that the trial did finally answer in a positive manner whether thymectomy could serve a beneficial role.
He also noted that the MGTX trial left at least four questions unanswered:
• The long-term effect of thymectomy on MG status with regard to future relapse.
• The role of surgery in the era of advances in medical treatment, including azathioprine to reduce the prednisone dose and emergence of stem-cell transplantation.
• The extent to which MGTX findings can be applied to acetylcholine receptor-negative pediatric patients.
• Whether alternative techniques to extended transsternal thymectomy can achieve comparable results.
Dr. Hsin had no financial relationships to disclose.
In the MGTX trial, patients in the thymectomy group still needed a high average dose of prednisone, and the rates of remission may decrease over time, Michael K. Hsin, MD, of Queen Mary Hospital, Hong Kong, wrote in his invited commentary (J Thorac Cardiovasc Surg. 2017;154:310-1). But he added that the trial did finally answer in a positive manner whether thymectomy could serve a beneficial role.
He also noted that the MGTX trial left at least four questions unanswered:
• The long-term effect of thymectomy on MG status with regard to future relapse.
• The role of surgery in the era of advances in medical treatment, including azathioprine to reduce the prednisone dose and emergence of stem-cell transplantation.
• The extent to which MGTX findings can be applied to acetylcholine receptor-negative pediatric patients.
• Whether alternative techniques to extended transsternal thymectomy can achieve comparable results.
Dr. Hsin had no financial relationships to disclose.
In the MGTX trial, patients in the thymectomy group still needed a high average dose of prednisone, and the rates of remission may decrease over time, Michael K. Hsin, MD, of Queen Mary Hospital, Hong Kong, wrote in his invited commentary (J Thorac Cardiovasc Surg. 2017;154:310-1). But he added that the trial did finally answer in a positive manner whether thymectomy could serve a beneficial role.
He also noted that the MGTX trial left at least four questions unanswered:
• The long-term effect of thymectomy on MG status with regard to future relapse.
• The role of surgery in the era of advances in medical treatment, including azathioprine to reduce the prednisone dose and emergence of stem-cell transplantation.
• The extent to which MGTX findings can be applied to acetylcholine receptor-negative pediatric patients.
• Whether alternative techniques to extended transsternal thymectomy can achieve comparable results.
Dr. Hsin had no financial relationships to disclose.
The effectiveness of thymectomy as a cure for myasthenia gravis has long been debated, but the publication of Myasthenia Gravis Thymectomy Treatment (MGTX) trial results, showing that thymectomy improved outcomes over 3 years in patients with nonthymomatous myasthenia gravis, has gone a long way toward settling the debate, Joshua R. Sonett, MD, and his coauthors noted in a feature expert opinion (J Thorac Cardiovasc Surg. 2017;154:306-9).
The MGTX trial randomized patients with nonthymomatous MG into two treatment groups: medical therapy alone or thymectomy with medical therapy (N Engl J Med. 2016;375:511-22). For uniformity, the study mandated one type of thymectomy, an extended transsternal approach. The study was 12 years in the making, with 6 years of patient accrual followed by 3 years of surveillance, Dr. Sonett and his coauthors noted.
Those markers include an average quantitative myasthenia score of 6.15 for the thymectomy group vs. 8.99 for the medical therapy group (P less than .0001); a lower dose of prednisone to attain improved neurologic status (44 mg vs. 60 mg; P less than .001); time-weighted average score on the Myasthenia Gravis Activities of Daily Living scale (2.24 vs. 3.41; P = .008); azathioprine use (17% vs. 48%; P less than .001); percentage of patients who had minimal-manifestation status at month 36 (67% vs. 47%; P = .03); and hospitalization for myasthenia-related symptoms (9% vs. 37%). “Interestingly,” the researchers wrote, “despite these quantitative results, no difference was seen in the quality of life measured surveys.”
An ancillary study, Bio-MGTX, was performed simultaneously to investigate pathologic and serum markers. “Many questions still need to be answered in regard to the role of thymectomy in MG,” Dr. Sonett and his coauthors maintained. They include an analysis of radiologic predictors of success with thymectomy, and the role of thymectomy in seronegative MG, ocular MG and elderly patients.
“Future studies may be directed at achieving a more rapid and consistent time to a complete symptom response,” they said.
The MGTX trial does support the use of high-dose prednisone induction combined with thymectomy to achieve higher complete early remission rates, but Bio-MGTX data may help to refine induction protocols. “The debate will likely continue in regard to widespread adoption of extended transsternal maximal thymectomy,” the researchers wrote. “What was categorically measured in this trial was the effect of maximal thymectomy, as sternotomy offers no particular independent therapeutic benefit.”
The structure of the MGTX trial despite its small cohort (126) “enabled the medical and surgical community to definitively answer an important question,” they noted. Nonetheless, further investigation of the role of thymectomy in MG is “sorely needed.”
Patients may need up to 3 years to achieve an optimal response, and complete cure in a shorter time frame should be the goal for each patient. Multimodal therapy should be the basis of MG treatment. “Continued progress in the management of MG will require diligent, multidisciplinary teams designing and completing prospective studies like the MGTX,” the researchers wrote.
Dr. Sonett and his coauthors had no financial relationships to disclose. The MGTX trial was funded by the U.S. National Institute of Neurological Disorders and Stroke. There was no commercial support for the trial.
The effectiveness of thymectomy as a cure for myasthenia gravis has long been debated, but the publication of Myasthenia Gravis Thymectomy Treatment (MGTX) trial results, showing that thymectomy improved outcomes over 3 years in patients with nonthymomatous myasthenia gravis, has gone a long way toward settling the debate, Joshua R. Sonett, MD, and his coauthors noted in a feature expert opinion (J Thorac Cardiovasc Surg. 2017;154:306-9).
The MGTX trial randomized patients with nonthymomatous MG into two treatment groups: medical therapy alone or thymectomy with medical therapy (N Engl J Med. 2016;375:511-22). For uniformity, the study mandated one type of thymectomy, an extended transsternal approach. The study was 12 years in the making, with 6 years of patient accrual followed by 3 years of surveillance, Dr. Sonett and his coauthors noted.
Those markers include an average quantitative myasthenia score of 6.15 for the thymectomy group vs. 8.99 for the medical therapy group (P less than .0001); a lower dose of prednisone to attain improved neurologic status (44 mg vs. 60 mg; P less than .001); time-weighted average score on the Myasthenia Gravis Activities of Daily Living scale (2.24 vs. 3.41; P = .008); azathioprine use (17% vs. 48%; P less than .001); percentage of patients who had minimal-manifestation status at month 36 (67% vs. 47%; P = .03); and hospitalization for myasthenia-related symptoms (9% vs. 37%). “Interestingly,” the researchers wrote, “despite these quantitative results, no difference was seen in the quality of life measured surveys.”
An ancillary study, Bio-MGTX, was performed simultaneously to investigate pathologic and serum markers. “Many questions still need to be answered in regard to the role of thymectomy in MG,” Dr. Sonett and his coauthors maintained. They include an analysis of radiologic predictors of success with thymectomy, and the role of thymectomy in seronegative MG, ocular MG and elderly patients.
“Future studies may be directed at achieving a more rapid and consistent time to a complete symptom response,” they said.
The MGTX trial does support the use of high-dose prednisone induction combined with thymectomy to achieve higher complete early remission rates, but Bio-MGTX data may help to refine induction protocols. “The debate will likely continue in regard to widespread adoption of extended transsternal maximal thymectomy,” the researchers wrote. “What was categorically measured in this trial was the effect of maximal thymectomy, as sternotomy offers no particular independent therapeutic benefit.”
The structure of the MGTX trial despite its small cohort (126) “enabled the medical and surgical community to definitively answer an important question,” they noted. Nonetheless, further investigation of the role of thymectomy in MG is “sorely needed.”
Patients may need up to 3 years to achieve an optimal response, and complete cure in a shorter time frame should be the goal for each patient. Multimodal therapy should be the basis of MG treatment. “Continued progress in the management of MG will require diligent, multidisciplinary teams designing and completing prospective studies like the MGTX,” the researchers wrote.
Dr. Sonett and his coauthors had no financial relationships to disclose. The MGTX trial was funded by the U.S. National Institute of Neurological Disorders and Stroke. There was no commercial support for the trial.
FROM THE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY
Key clinical point: A recently published prospective randomized trial provides definitive evidence that thymectomy significantly improves outcomes of patients with myasthenia gravis.
Major finding: Patients who underwent thymectomy had an average quantitative myasthenia score of 6.15 vs. 8.99 for the medical therapy group, a significant difference.
Data source: Myasthenia Gravis Thymectomy Trial, a prospective trial of 126 patients randomized to thymectomy with medical therapy or medical therapy alone.
Disclosures: Dr. Sonett and his coauthors had no financial relationships to disclose. The MGTX trial was funded by the U.S. National Institute of Neurological Disorders and Stroke. There was no commercial support for the trial.
Surgeon, primary care collaboration needed to catch hyperparathyroidism
A report from the University of Alabama at Birmingham provides further evidence that hyperparathyroidism is often missed in the United States health care system.
Investigators reviewed the electronic health records for 682,704 patients at the university from 2011 to 2015 and identified hypercalcemia (serum calcium greater than 10.5 mg/dL) – usually the first indication of disease – in 10,432 patients. The next step should have been a parathyroid hormone (PTH) measurement, but PTH was measured in only 3,200 patients (31%), and it usually took multiple abnormal calcium levels before PTH was checked, reported Courtney Balentine, MD, and her colleagues at the University of Alabama at Birmingham.
In addition, 592 of 2,666 patients (22%) with both elevated calcium and PTH levels were referred to surgeons for a parathyroidectomy consult, although parathyroidectomy is a low-risk outpatient procedure that cures up to 95% of patients, and surgeons are best suited to discuss the risks and benefits of the procedure with patients, investigators said (Ann Surg. 2017 Jul 3. doi: 10.1097/SLA.0000000000002370).
Underdiagnosis and treatment of hyperparathyroidism can lead to fractures, kidney stones, depression, cognitive impairment, hypertension, stroke, and myocardial infarction.
The investigators plan to meet with primary care doctors to hear how they think the problem should be addressed. Alerts and automatic referrals are also being considered for the EHR. “The combination of systems changes and stakeholder engagement is more likely to succeed than focusing on one component to the exclusion of others,” Dr. Balentine and colleagues said.
The issue could be that primary care physicians are just too overwhelmed to notice or be concerned about an isolated abnormal calcium level in an otherwise routine assessment. Or perhaps they assume surgeons come into play only if there are kidney stones, bone changes, or other obvious signs of trouble, they said.
The team has started to look at charts to get a better understanding of what’s going wrong. “I have been a little bit flabbergasted by how many excuses there are for either not checking a PTH or not referring once the diagnosis is there. … ‘This patient probably would not benefit from the surgery; the risk is too high; he or she does not want X, Y, or Z.’ I think if they just refer [patients to surgeons] to have the conversation, we might very well agree with them, but at least we [could] have the conversation with the patient, and I think [that] would make more sense,” Dr. Balentine said in a transcript of a question and answer session that was published with the report.
“Indeed, the recent American Association of Endocrine Surgery guidelines emphasize the importance of referring patients to surgical experts for discussion of treatment options,” the investigators said in the report.
It’s possible that elevated calcium and PTH levels were evaluated and treated at other institutions and so were not captured by the analysis. “Our mean follow-up was 16 months, however, which suggests that most patients were seen in the UAB system long enough to undergo appropriate evaluation and referral.” Also, patients with “two or more abnormal calcium values had similarly low rates of surgical referral, which suggests that loss to follow-up is unlikely to explain our findings,” they said.
The mean age of the cohort was 54 years; 56% of the patients were white, and 61% were women.
The work was supported by the Agency for Healthcare Research and Quality. The authors reported no conflicts of interest.
A report from the University of Alabama at Birmingham provides further evidence that hyperparathyroidism is often missed in the United States health care system.
Investigators reviewed the electronic health records for 682,704 patients at the university from 2011 to 2015 and identified hypercalcemia (serum calcium greater than 10.5 mg/dL) – usually the first indication of disease – in 10,432 patients. The next step should have been a parathyroid hormone (PTH) measurement, but PTH was measured in only 3,200 patients (31%), and it usually took multiple abnormal calcium levels before PTH was checked, reported Courtney Balentine, MD, and her colleagues at the University of Alabama at Birmingham.
In addition, 592 of 2,666 patients (22%) with both elevated calcium and PTH levels were referred to surgeons for a parathyroidectomy consult, although parathyroidectomy is a low-risk outpatient procedure that cures up to 95% of patients, and surgeons are best suited to discuss the risks and benefits of the procedure with patients, investigators said (Ann Surg. 2017 Jul 3. doi: 10.1097/SLA.0000000000002370).
Underdiagnosis and treatment of hyperparathyroidism can lead to fractures, kidney stones, depression, cognitive impairment, hypertension, stroke, and myocardial infarction.
The investigators plan to meet with primary care doctors to hear how they think the problem should be addressed. Alerts and automatic referrals are also being considered for the EHR. “The combination of systems changes and stakeholder engagement is more likely to succeed than focusing on one component to the exclusion of others,” Dr. Balentine and colleagues said.
The issue could be that primary care physicians are just too overwhelmed to notice or be concerned about an isolated abnormal calcium level in an otherwise routine assessment. Or perhaps they assume surgeons come into play only if there are kidney stones, bone changes, or other obvious signs of trouble, they said.
The team has started to look at charts to get a better understanding of what’s going wrong. “I have been a little bit flabbergasted by how many excuses there are for either not checking a PTH or not referring once the diagnosis is there. … ‘This patient probably would not benefit from the surgery; the risk is too high; he or she does not want X, Y, or Z.’ I think if they just refer [patients to surgeons] to have the conversation, we might very well agree with them, but at least we [could] have the conversation with the patient, and I think [that] would make more sense,” Dr. Balentine said in a transcript of a question and answer session that was published with the report.
“Indeed, the recent American Association of Endocrine Surgery guidelines emphasize the importance of referring patients to surgical experts for discussion of treatment options,” the investigators said in the report.
It’s possible that elevated calcium and PTH levels were evaluated and treated at other institutions and so were not captured by the analysis. “Our mean follow-up was 16 months, however, which suggests that most patients were seen in the UAB system long enough to undergo appropriate evaluation and referral.” Also, patients with “two or more abnormal calcium values had similarly low rates of surgical referral, which suggests that loss to follow-up is unlikely to explain our findings,” they said.
The mean age of the cohort was 54 years; 56% of the patients were white, and 61% were women.
The work was supported by the Agency for Healthcare Research and Quality. The authors reported no conflicts of interest.
A report from the University of Alabama at Birmingham provides further evidence that hyperparathyroidism is often missed in the United States health care system.
Investigators reviewed the electronic health records for 682,704 patients at the university from 2011 to 2015 and identified hypercalcemia (serum calcium greater than 10.5 mg/dL) – usually the first indication of disease – in 10,432 patients. The next step should have been a parathyroid hormone (PTH) measurement, but PTH was measured in only 3,200 patients (31%), and it usually took multiple abnormal calcium levels before PTH was checked, reported Courtney Balentine, MD, and her colleagues at the University of Alabama at Birmingham.
In addition, 592 of 2,666 patients (22%) with both elevated calcium and PTH levels were referred to surgeons for a parathyroidectomy consult, although parathyroidectomy is a low-risk outpatient procedure that cures up to 95% of patients, and surgeons are best suited to discuss the risks and benefits of the procedure with patients, investigators said (Ann Surg. 2017 Jul 3. doi: 10.1097/SLA.0000000000002370).
Underdiagnosis and treatment of hyperparathyroidism can lead to fractures, kidney stones, depression, cognitive impairment, hypertension, stroke, and myocardial infarction.
The investigators plan to meet with primary care doctors to hear how they think the problem should be addressed. Alerts and automatic referrals are also being considered for the EHR. “The combination of systems changes and stakeholder engagement is more likely to succeed than focusing on one component to the exclusion of others,” Dr. Balentine and colleagues said.
The issue could be that primary care physicians are just too overwhelmed to notice or be concerned about an isolated abnormal calcium level in an otherwise routine assessment. Or perhaps they assume surgeons come into play only if there are kidney stones, bone changes, or other obvious signs of trouble, they said.
The team has started to look at charts to get a better understanding of what’s going wrong. “I have been a little bit flabbergasted by how many excuses there are for either not checking a PTH or not referring once the diagnosis is there. … ‘This patient probably would not benefit from the surgery; the risk is too high; he or she does not want X, Y, or Z.’ I think if they just refer [patients to surgeons] to have the conversation, we might very well agree with them, but at least we [could] have the conversation with the patient, and I think [that] would make more sense,” Dr. Balentine said in a transcript of a question and answer session that was published with the report.
“Indeed, the recent American Association of Endocrine Surgery guidelines emphasize the importance of referring patients to surgical experts for discussion of treatment options,” the investigators said in the report.
It’s possible that elevated calcium and PTH levels were evaluated and treated at other institutions and so were not captured by the analysis. “Our mean follow-up was 16 months, however, which suggests that most patients were seen in the UAB system long enough to undergo appropriate evaluation and referral.” Also, patients with “two or more abnormal calcium values had similarly low rates of surgical referral, which suggests that loss to follow-up is unlikely to explain our findings,” they said.
The mean age of the cohort was 54 years; 56% of the patients were white, and 61% were women.
The work was supported by the Agency for Healthcare Research and Quality. The authors reported no conflicts of interest.
FROM ANNALS OF SURGERY
Key clinical point:
Major finding: Just 31% of patients with a finding of hypercalcemia went on to have their parathyroid hormone levels checked.
Data source: Electronic health record review of 682,704 patients at a large American university.
Disclosures: The work was supported by the Agency for Healthcare Research and Quality. The authors reported no conflicts of interest.
Sjögren’s syndrome most common extrahepatic PBC manifestation
Extrahepatic manifestations of primary biliary cholangitis (PBC) occur in 73% of patients, with Sjögren’s syndrome, thyroid dysfunction, and systemic sclerosis being the most common, according to a literature review from Sara Chalifoux, MD, and her associates.
Sjögren’s syndrome occurs in 3.5%-73% of PBC patients, usually presenting with dry eyes and oral complications. Sjögren’s treatment in PBC patients involves symptom management associated with exocrine gland infiltration.
Thyroid diseases are present in 5.6%-23.6% of PBC patients. Hashimoto’s thyroiditis is the most common hypothyroidism in PBC patients, presenting with symptoms such as constipation, bradycardia, oligomenorrhea, and inability to concentrate. Grave’s disease is the most common hyperthyroidism, presenting with symptoms such as palpitations, tremulousness, heat intolerance, and weight loss.
Systemic sclerosis occurs in 1.4%-12.3% of PBC patients. Multiple studies found that limited cutaneous systemic sclerosis was more common in PBC patients than was the diffuse form of the disease.
Other diseases that may have a connection to PBC but lack solid, compelling evidence to make a firm association include rheumatoid arthritis, systemic lupus erythematosus, and celiac disease. While many PBC patients have irritable bowel disorder, there is no significant association between the two conditions.
“The patient care team should include practitioners in rheumatology, endocrinology, pulmonology, and cardiology when indicated. Patients should follow up regularly with their primary care physicians. As some of these extrahepatic manifestations can lead to diseases with a poor prognosis, vigilant screening and close follow-up will lead to prompt identification and treatment,” the investigators noted.
The investigators reported no financial conflicts of interest.
Find the full study in Gut and Liver (doi: 10.5009/gnl16365).
Extrahepatic manifestations of primary biliary cholangitis (PBC) occur in 73% of patients, with Sjögren’s syndrome, thyroid dysfunction, and systemic sclerosis being the most common, according to a literature review from Sara Chalifoux, MD, and her associates.
Sjögren’s syndrome occurs in 3.5%-73% of PBC patients, usually presenting with dry eyes and oral complications. Sjögren’s treatment in PBC patients involves symptom management associated with exocrine gland infiltration.
Thyroid diseases are present in 5.6%-23.6% of PBC patients. Hashimoto’s thyroiditis is the most common hypothyroidism in PBC patients, presenting with symptoms such as constipation, bradycardia, oligomenorrhea, and inability to concentrate. Grave’s disease is the most common hyperthyroidism, presenting with symptoms such as palpitations, tremulousness, heat intolerance, and weight loss.
Systemic sclerosis occurs in 1.4%-12.3% of PBC patients. Multiple studies found that limited cutaneous systemic sclerosis was more common in PBC patients than was the diffuse form of the disease.
Other diseases that may have a connection to PBC but lack solid, compelling evidence to make a firm association include rheumatoid arthritis, systemic lupus erythematosus, and celiac disease. While many PBC patients have irritable bowel disorder, there is no significant association between the two conditions.
“The patient care team should include practitioners in rheumatology, endocrinology, pulmonology, and cardiology when indicated. Patients should follow up regularly with their primary care physicians. As some of these extrahepatic manifestations can lead to diseases with a poor prognosis, vigilant screening and close follow-up will lead to prompt identification and treatment,” the investigators noted.
The investigators reported no financial conflicts of interest.
Find the full study in Gut and Liver (doi: 10.5009/gnl16365).
Extrahepatic manifestations of primary biliary cholangitis (PBC) occur in 73% of patients, with Sjögren’s syndrome, thyroid dysfunction, and systemic sclerosis being the most common, according to a literature review from Sara Chalifoux, MD, and her associates.
Sjögren’s syndrome occurs in 3.5%-73% of PBC patients, usually presenting with dry eyes and oral complications. Sjögren’s treatment in PBC patients involves symptom management associated with exocrine gland infiltration.
Thyroid diseases are present in 5.6%-23.6% of PBC patients. Hashimoto’s thyroiditis is the most common hypothyroidism in PBC patients, presenting with symptoms such as constipation, bradycardia, oligomenorrhea, and inability to concentrate. Grave’s disease is the most common hyperthyroidism, presenting with symptoms such as palpitations, tremulousness, heat intolerance, and weight loss.
Systemic sclerosis occurs in 1.4%-12.3% of PBC patients. Multiple studies found that limited cutaneous systemic sclerosis was more common in PBC patients than was the diffuse form of the disease.
Other diseases that may have a connection to PBC but lack solid, compelling evidence to make a firm association include rheumatoid arthritis, systemic lupus erythematosus, and celiac disease. While many PBC patients have irritable bowel disorder, there is no significant association between the two conditions.
“The patient care team should include practitioners in rheumatology, endocrinology, pulmonology, and cardiology when indicated. Patients should follow up regularly with their primary care physicians. As some of these extrahepatic manifestations can lead to diseases with a poor prognosis, vigilant screening and close follow-up will lead to prompt identification and treatment,” the investigators noted.
The investigators reported no financial conflicts of interest.
Find the full study in Gut and Liver (doi: 10.5009/gnl16365).
FROM GUT AND LIVER