Pituitary, Thyroid & Adrenal Disorders

BOSTON – Eighty-six percent of Graves disease patients with TSH receptor antibody levels of at least 2.0 mU/L at the end of thionamide therapy will relapse within 4 years, according to a British review.

TSH receptor antibody (TRAb) levels “are useful not only as a diagnostic tool but also as a prognostic tool. In patients where the risks of recurrent thyrotoxicosis are unacceptably high” – the elderly and those at risk for cardiovascular disease – “strong consideration should be given to primary radioiodine therapy” instead of thionamides, said investigator Nyo Nyo Tun of the Edinburgh Centre for Endocrinology and Diabetes.

Previous studies have suggested age and other risk factors for relapse after thionamides, but “have not [definitively] shown if elevation of TRAb levels” are predictive, she said at the annual meeting of the Endocrine Society.

Primary therapy with thionamides is more common in Europe than in the United States, where radioiodine tends to be the first choice. Part of the problem is that recurrence is known to be high after thionamides. The study suggests that using TRAb can help weed out patients who are likely to fail so that thionamides can be used with greater long-term success. Ms. Tun said the Edinburgh center routinely uses TRAb to guide Graves treatment; patients with high levels either stay on thionamide for prolonged periods or opt for radioiodine.

The investigators retrospectively studied 266 patients with a first presentation of Graves disease who completed a course of thionamide at two U.K. hospitals. In addition to TRAb levels at diagnosis and cessation of thionamide, they assessed age, sex, smoking status, free T₄ levels, total T₃, and time to normalization of thyroid function over 4 years of follow-up.

After thionamide cessation, thyrotoxicosis recurred in 31% of patients (82/266) at 1 year, 43% (111/261) at 2 years, 54% (125/232) at 3 years, and 66% (128/193) at 4 years.

Very high TRAb levels at diagnosis – those above 12 mU/L – were associated with a statistically significant 84% risk of recurrence over a 4-year period, compared with a 57% risk with diagnosis levels below 5mU/L (P = .002).

TRAb levels below 0.9 mU/L at cessation of an 18-month course of thionamide treatment were associated with a 22% risk of recurrence at 1 year and a 58% risk at 4 years. Those risks were significantly higher in patients whose TRAb levels were at least 2 mU/L at thionamide cessation, who had a 51% risk at 1 year and an 86% risk at 4 years (P less than 0.001). Relapse risk was highest in the first 18 months after cessation.

Younger age and time to TSH normalization also predicted relapse to some extent. Among patients who stayed in remission for 4 years, TSH normalized at a median of about 4 months after the start of drug treatment, but 6 months in those who relapsed. Similarly, patients who relapsed were a median of 39 years old at diagnosis; those who did not were a median of 47.

The investigators had no relevant financial disclosures.

BOSTON – Eighty-six percent of Graves disease patients with TSH receptor antibody levels of at least 2.0 mU/L at the end of thionamide therapy will relapse within 4 years, according to a British review.

TSH receptor antibody (TRAb) levels “are useful not only as a diagnostic tool but also as a prognostic tool. In patients where the risks of recurrent thyrotoxicosis are unacceptably high” – the elderly and those at risk for cardiovascular disease – “strong consideration should be given to primary radioiodine therapy” instead of thionamides, said investigator Nyo Nyo Tun of the Edinburgh Centre for Endocrinology and Diabetes.

Previous studies have suggested age and other risk factors for relapse after thionamides, but “have not [definitively] shown if elevation of TRAb levels” are predictive, she said at the annual meeting of the Endocrine Society.

Primary therapy with thionamides is more common in Europe than in the United States, where radioiodine tends to be the first choice. Part of the problem is that recurrence is known to be high after thionamides. The study suggests that using TRAb can help weed out patients who are likely to fail so that thionamides can be used with greater long-term success. Ms. Tun said the Edinburgh center routinely uses TRAb to guide Graves treatment; patients with high levels either stay on thionamide for prolonged periods or opt for radioiodine.

The investigators retrospectively studied 266 patients with a first presentation of Graves disease who completed a course of thionamide at two U.K. hospitals. In addition to TRAb levels at diagnosis and cessation of thionamide, they assessed age, sex, smoking status, free T₄ levels, total T₃, and time to normalization of thyroid function over 4 years of follow-up.

After thionamide cessation, thyrotoxicosis recurred in 31% of patients (82/266) at 1 year, 43% (111/261) at 2 years, 54% (125/232) at 3 years, and 66% (128/193) at 4 years.

Very high TRAb levels at diagnosis – those above 12 mU/L – were associated with a statistically significant 84% risk of recurrence over a 4-year period, compared with a 57% risk with diagnosis levels below 5mU/L (P = .002).

TRAb levels below 0.9 mU/L at cessation of an 18-month course of thionamide treatment were associated with a 22% risk of recurrence at 1 year and a 58% risk at 4 years. Those risks were significantly higher in patients whose TRAb levels were at least 2 mU/L at thionamide cessation, who had a 51% risk at 1 year and an 86% risk at 4 years (P less than 0.001). Relapse risk was highest in the first 18 months after cessation.

Younger age and time to TSH normalization also predicted relapse to some extent. Among patients who stayed in remission for 4 years, TSH normalized at a median of about 4 months after the start of drug treatment, but 6 months in those who relapsed. Similarly, patients who relapsed were a median of 39 years old at diagnosis; those who did not were a median of 47.

The investigators had no relevant financial disclosures.

BOSTON – Eighty-six percent of Graves disease patients with TSH receptor antibody levels of at least 2.0 mU/L at the end of thionamide therapy will relapse within 4 years, according to a British review.

TSH receptor antibody (TRAb) levels “are useful not only as a diagnostic tool but also as a prognostic tool. In patients where the risks of recurrent thyrotoxicosis are unacceptably high” – the elderly and those at risk for cardiovascular disease – “strong consideration should be given to primary radioiodine therapy” instead of thionamides, said investigator Nyo Nyo Tun of the Edinburgh Centre for Endocrinology and Diabetes.

Previous studies have suggested age and other risk factors for relapse after thionamides, but “have not [definitively] shown if elevation of TRAb levels” are predictive, she said at the annual meeting of the Endocrine Society.

Primary therapy with thionamides is more common in Europe than in the United States, where radioiodine tends to be the first choice. Part of the problem is that recurrence is known to be high after thionamides. The study suggests that using TRAb can help weed out patients who are likely to fail so that thionamides can be used with greater long-term success. Ms. Tun said the Edinburgh center routinely uses TRAb to guide Graves treatment; patients with high levels either stay on thionamide for prolonged periods or opt for radioiodine.

The investigators retrospectively studied 266 patients with a first presentation of Graves disease who completed a course of thionamide at two U.K. hospitals. In addition to TRAb levels at diagnosis and cessation of thionamide, they assessed age, sex, smoking status, free T₄ levels, total T₃, and time to normalization of thyroid function over 4 years of follow-up.

After thionamide cessation, thyrotoxicosis recurred in 31% of patients (82/266) at 1 year, 43% (111/261) at 2 years, 54% (125/232) at 3 years, and 66% (128/193) at 4 years.

Very high TRAb levels at diagnosis – those above 12 mU/L – were associated with a statistically significant 84% risk of recurrence over a 4-year period, compared with a 57% risk with diagnosis levels below 5mU/L (P = .002).

TRAb levels below 0.9 mU/L at cessation of an 18-month course of thionamide treatment were associated with a 22% risk of recurrence at 1 year and a 58% risk at 4 years. Those risks were significantly higher in patients whose TRAb levels were at least 2 mU/L at thionamide cessation, who had a 51% risk at 1 year and an 86% risk at 4 years (P less than 0.001). Relapse risk was highest in the first 18 months after cessation.

Younger age and time to TSH normalization also predicted relapse to some extent. Among patients who stayed in remission for 4 years, TSH normalized at a median of about 4 months after the start of drug treatment, but 6 months in those who relapsed. Similarly, patients who relapsed were a median of 39 years old at diagnosis; those who did not were a median of 47.

The investigators had no relevant financial disclosures.

BALTIMORE – Research into how primary hyperparathyroidism and parathyroidectomy affect sleep quality has been limited, but investigators at the Medical College of Wisconsin, Milwaukee, reported that primary hyperparathyroidism does indeed disrupt sleep patterns and that curative surgery can improve sleep quality in a third of patients.

“Today, most patients with primary hyperparathyroidism have what is considered asymptomatic disease,” Justin La reported at the annual meeting of the American Association of Endocrine Surgeons. “However, recent studies demonstrate that many of these asymptomatic patients commonly exhibit neuropsychological problems, including sleep disturbances.” Mr. La is a fourth-year medical student at the Medical College of Wisconsin.

This prospective study, led by Dr. Tina Yen, recruited patients between June 2013 and September 2015 and compared 110 patients who had parathyroidectomy for primary hyperparathyroidism (PHPT) with 45 controls who had thyroidectomy for benign euthyroid disease between June 2013 and September 2015.

“Multiple studies, including recent meta-analyses, have demonstrated lower quality of life in patients with primary hyperparathyroidism and have suggested that patients, regardless of symptoms or degree of hypercalcemia, report varying degrees of improvement after parathyroidectomy,” Mr. La said. “In contrast there is a relative paucity of literature on the effects of primary hyperparathyroidism on sleep quality and changes after parathyroidectomy.”

He noted studies from both the University of Texas M.D. Anderson Cancer Center, Houston, and the University of Wisconsin–Madison had demonstrated a 44%-63% incidence of sleep disturbance preoperatively and improvement postoperatively in patients with PHPT who had parathyroidectomy (Endocr Pract. 2007 Jul-Aug;13:338-44; World J Surg. 2014 Mar;38:542-8; Surgery. 2009 Dec;146:1116-22).

“However, these studies were limited by small sample sizes and lack of a control group,” La said.

The latest study had subjects complete questionnaires inquiring about quality of life and sleep patterns at three different intervals: before surgery; and 1 and 6 months after surgery. The study used the Medical Outcomes Study SF-36 to assess quality of life and the Pittsburgh Sleep Quality Index (PSQI) to evaluate sleep quality. The PSQI rates sleep quality on a scale of 0 to 21; a score of 5 or higher indicates poor sleep quality.

“Compared to the preoperative scores, sleep scores after parathyroidectomy were lower, signifying better sleep quality among the 105 patients who completed 1-month postoperative surveys and the 94 patients who completed the 6-month surveys,” La said.

Before surgery, PHPT patients had worse sleep quality than their thyroid counterparts with PSQI scores of 8.1 vs. 5.3, respectively. After surgery, sleep quality scores between the two groups were similar, with mean PSQI scores of 6.3 vs. 5.3 at 1 month after surgery for the parathyroid and thyroid groups, respectively, and 5.8 vs. 4.6 for the two groups at 6 months.

Also, the proportion of patients in both groups who had poor sleep quality after surgery showed no statistical difference. At 1 month after surgery, 50% of patients in the parathyroid group and 40% in the thyroid group continued to have poor sleep quality, La said. However, when comparing preoperative with postoperative sleep scores, 37% in the parathyroid group had a noticeable improvement in their sleep scores, while only 10% of the thyroid group demonstrated improvement.

The researchers also evaluated physical and mental function in the two groups. “Preoperative overall health status was significantly worse in the parathyroid group,” La said. At 1 and 6 months after parathyroidectomy, only two physical components, physical functioning and bodily pain, remained worse in the PHPT patients. Compared with preoperative scores, PHPT patients showed statistically significant improvement in all four mental components at both postoperative periods. “In contrast, the thyroid group demonstrated no significant changes in the preoperative to postoperative scores in all eight components,” La said.

“Our study adds to the body of literature suggesting that asymptomatic patients with primary hyperparathyroidism are unlikely to be truly asymptomatic,” La said. “All patients with primary hyperparathyroidism should be referred for surgical consultation, particularly those with neurocognitive symptoms.”

He also said that patients should be counseled that improvement in sleep quality and quality of life, if they are to occur, typically are seen within 1 month after surgery.

Mr. La, Dr. Yen, and the study coauthors had no relationships to disclose.

BALTIMORE – Research into how primary hyperparathyroidism and parathyroidectomy affect sleep quality has been limited, but investigators at the Medical College of Wisconsin, Milwaukee, reported that primary hyperparathyroidism does indeed disrupt sleep patterns and that curative surgery can improve sleep quality in a third of patients.

“Today, most patients with primary hyperparathyroidism have what is considered asymptomatic disease,” Justin La reported at the annual meeting of the American Association of Endocrine Surgeons. “However, recent studies demonstrate that many of these asymptomatic patients commonly exhibit neuropsychological problems, including sleep disturbances.” Mr. La is a fourth-year medical student at the Medical College of Wisconsin.

This prospective study, led by Dr. Tina Yen, recruited patients between June 2013 and September 2015 and compared 110 patients who had parathyroidectomy for primary hyperparathyroidism (PHPT) with 45 controls who had thyroidectomy for benign euthyroid disease between June 2013 and September 2015.

“Multiple studies, including recent meta-analyses, have demonstrated lower quality of life in patients with primary hyperparathyroidism and have suggested that patients, regardless of symptoms or degree of hypercalcemia, report varying degrees of improvement after parathyroidectomy,” Mr. La said. “In contrast there is a relative paucity of literature on the effects of primary hyperparathyroidism on sleep quality and changes after parathyroidectomy.”

He noted studies from both the University of Texas M.D. Anderson Cancer Center, Houston, and the University of Wisconsin–Madison had demonstrated a 44%-63% incidence of sleep disturbance preoperatively and improvement postoperatively in patients with PHPT who had parathyroidectomy (Endocr Pract. 2007 Jul-Aug;13:338-44; World J Surg. 2014 Mar;38:542-8; Surgery. 2009 Dec;146:1116-22).

“However, these studies were limited by small sample sizes and lack of a control group,” La said.

The latest study had subjects complete questionnaires inquiring about quality of life and sleep patterns at three different intervals: before surgery; and 1 and 6 months after surgery. The study used the Medical Outcomes Study SF-36 to assess quality of life and the Pittsburgh Sleep Quality Index (PSQI) to evaluate sleep quality. The PSQI rates sleep quality on a scale of 0 to 21; a score of 5 or higher indicates poor sleep quality.

“Compared to the preoperative scores, sleep scores after parathyroidectomy were lower, signifying better sleep quality among the 105 patients who completed 1-month postoperative surveys and the 94 patients who completed the 6-month surveys,” La said.

Before surgery, PHPT patients had worse sleep quality than their thyroid counterparts with PSQI scores of 8.1 vs. 5.3, respectively. After surgery, sleep quality scores between the two groups were similar, with mean PSQI scores of 6.3 vs. 5.3 at 1 month after surgery for the parathyroid and thyroid groups, respectively, and 5.8 vs. 4.6 for the two groups at 6 months.

Also, the proportion of patients in both groups who had poor sleep quality after surgery showed no statistical difference. At 1 month after surgery, 50% of patients in the parathyroid group and 40% in the thyroid group continued to have poor sleep quality, La said. However, when comparing preoperative with postoperative sleep scores, 37% in the parathyroid group had a noticeable improvement in their sleep scores, while only 10% of the thyroid group demonstrated improvement.

The researchers also evaluated physical and mental function in the two groups. “Preoperative overall health status was significantly worse in the parathyroid group,” La said. At 1 and 6 months after parathyroidectomy, only two physical components, physical functioning and bodily pain, remained worse in the PHPT patients. Compared with preoperative scores, PHPT patients showed statistically significant improvement in all four mental components at both postoperative periods. “In contrast, the thyroid group demonstrated no significant changes in the preoperative to postoperative scores in all eight components,” La said.

“Our study adds to the body of literature suggesting that asymptomatic patients with primary hyperparathyroidism are unlikely to be truly asymptomatic,” La said. “All patients with primary hyperparathyroidism should be referred for surgical consultation, particularly those with neurocognitive symptoms.”

He also said that patients should be counseled that improvement in sleep quality and quality of life, if they are to occur, typically are seen within 1 month after surgery.

Mr. La, Dr. Yen, and the study coauthors had no relationships to disclose.

BALTIMORE – Research into how primary hyperparathyroidism and parathyroidectomy affect sleep quality has been limited, but investigators at the Medical College of Wisconsin, Milwaukee, reported that primary hyperparathyroidism does indeed disrupt sleep patterns and that curative surgery can improve sleep quality in a third of patients.

“Today, most patients with primary hyperparathyroidism have what is considered asymptomatic disease,” Justin La reported at the annual meeting of the American Association of Endocrine Surgeons. “However, recent studies demonstrate that many of these asymptomatic patients commonly exhibit neuropsychological problems, including sleep disturbances.” Mr. La is a fourth-year medical student at the Medical College of Wisconsin.

This prospective study, led by Dr. Tina Yen, recruited patients between June 2013 and September 2015 and compared 110 patients who had parathyroidectomy for primary hyperparathyroidism (PHPT) with 45 controls who had thyroidectomy for benign euthyroid disease between June 2013 and September 2015.

“Multiple studies, including recent meta-analyses, have demonstrated lower quality of life in patients with primary hyperparathyroidism and have suggested that patients, regardless of symptoms or degree of hypercalcemia, report varying degrees of improvement after parathyroidectomy,” Mr. La said. “In contrast there is a relative paucity of literature on the effects of primary hyperparathyroidism on sleep quality and changes after parathyroidectomy.”

He noted studies from both the University of Texas M.D. Anderson Cancer Center, Houston, and the University of Wisconsin–Madison had demonstrated a 44%-63% incidence of sleep disturbance preoperatively and improvement postoperatively in patients with PHPT who had parathyroidectomy (Endocr Pract. 2007 Jul-Aug;13:338-44; World J Surg. 2014 Mar;38:542-8; Surgery. 2009 Dec;146:1116-22).

“However, these studies were limited by small sample sizes and lack of a control group,” La said.

The latest study had subjects complete questionnaires inquiring about quality of life and sleep patterns at three different intervals: before surgery; and 1 and 6 months after surgery. The study used the Medical Outcomes Study SF-36 to assess quality of life and the Pittsburgh Sleep Quality Index (PSQI) to evaluate sleep quality. The PSQI rates sleep quality on a scale of 0 to 21; a score of 5 or higher indicates poor sleep quality.

“Compared to the preoperative scores, sleep scores after parathyroidectomy were lower, signifying better sleep quality among the 105 patients who completed 1-month postoperative surveys and the 94 patients who completed the 6-month surveys,” La said.

Before surgery, PHPT patients had worse sleep quality than their thyroid counterparts with PSQI scores of 8.1 vs. 5.3, respectively. After surgery, sleep quality scores between the two groups were similar, with mean PSQI scores of 6.3 vs. 5.3 at 1 month after surgery for the parathyroid and thyroid groups, respectively, and 5.8 vs. 4.6 for the two groups at 6 months.

Also, the proportion of patients in both groups who had poor sleep quality after surgery showed no statistical difference. At 1 month after surgery, 50% of patients in the parathyroid group and 40% in the thyroid group continued to have poor sleep quality, La said. However, when comparing preoperative with postoperative sleep scores, 37% in the parathyroid group had a noticeable improvement in their sleep scores, while only 10% of the thyroid group demonstrated improvement.

The researchers also evaluated physical and mental function in the two groups. “Preoperative overall health status was significantly worse in the parathyroid group,” La said. At 1 and 6 months after parathyroidectomy, only two physical components, physical functioning and bodily pain, remained worse in the PHPT patients. Compared with preoperative scores, PHPT patients showed statistically significant improvement in all four mental components at both postoperative periods. “In contrast, the thyroid group demonstrated no significant changes in the preoperative to postoperative scores in all eight components,” La said.

“Our study adds to the body of literature suggesting that asymptomatic patients with primary hyperparathyroidism are unlikely to be truly asymptomatic,” La said. “All patients with primary hyperparathyroidism should be referred for surgical consultation, particularly those with neurocognitive symptoms.”

He also said that patients should be counseled that improvement in sleep quality and quality of life, if they are to occur, typically are seen within 1 month after surgery.

Mr. La, Dr. Yen, and the study coauthors had no relationships to disclose.

BALTIMORE – Hemithyroidectomy for low-risk micropapillary thyroid cancer can have advantages over active surveillance, according to findings from a study that examined outcomes by cost and quality of life data.

Endocrinologists and surgeons need to have in-depth conversations with their patients to determine their level of anxiety about cancer, surgery, and about their quality of life, to determine the best course of treatment, researchers at the University of California, San Francisco (UCSF) reported at the annual meeting of the American Association of Endocrine Surgeons.

“Our study found that hemithyroidectomy is cost effective in the majority of scenarios,” presenter Shriya Venkatesh said. “However, patient perception of micropapillary thyroid cancer as well as [the patient’s] life expectancy can play a major role in deciding which therapeutic option to choose.”

The study involved a cost-effectiveness analysis of the surgery vs. active surveillance, “which is especially relevant in our current times,” Ms. Venkatesh said in an interview. “What we wanted to do is give physicians information for when they approach their patients, not only in assessing the tumor from the medical aspect but also when looking at it from quality-of-life and cost-benefit perspectives.”

Both courses of management were modeled over a 20-year period with Medicare data and literature review to calculate costs and health utilities. The UCSF researchers used Markov statistical models for both approaches in which the reference case was a 40-year-old, otherwise healthy patient with a recent diagnosis of micropapillary thyroid cancer without high-risk factors. Either hemithyroidectomy or surveillance would be reasonable treatment options.

“We found that hemithyroidectomy was about $8,000 more costly than active surveillance, but it also afforded an increase in about 1.09 quality-adjusted life years,” Ms. Venkatesh said. Hemithyroidectomy is most cost effective for patients with a life expectancy of 3 years or more and who perceive that living with low-grade thyroid cancer would have even a modest detriment on their quality of life, she said.

“Unfortunately there is no current published quality-of-life assessment of active surveillance for thyroid cancer,” Ms. Venkatesh said. “We believe that estimating active surveillance to the equivalent of surgery underestimates the anxiety some patients may feel upon receiving their diagnosis.”

The paucity of literature on active surveillance for thyroid cancer prompted the UCSF researchers to turn to the prostate cancer literature, which has more data on active surveillance, to try to determine the disutility of active surveillance for micropapillary thyroid cancer. “Our extrapolation from the literature yields a mean disutility of 0.11,” she said.

However, the utility estimates the researchers came up with were variable, Ms. Venkatesh said. “This really pushes physicians to have that conversation with their patients, not only about the physical aspects of how they’re doing but also the mental aspects,” she said.

But quality of life is difficult to quantify, senior author Dr. Insoo Suh said in an interview. “What we found is that no matter how one measures quality of life, the qualitative degree of quality of life decrease that people associate with ‘living with cancer’ need not be that significant in order for surgery to be a potentially cost-effective treatment for them,” said Dr. Suh, an endocrine surgeon at UCSF and an ACS Fellow.

During the discussion, Dr. Peter Angelos of the University of Chicago and an ACS Fellow, said, “I’m curious how this information should impact the individual decision-making and informed consent for a specific patient, because I’m not sure that an individual patient would care if active surveillance is more cost effective or not.”

“When speaking to your patients, obviously discussing the rates of progression of the disease is important and then [so is] talking to them about different therapeutic options,” Ms. Venkatesh said. “The physician should also make an assessment about the patient’s quality of life to see if there are likely to be any changes due to the diagnosis.”

The limitations of the study include the extrapolation of data from the prostate cancer literature to define a utility scale and also the reference case used in the Markov model. Other utility measures showed variability as well.

Ms. Venkatesh, Dr. Suh and their coauthors had no financial relationships to disclose.

BALTIMORE – Hemithyroidectomy for low-risk micropapillary thyroid cancer can have advantages over active surveillance, according to findings from a study that examined outcomes by cost and quality of life data.

Endocrinologists and surgeons need to have in-depth conversations with their patients to determine their level of anxiety about cancer, surgery, and about their quality of life, to determine the best course of treatment, researchers at the University of California, San Francisco (UCSF) reported at the annual meeting of the American Association of Endocrine Surgeons.

“Our study found that hemithyroidectomy is cost effective in the majority of scenarios,” presenter Shriya Venkatesh said. “However, patient perception of micropapillary thyroid cancer as well as [the patient’s] life expectancy can play a major role in deciding which therapeutic option to choose.”

The study involved a cost-effectiveness analysis of the surgery vs. active surveillance, “which is especially relevant in our current times,” Ms. Venkatesh said in an interview. “What we wanted to do is give physicians information for when they approach their patients, not only in assessing the tumor from the medical aspect but also when looking at it from quality-of-life and cost-benefit perspectives.”

Both courses of management were modeled over a 20-year period with Medicare data and literature review to calculate costs and health utilities. The UCSF researchers used Markov statistical models for both approaches in which the reference case was a 40-year-old, otherwise healthy patient with a recent diagnosis of micropapillary thyroid cancer without high-risk factors. Either hemithyroidectomy or surveillance would be reasonable treatment options.

“We found that hemithyroidectomy was about $8,000 more costly than active surveillance, but it also afforded an increase in about 1.09 quality-adjusted life years,” Ms. Venkatesh said. Hemithyroidectomy is most cost effective for patients with a life expectancy of 3 years or more and who perceive that living with low-grade thyroid cancer would have even a modest detriment on their quality of life, she said.

“Unfortunately there is no current published quality-of-life assessment of active surveillance for thyroid cancer,” Ms. Venkatesh said. “We believe that estimating active surveillance to the equivalent of surgery underestimates the anxiety some patients may feel upon receiving their diagnosis.”

The paucity of literature on active surveillance for thyroid cancer prompted the UCSF researchers to turn to the prostate cancer literature, which has more data on active surveillance, to try to determine the disutility of active surveillance for micropapillary thyroid cancer. “Our extrapolation from the literature yields a mean disutility of 0.11,” she said.

However, the utility estimates the researchers came up with were variable, Ms. Venkatesh said. “This really pushes physicians to have that conversation with their patients, not only about the physical aspects of how they’re doing but also the mental aspects,” she said.

But quality of life is difficult to quantify, senior author Dr. Insoo Suh said in an interview. “What we found is that no matter how one measures quality of life, the qualitative degree of quality of life decrease that people associate with ‘living with cancer’ need not be that significant in order for surgery to be a potentially cost-effective treatment for them,” said Dr. Suh, an endocrine surgeon at UCSF and an ACS Fellow.

During the discussion, Dr. Peter Angelos of the University of Chicago and an ACS Fellow, said, “I’m curious how this information should impact the individual decision-making and informed consent for a specific patient, because I’m not sure that an individual patient would care if active surveillance is more cost effective or not.”

“When speaking to your patients, obviously discussing the rates of progression of the disease is important and then [so is] talking to them about different therapeutic options,” Ms. Venkatesh said. “The physician should also make an assessment about the patient’s quality of life to see if there are likely to be any changes due to the diagnosis.”

The limitations of the study include the extrapolation of data from the prostate cancer literature to define a utility scale and also the reference case used in the Markov model. Other utility measures showed variability as well.

Ms. Venkatesh, Dr. Suh and their coauthors had no financial relationships to disclose.

BALTIMORE – Hemithyroidectomy for low-risk micropapillary thyroid cancer can have advantages over active surveillance, according to findings from a study that examined outcomes by cost and quality of life data.

Endocrinologists and surgeons need to have in-depth conversations with their patients to determine their level of anxiety about cancer, surgery, and about their quality of life, to determine the best course of treatment, researchers at the University of California, San Francisco (UCSF) reported at the annual meeting of the American Association of Endocrine Surgeons.

“Our study found that hemithyroidectomy is cost effective in the majority of scenarios,” presenter Shriya Venkatesh said. “However, patient perception of micropapillary thyroid cancer as well as [the patient’s] life expectancy can play a major role in deciding which therapeutic option to choose.”

The study involved a cost-effectiveness analysis of the surgery vs. active surveillance, “which is especially relevant in our current times,” Ms. Venkatesh said in an interview. “What we wanted to do is give physicians information for when they approach their patients, not only in assessing the tumor from the medical aspect but also when looking at it from quality-of-life and cost-benefit perspectives.”

Both courses of management were modeled over a 20-year period with Medicare data and literature review to calculate costs and health utilities. The UCSF researchers used Markov statistical models for both approaches in which the reference case was a 40-year-old, otherwise healthy patient with a recent diagnosis of micropapillary thyroid cancer without high-risk factors. Either hemithyroidectomy or surveillance would be reasonable treatment options.

“We found that hemithyroidectomy was about $8,000 more costly than active surveillance, but it also afforded an increase in about 1.09 quality-adjusted life years,” Ms. Venkatesh said. Hemithyroidectomy is most cost effective for patients with a life expectancy of 3 years or more and who perceive that living with low-grade thyroid cancer would have even a modest detriment on their quality of life, she said.

“Unfortunately there is no current published quality-of-life assessment of active surveillance for thyroid cancer,” Ms. Venkatesh said. “We believe that estimating active surveillance to the equivalent of surgery underestimates the anxiety some patients may feel upon receiving their diagnosis.”

The paucity of literature on active surveillance for thyroid cancer prompted the UCSF researchers to turn to the prostate cancer literature, which has more data on active surveillance, to try to determine the disutility of active surveillance for micropapillary thyroid cancer. “Our extrapolation from the literature yields a mean disutility of 0.11,” she said.

However, the utility estimates the researchers came up with were variable, Ms. Venkatesh said. “This really pushes physicians to have that conversation with their patients, not only about the physical aspects of how they’re doing but also the mental aspects,” she said.

But quality of life is difficult to quantify, senior author Dr. Insoo Suh said in an interview. “What we found is that no matter how one measures quality of life, the qualitative degree of quality of life decrease that people associate with ‘living with cancer’ need not be that significant in order for surgery to be a potentially cost-effective treatment for them,” said Dr. Suh, an endocrine surgeon at UCSF and an ACS Fellow.

During the discussion, Dr. Peter Angelos of the University of Chicago and an ACS Fellow, said, “I’m curious how this information should impact the individual decision-making and informed consent for a specific patient, because I’m not sure that an individual patient would care if active surveillance is more cost effective or not.”

“When speaking to your patients, obviously discussing the rates of progression of the disease is important and then [so is] talking to them about different therapeutic options,” Ms. Venkatesh said. “The physician should also make an assessment about the patient’s quality of life to see if there are likely to be any changes due to the diagnosis.”

The limitations of the study include the extrapolation of data from the prostate cancer literature to define a utility scale and also the reference case used in the Markov model. Other utility measures showed variability as well.

Ms. Venkatesh, Dr. Suh and their coauthors had no financial relationships to disclose.

BALTIMORE – Patients who have had parathyroidectomy for primary hyperparathyroidism can have disease recurrence 10 years or longer after surgery, raising the possibility that postop follow-up should never end, according to a study presented at the annual meeting of the American Association of Endocrine Surgeons.

Dr. Irene Lou of the University of Wisconsin–Madison reported on results of a retrospective study of 196 patients who had a presumably “curative” parathyroidectomy at the institution between November 2000 and June 2005. The mean age of the study population was 61 years.

“The long-term recurrences of primary hyperparathyroidism after curative parathyroidectomy is likely higher than previously reported, with over a third of recurrences occurring 10 years after their operation,” Dr. Lou said.

The study also identified independent predictors of recurrence, among them younger age, a drop in intraoperative parathyroid hormone less than 70%, and double adenoma, Dr. Lou said. All patients after parathyroidectomy should have at minimum an annual serum calcium test, especially younger patients with longer life expectancies, she said. This recommendation, however, may be altered for older patients or those with additional comorbidities.

The study defined recurrence as serum calcium of 10.2 mg/dL or greater 6 months or longer after the initial operation. The overall 10-year recurrence rate was 14.8% and the median time to recurrence was 6.3 years. “We found that 41.4% of patients who recurred did so by 5 years and 65.5% by 10 years,” Dr. Lou said.

The University of Wisconsin and University of Alabama at Birmingham investigators undertook the study because the recent data on recurrence was limited, with the longest study topping out at 7 years, Dr. Lou said. “We previously looked at this problem in other perspectives and we found that a lot of curves separated at around 8 years,” she said.

With regard to the type of operation the patients had, whether unilateral minimally invasive parathyroidectomy or bilateral open surgery, the study found no significant differences in recurrence rates, Dr. Lou said. “This is an excellent study,” Dr. Samuel K. Snyder of Temple, Tex., said during the discussion. “You’re telling us we need to follow patients much longer than perhaps we did previously, but we all see patients who have normal calcium and still have a residual elevated parathyroid hormone level.” He asked if the study considered parathyroid hormone levels at 6 months or more after surgery or vitamin D levels, but Dr. Lou said this information was not available, therefore could not be evaluated.

Dr. Lou and her coauthors had no financial relationships to disclose.

BALTIMORE – Patients who have had parathyroidectomy for primary hyperparathyroidism can have disease recurrence 10 years or longer after surgery, raising the possibility that postop follow-up should never end, according to a study presented at the annual meeting of the American Association of Endocrine Surgeons.

Dr. Irene Lou of the University of Wisconsin–Madison reported on results of a retrospective study of 196 patients who had a presumably “curative” parathyroidectomy at the institution between November 2000 and June 2005. The mean age of the study population was 61 years.

“The long-term recurrences of primary hyperparathyroidism after curative parathyroidectomy is likely higher than previously reported, with over a third of recurrences occurring 10 years after their operation,” Dr. Lou said.

The study also identified independent predictors of recurrence, among them younger age, a drop in intraoperative parathyroid hormone less than 70%, and double adenoma, Dr. Lou said. All patients after parathyroidectomy should have at minimum an annual serum calcium test, especially younger patients with longer life expectancies, she said. This recommendation, however, may be altered for older patients or those with additional comorbidities.

The study defined recurrence as serum calcium of 10.2 mg/dL or greater 6 months or longer after the initial operation. The overall 10-year recurrence rate was 14.8% and the median time to recurrence was 6.3 years. “We found that 41.4% of patients who recurred did so by 5 years and 65.5% by 10 years,” Dr. Lou said.

The University of Wisconsin and University of Alabama at Birmingham investigators undertook the study because the recent data on recurrence was limited, with the longest study topping out at 7 years, Dr. Lou said. “We previously looked at this problem in other perspectives and we found that a lot of curves separated at around 8 years,” she said.

With regard to the type of operation the patients had, whether unilateral minimally invasive parathyroidectomy or bilateral open surgery, the study found no significant differences in recurrence rates, Dr. Lou said. “This is an excellent study,” Dr. Samuel K. Snyder of Temple, Tex., said during the discussion. “You’re telling us we need to follow patients much longer than perhaps we did previously, but we all see patients who have normal calcium and still have a residual elevated parathyroid hormone level.” He asked if the study considered parathyroid hormone levels at 6 months or more after surgery or vitamin D levels, but Dr. Lou said this information was not available, therefore could not be evaluated.

Dr. Lou and her coauthors had no financial relationships to disclose.

BALTIMORE – Patients who have had parathyroidectomy for primary hyperparathyroidism can have disease recurrence 10 years or longer after surgery, raising the possibility that postop follow-up should never end, according to a study presented at the annual meeting of the American Association of Endocrine Surgeons.

Dr. Irene Lou of the University of Wisconsin–Madison reported on results of a retrospective study of 196 patients who had a presumably “curative” parathyroidectomy at the institution between November 2000 and June 2005. The mean age of the study population was 61 years.

“The long-term recurrences of primary hyperparathyroidism after curative parathyroidectomy is likely higher than previously reported, with over a third of recurrences occurring 10 years after their operation,” Dr. Lou said.

The study also identified independent predictors of recurrence, among them younger age, a drop in intraoperative parathyroid hormone less than 70%, and double adenoma, Dr. Lou said. All patients after parathyroidectomy should have at minimum an annual serum calcium test, especially younger patients with longer life expectancies, she said. This recommendation, however, may be altered for older patients or those with additional comorbidities.

The study defined recurrence as serum calcium of 10.2 mg/dL or greater 6 months or longer after the initial operation. The overall 10-year recurrence rate was 14.8% and the median time to recurrence was 6.3 years. “We found that 41.4% of patients who recurred did so by 5 years and 65.5% by 10 years,” Dr. Lou said.

The University of Wisconsin and University of Alabama at Birmingham investigators undertook the study because the recent data on recurrence was limited, with the longest study topping out at 7 years, Dr. Lou said. “We previously looked at this problem in other perspectives and we found that a lot of curves separated at around 8 years,” she said.

With regard to the type of operation the patients had, whether unilateral minimally invasive parathyroidectomy or bilateral open surgery, the study found no significant differences in recurrence rates, Dr. Lou said. “This is an excellent study,” Dr. Samuel K. Snyder of Temple, Tex., said during the discussion. “You’re telling us we need to follow patients much longer than perhaps we did previously, but we all see patients who have normal calcium and still have a residual elevated parathyroid hormone level.” He asked if the study considered parathyroid hormone levels at 6 months or more after surgery or vitamin D levels, but Dr. Lou said this information was not available, therefore could not be evaluated.

Dr. Lou and her coauthors had no financial relationships to disclose.

BALTIMORE – In the treatment of primary hyperparathyroidism, clinical guidelines recommend using sestamibi scan for localizing adenoma, but increasingly endocrinologists are using sestamibi results to determine whether or not to refer a patient for parathyroidectomy surgery, while surgeons are using the scans as a factor in deciding whether to perform the operation.

That was the conclusion of a paper Dr. Susana Wu presented at the American Association of Endocrine Surgeons annual meeting. Dr. Wu reported on behalf of her colleagues at Kaiser Permanente Los Angeles Medical Center and at Scripps Clinic in San Diego.

“This study suggests that negative sestamibi scan (SS) results influence management of patients with primary hyperparathyroidism,” Dr. Wu said. “Endocrinologists were less likely to refer to surgeons and surgeons were less likely to offer parathyroidectomy to a patient with a negative sestamibi scan.”

The study involved a retrospective chart review of all 539 patients with primary hyperparathyroidism in the Kaiser Permanente Southern California database from December 2011 to December 2013, 452 of whom were seen by 63 endocrinologists at 14 centers. Among these patients, 260 had SS – 120 negative and 140 positive. The study identified statistically significant variations in how both endocrinologists and surgeons managed patients depending on SS results. The researchers used Kaiser Permanente’s electronic referral system to track referrals.

“The most significant negative predictor for endocrinologists referring to surgeons was a negative sestamibi scan, with an odds ratio of 0.36,” Dr. Wu said.

Endocrinologists referred 86% of patients with positive SS to surgeons, but only 68% of those with negative SS. Surgeons exhibited a similar practice pattern. “Surgeons were less likely to recommend parathyroidectomy for patients with a negative sestamibi scan, with an odds ratio of 0.20,” Dr. Wu said. Surgeons operated on 87% of patients with a negative SS scan but 96% with a positive SS.

In an interview, study coauthor Dr. Philip Haigh explained that parathyroidectomy when the SS is negative is a more difficult operation for the surgeon, and that might make some physicians hesitate before going forward with surgery. “It has been previously shown by other studies that it is a more difficult operation when the sestamibi scan is negative because you have to look at four glands instead of removing just one, but if the surgeon is experienced, it should achieve a high success rate,” Dr. Haigh said. He said that parathyroidectomy in sestamibi-negative hyperparathyroidism had a cure rate as high as 98% in the study presented.

He offered two thoughts on how clinicians should use the study results. “To the endocrinologist, if you’re going to order a sestamibi scan, don’t change your referral practice depending on the result,” Dr. Haigh said. “To the surgeon, if you’re not comfortable operating on a patient with a negative sestamibi scan, then find someone who is.”

The study had a few limitations, Dr. Wu said. Along with its retrospective nature, the study also did not account for potential disparity in radiological vs. surgeon interpretation of the scans.

During the discussion, Dr. Samuel Snyder, of Baylor Scott & White Health, Temple, Tex., said he concurred with the results Dr. Wu reported. “It really worries me about what is happening to patients who have negative scans,” he said. “What I’ve seen in patients referred for surgery is a lot of variation in how the sestamibi scan is done.” He asked if the study accounted for the different types of sestamibi scans and how they were performed, but Dr. Wu said it did not.

Dr. Christopher McHenry of MetroHealth Medical Center, Cleveland, also concurred. “I think this is a phenomenon that occurs more often than we think or we’re aware of,” he said. “I continue to be amazed with how clinicians equate a negative sestamibi scan with not having primary hyperparathyroidism. I think it needs to reemphasized that the sestamibi scan is not diagnostic; it’s for localization.”

He asked Dr. Wu, “How do we change behavior to deal with this problem?”

Dr. Wu said her institution is developing a safety-net program that would aim to increase the identification and chart coding of patients with primary hyperparathyroidism, automate essential labs to be ordered in patients with high calcium, and automate referral to endocrinologists. The study and its findings will be disseminated to endocrinologists in the region.

The study authors had no disclosures.

BALTIMORE – In the treatment of primary hyperparathyroidism, clinical guidelines recommend using sestamibi scan for localizing adenoma, but increasingly endocrinologists are using sestamibi results to determine whether or not to refer a patient for parathyroidectomy surgery, while surgeons are using the scans as a factor in deciding whether to perform the operation.

That was the conclusion of a paper Dr. Susana Wu presented at the American Association of Endocrine Surgeons annual meeting. Dr. Wu reported on behalf of her colleagues at Kaiser Permanente Los Angeles Medical Center and at Scripps Clinic in San Diego.

“This study suggests that negative sestamibi scan (SS) results influence management of patients with primary hyperparathyroidism,” Dr. Wu said. “Endocrinologists were less likely to refer to surgeons and surgeons were less likely to offer parathyroidectomy to a patient with a negative sestamibi scan.”

The study involved a retrospective chart review of all 539 patients with primary hyperparathyroidism in the Kaiser Permanente Southern California database from December 2011 to December 2013, 452 of whom were seen by 63 endocrinologists at 14 centers. Among these patients, 260 had SS – 120 negative and 140 positive. The study identified statistically significant variations in how both endocrinologists and surgeons managed patients depending on SS results. The researchers used Kaiser Permanente’s electronic referral system to track referrals.

“The most significant negative predictor for endocrinologists referring to surgeons was a negative sestamibi scan, with an odds ratio of 0.36,” Dr. Wu said.

Endocrinologists referred 86% of patients with positive SS to surgeons, but only 68% of those with negative SS. Surgeons exhibited a similar practice pattern. “Surgeons were less likely to recommend parathyroidectomy for patients with a negative sestamibi scan, with an odds ratio of 0.20,” Dr. Wu said. Surgeons operated on 87% of patients with a negative SS scan but 96% with a positive SS.

In an interview, study coauthor Dr. Philip Haigh explained that parathyroidectomy when the SS is negative is a more difficult operation for the surgeon, and that might make some physicians hesitate before going forward with surgery. “It has been previously shown by other studies that it is a more difficult operation when the sestamibi scan is negative because you have to look at four glands instead of removing just one, but if the surgeon is experienced, it should achieve a high success rate,” Dr. Haigh said. He said that parathyroidectomy in sestamibi-negative hyperparathyroidism had a cure rate as high as 98% in the study presented.

He offered two thoughts on how clinicians should use the study results. “To the endocrinologist, if you’re going to order a sestamibi scan, don’t change your referral practice depending on the result,” Dr. Haigh said. “To the surgeon, if you’re not comfortable operating on a patient with a negative sestamibi scan, then find someone who is.”

The study had a few limitations, Dr. Wu said. Along with its retrospective nature, the study also did not account for potential disparity in radiological vs. surgeon interpretation of the scans.

During the discussion, Dr. Samuel Snyder, of Baylor Scott & White Health, Temple, Tex., said he concurred with the results Dr. Wu reported. “It really worries me about what is happening to patients who have negative scans,” he said. “What I’ve seen in patients referred for surgery is a lot of variation in how the sestamibi scan is done.” He asked if the study accounted for the different types of sestamibi scans and how they were performed, but Dr. Wu said it did not.

Dr. Christopher McHenry of MetroHealth Medical Center, Cleveland, also concurred. “I think this is a phenomenon that occurs more often than we think or we’re aware of,” he said. “I continue to be amazed with how clinicians equate a negative sestamibi scan with not having primary hyperparathyroidism. I think it needs to reemphasized that the sestamibi scan is not diagnostic; it’s for localization.”

He asked Dr. Wu, “How do we change behavior to deal with this problem?”

Dr. Wu said her institution is developing a safety-net program that would aim to increase the identification and chart coding of patients with primary hyperparathyroidism, automate essential labs to be ordered in patients with high calcium, and automate referral to endocrinologists. The study and its findings will be disseminated to endocrinologists in the region.

The study authors had no disclosures.

BALTIMORE – In the treatment of primary hyperparathyroidism, clinical guidelines recommend using sestamibi scan for localizing adenoma, but increasingly endocrinologists are using sestamibi results to determine whether or not to refer a patient for parathyroidectomy surgery, while surgeons are using the scans as a factor in deciding whether to perform the operation.

That was the conclusion of a paper Dr. Susana Wu presented at the American Association of Endocrine Surgeons annual meeting. Dr. Wu reported on behalf of her colleagues at Kaiser Permanente Los Angeles Medical Center and at Scripps Clinic in San Diego.

“This study suggests that negative sestamibi scan (SS) results influence management of patients with primary hyperparathyroidism,” Dr. Wu said. “Endocrinologists were less likely to refer to surgeons and surgeons were less likely to offer parathyroidectomy to a patient with a negative sestamibi scan.”

The study involved a retrospective chart review of all 539 patients with primary hyperparathyroidism in the Kaiser Permanente Southern California database from December 2011 to December 2013, 452 of whom were seen by 63 endocrinologists at 14 centers. Among these patients, 260 had SS – 120 negative and 140 positive. The study identified statistically significant variations in how both endocrinologists and surgeons managed patients depending on SS results. The researchers used Kaiser Permanente’s electronic referral system to track referrals.

“The most significant negative predictor for endocrinologists referring to surgeons was a negative sestamibi scan, with an odds ratio of 0.36,” Dr. Wu said.

Endocrinologists referred 86% of patients with positive SS to surgeons, but only 68% of those with negative SS. Surgeons exhibited a similar practice pattern. “Surgeons were less likely to recommend parathyroidectomy for patients with a negative sestamibi scan, with an odds ratio of 0.20,” Dr. Wu said. Surgeons operated on 87% of patients with a negative SS scan but 96% with a positive SS.

In an interview, study coauthor Dr. Philip Haigh explained that parathyroidectomy when the SS is negative is a more difficult operation for the surgeon, and that might make some physicians hesitate before going forward with surgery. “It has been previously shown by other studies that it is a more difficult operation when the sestamibi scan is negative because you have to look at four glands instead of removing just one, but if the surgeon is experienced, it should achieve a high success rate,” Dr. Haigh said. He said that parathyroidectomy in sestamibi-negative hyperparathyroidism had a cure rate as high as 98% in the study presented.

He offered two thoughts on how clinicians should use the study results. “To the endocrinologist, if you’re going to order a sestamibi scan, don’t change your referral practice depending on the result,” Dr. Haigh said. “To the surgeon, if you’re not comfortable operating on a patient with a negative sestamibi scan, then find someone who is.”

The study had a few limitations, Dr. Wu said. Along with its retrospective nature, the study also did not account for potential disparity in radiological vs. surgeon interpretation of the scans.

During the discussion, Dr. Samuel Snyder, of Baylor Scott & White Health, Temple, Tex., said he concurred with the results Dr. Wu reported. “It really worries me about what is happening to patients who have negative scans,” he said. “What I’ve seen in patients referred for surgery is a lot of variation in how the sestamibi scan is done.” He asked if the study accounted for the different types of sestamibi scans and how they were performed, but Dr. Wu said it did not.

Dr. Christopher McHenry of MetroHealth Medical Center, Cleveland, also concurred. “I think this is a phenomenon that occurs more often than we think or we’re aware of,” he said. “I continue to be amazed with how clinicians equate a negative sestamibi scan with not having primary hyperparathyroidism. I think it needs to reemphasized that the sestamibi scan is not diagnostic; it’s for localization.”

He asked Dr. Wu, “How do we change behavior to deal with this problem?”

Dr. Wu said her institution is developing a safety-net program that would aim to increase the identification and chart coding of patients with primary hyperparathyroidism, automate essential labs to be ordered in patients with high calcium, and automate referral to endocrinologists. The study and its findings will be disseminated to endocrinologists in the region.

The study authors had no disclosures.

BOSTON – An analysis of data from medullary thyroid cancer patients that partitioned the patients into groups with similar overall survival has spurred a rethink of the current American Joint Committee on Cancer (AJCC) staging system.

The results from researchers at Duke University, Durham, N.C., presented at the annual meeting of the Endocrine Society by Dr. Mohamed Abdelgadir Adam, are timely, as the AJCC has embarked on a reconsideration of the staging of cancers, including medullary thyroid cancer (MTC), as part revisions for the eighth edition of the staging system.

“The existing AJCC staging system for MTC appears to be less than optimal in discriminating the risk of mortality among disease stage groups,” said Dr. Adam, who discussed the findings in a video interview.

MTC, a neuroendocrine tumor that affects C cells of the thyroid, comprises 3%-5% of all cases of thyroid cancer and it can be a more aggressive disease than differentiated thyroid cancer. Yet the current AJCC MTC staging system has been extrapolated from differentiated thyroid cancer data.

“We sought to evaluate how well the current AJCC seventh edition stage groupings predict survival for patients with MTC, to suggest a possible staging revision to sharpen estimates of prognosis,” said Dr. Adam.

The researchers utilized the National Cancer Data Base, representing over 70% of incident cancer cases in the United States.

MTC patients who underwent thyroid surgery from 1998 to 2012 were identified. Patients with missing values for pathologic T, N, or M were excluded. The primary outcome in the 3,315 patients was survival.

The researchers used a form of decision-tree analysis called recursive partitioning. In general, recursive partitioning is able to classify a population by splitting subjects into subgroups, each of which is homogeneous based on the particular outcome. In this study, the subgroup allocations were based on T, N, and M stages, with the outcome being overall survival. Kaplan-Meier and adjusted survival analyses enabled survival differences among the four subgroups (groups I, II, III and IV) to be explored.

The four groups were distinct in terms of survival time and allowed more accurate risk stratification. In particular, groups I and II were markedly better distinguished from one another than is the case with the current staging system. Survival differences across the stages were more distinct with the newly created T, N, and M groupings, compared with the current AJCC staging system.

After adjustment, survival differences across TNM groups were more distinct with the newly created TNM groupings (compared to subgroup I, hazard ratio of 3.06 for subgroup II; HR, 6.79 for III; and HR, 17.03 for IV), compared with the current AJCC staging (compared to stage I, HR, 1.45 for stage II; HR, 2.17 for III; and HR, 5.33 for IV).

“The AJCC is reevaluating all staging schemas, including MTC. The current AJCC staging system could be improved with the newly identified TNM groupings suggested here for more accurate patient risk stratification and possibly treatment selection,” said Dr. Adam.

Dr. Adam had no disclosures.

BOSTON – An analysis of data from medullary thyroid cancer patients that partitioned the patients into groups with similar overall survival has spurred a rethink of the current American Joint Committee on Cancer (AJCC) staging system.

The results from researchers at Duke University, Durham, N.C., presented at the annual meeting of the Endocrine Society by Dr. Mohamed Abdelgadir Adam, are timely, as the AJCC has embarked on a reconsideration of the staging of cancers, including medullary thyroid cancer (MTC), as part revisions for the eighth edition of the staging system.

“The existing AJCC staging system for MTC appears to be less than optimal in discriminating the risk of mortality among disease stage groups,” said Dr. Adam, who discussed the findings in a video interview.

MTC, a neuroendocrine tumor that affects C cells of the thyroid, comprises 3%-5% of all cases of thyroid cancer and it can be a more aggressive disease than differentiated thyroid cancer. Yet the current AJCC MTC staging system has been extrapolated from differentiated thyroid cancer data.

“We sought to evaluate how well the current AJCC seventh edition stage groupings predict survival for patients with MTC, to suggest a possible staging revision to sharpen estimates of prognosis,” said Dr. Adam.

The researchers utilized the National Cancer Data Base, representing over 70% of incident cancer cases in the United States.

MTC patients who underwent thyroid surgery from 1998 to 2012 were identified. Patients with missing values for pathologic T, N, or M were excluded. The primary outcome in the 3,315 patients was survival.

The researchers used a form of decision-tree analysis called recursive partitioning. In general, recursive partitioning is able to classify a population by splitting subjects into subgroups, each of which is homogeneous based on the particular outcome. In this study, the subgroup allocations were based on T, N, and M stages, with the outcome being overall survival. Kaplan-Meier and adjusted survival analyses enabled survival differences among the four subgroups (groups I, II, III and IV) to be explored.

The four groups were distinct in terms of survival time and allowed more accurate risk stratification. In particular, groups I and II were markedly better distinguished from one another than is the case with the current staging system. Survival differences across the stages were more distinct with the newly created T, N, and M groupings, compared with the current AJCC staging system.

After adjustment, survival differences across TNM groups were more distinct with the newly created TNM groupings (compared to subgroup I, hazard ratio of 3.06 for subgroup II; HR, 6.79 for III; and HR, 17.03 for IV), compared with the current AJCC staging (compared to stage I, HR, 1.45 for stage II; HR, 2.17 for III; and HR, 5.33 for IV).

“The AJCC is reevaluating all staging schemas, including MTC. The current AJCC staging system could be improved with the newly identified TNM groupings suggested here for more accurate patient risk stratification and possibly treatment selection,” said Dr. Adam.

Dr. Adam had no disclosures.

BOSTON – An analysis of data from medullary thyroid cancer patients that partitioned the patients into groups with similar overall survival has spurred a rethink of the current American Joint Committee on Cancer (AJCC) staging system.

The results from researchers at Duke University, Durham, N.C., presented at the annual meeting of the Endocrine Society by Dr. Mohamed Abdelgadir Adam, are timely, as the AJCC has embarked on a reconsideration of the staging of cancers, including medullary thyroid cancer (MTC), as part revisions for the eighth edition of the staging system.

“The existing AJCC staging system for MTC appears to be less than optimal in discriminating the risk of mortality among disease stage groups,” said Dr. Adam, who discussed the findings in a video interview.

MTC, a neuroendocrine tumor that affects C cells of the thyroid, comprises 3%-5% of all cases of thyroid cancer and it can be a more aggressive disease than differentiated thyroid cancer. Yet the current AJCC MTC staging system has been extrapolated from differentiated thyroid cancer data.

“We sought to evaluate how well the current AJCC seventh edition stage groupings predict survival for patients with MTC, to suggest a possible staging revision to sharpen estimates of prognosis,” said Dr. Adam.

The researchers utilized the National Cancer Data Base, representing over 70% of incident cancer cases in the United States.

MTC patients who underwent thyroid surgery from 1998 to 2012 were identified. Patients with missing values for pathologic T, N, or M were excluded. The primary outcome in the 3,315 patients was survival.

The researchers used a form of decision-tree analysis called recursive partitioning. In general, recursive partitioning is able to classify a population by splitting subjects into subgroups, each of which is homogeneous based on the particular outcome. In this study, the subgroup allocations were based on T, N, and M stages, with the outcome being overall survival. Kaplan-Meier and adjusted survival analyses enabled survival differences among the four subgroups (groups I, II, III and IV) to be explored.

The four groups were distinct in terms of survival time and allowed more accurate risk stratification. In particular, groups I and II were markedly better distinguished from one another than is the case with the current staging system. Survival differences across the stages were more distinct with the newly created T, N, and M groupings, compared with the current AJCC staging system.

After adjustment, survival differences across TNM groups were more distinct with the newly created TNM groupings (compared to subgroup I, hazard ratio of 3.06 for subgroup II; HR, 6.79 for III; and HR, 17.03 for IV), compared with the current AJCC staging (compared to stage I, HR, 1.45 for stage II; HR, 2.17 for III; and HR, 5.33 for IV).

“The AJCC is reevaluating all staging schemas, including MTC. The current AJCC staging system could be improved with the newly identified TNM groupings suggested here for more accurate patient risk stratification and possibly treatment selection,” said Dr. Adam.

Dr. Adam had no disclosures.

BOSTON – A study of over 60 years of patient data from the Mayo Clinic suggests a reconsideration of the routine use of unilateral thyroid lobectomy (UL) as the initial treatment for papillary thyroid microcarcinoma.

“Papillary thyroid microcarcinoma [PTM] patients have a normal life expectancy and typically are cured by adequate tumor resection. More than 99% of PTM patients are not at risk of either distant spread or mortality from cancer,” said Dr. Ian D. Hay of the Mayo Clinic, Rochester, Minn. Unilateral thyroid lobectomy is one treatment option for papillary thyroid microcarcinoma along with conventional bilateral nodal resection approaches of near-total thyroidectomy (NT) or total thyroidectomy (TT), or selective radioactive iodine remnant ablation (RRA).

Awareness of PTM is not new; examination of thyroid glands at autopsy going back decades has revealed their presence in 6%-36% of samples. A more recent development is the use of high-resolution ultrasound-guided biopsies of papillary thyroid carcinoma (PTC) lesions as small as 3 cm. For example, at the Mayo Clinic the diagnosis of PTM was about one annually from 1935 to 1944, while from 2005 to 2014 the average was close to one per day. “At Mayo, 34% of PTCs seen since 1995 are PTMs,” Dr. Hay said at the annual meeting of the Endocrine Society.

The best initial management of PTMs is disputed, with observation favored by some, TT and RRA favored by others, and ethanol ablation having been found to be effective by institutions including the Mayo Clinic. UL has been deemphasized, despite the 2015 American Thyroid Association Guidelines recommendation of UL as the usual surgical procedure for adults with PTM.

Dr. Hay and his colleagues sought to provide some clarity to the issue by taking advantage of the institute’s database of adult (18+ years) PTM patients who were consecutively treated from 1935 to 2014. The decades of data allowed a long-term look at patient outcomes. They examined data from 1,345 patients, 954 women and 391 men with a median age at surgery of 48 years. The mean follow-up was 15.4 years, representing almost 21,000 patient years. Data on tumor recurrence and cause-specific mortality were derived from a data base of over 4,300 PTC patients representing over 66,000 patient-years of observation.

Median tumor size was 7 mm (range, 0.08-1.0 cm). Extrathyroid invasion was evident in 18 (1.3%) cases and 298 tumors (26%) were multifocal. There were 399 (30%) node-positive tumors at diagnosis and 4 (0.3%) cases featuring initial distant metastases.

The mean MACIS (metastasis, age at presentation, completeness of surgical resection, invasion [extrathyroidal], size) score was 4.25 with little variation in score over time. Almost all (96%) patients had a MACIS score of under 6. Bilateral lobar resection was done in 1,132 (95%) patients, with NT or TT comprising 80% of the cases. UL was done in only 202 (15%) cases. The use of TT skyrocketed from 3% of the cases done in the first 2 decades to 40% in the last 2 decades. Regional nodes were removed at surgery in 743 (55%) cases, either by “node picking” (23%) or compartmental dissection (32%).

Overall survival following surgery in PTM patients was similar to age- and gender-matched controls (397 deaths observed, 431 deaths expected; P = .16). Only four (0.3%) patients died of PTM. The rates of locoregional recurrence were similar for the unilateral and bilateral approaches (P = .90). In 1,148 patients with potentially curable PTM, defined as the absence of metastasis at diagnosis and no gross residual disease, the rates of tumor recurrence 10, 20, and 40 years after surgery were 6%, 7%, and 10%, respectively. In these 1,148 patients, the 30-year locoregional recurrence rates after UL alone were similar to those seen after NT or TT followed by RRA (P = .99).

UL did not result in permanent unilateral vocal cord paresis or permanent hypoparathyroidism. These adversities were more likely to develop following bilateral lobectomy.

“Since [UL] produces comparable recurrence results when compared to bilateral surgery and is not associated with either cord paresis or hypoparathyroidism, then perhaps it is overdue for institutions like Mayo to individualize our treatment policies and more often employ UL when surgery, and not observation or ultrasound-guided percutaneous ethanol ablation, is chosen to treat PTM,” said Dr. Hay.

Dr. Hay was adamant on the overuse of ultrasound in the detection of small-diameter carcinomas in the decision for bilateral surgery. “It’s embarrassing how much we are wasting resources and doing too much ultrasound too often,” he said in an interview.

Dr. Hay had no disclosures.

BOSTON – A study of over 60 years of patient data from the Mayo Clinic suggests a reconsideration of the routine use of unilateral thyroid lobectomy (UL) as the initial treatment for papillary thyroid microcarcinoma.

“Papillary thyroid microcarcinoma [PTM] patients have a normal life expectancy and typically are cured by adequate tumor resection. More than 99% of PTM patients are not at risk of either distant spread or mortality from cancer,” said Dr. Ian D. Hay of the Mayo Clinic, Rochester, Minn. Unilateral thyroid lobectomy is one treatment option for papillary thyroid microcarcinoma along with conventional bilateral nodal resection approaches of near-total thyroidectomy (NT) or total thyroidectomy (TT), or selective radioactive iodine remnant ablation (RRA).

Awareness of PTM is not new; examination of thyroid glands at autopsy going back decades has revealed their presence in 6%-36% of samples. A more recent development is the use of high-resolution ultrasound-guided biopsies of papillary thyroid carcinoma (PTC) lesions as small as 3 cm. For example, at the Mayo Clinic the diagnosis of PTM was about one annually from 1935 to 1944, while from 2005 to 2014 the average was close to one per day. “At Mayo, 34% of PTCs seen since 1995 are PTMs,” Dr. Hay said at the annual meeting of the Endocrine Society.

The best initial management of PTMs is disputed, with observation favored by some, TT and RRA favored by others, and ethanol ablation having been found to be effective by institutions including the Mayo Clinic. UL has been deemphasized, despite the 2015 American Thyroid Association Guidelines recommendation of UL as the usual surgical procedure for adults with PTM.

Dr. Hay and his colleagues sought to provide some clarity to the issue by taking advantage of the institute’s database of adult (18+ years) PTM patients who were consecutively treated from 1935 to 2014. The decades of data allowed a long-term look at patient outcomes. They examined data from 1,345 patients, 954 women and 391 men with a median age at surgery of 48 years. The mean follow-up was 15.4 years, representing almost 21,000 patient years. Data on tumor recurrence and cause-specific mortality were derived from a data base of over 4,300 PTC patients representing over 66,000 patient-years of observation.

Median tumor size was 7 mm (range, 0.08-1.0 cm). Extrathyroid invasion was evident in 18 (1.3%) cases and 298 tumors (26%) were multifocal. There were 399 (30%) node-positive tumors at diagnosis and 4 (0.3%) cases featuring initial distant metastases.

The mean MACIS (metastasis, age at presentation, completeness of surgical resection, invasion [extrathyroidal], size) score was 4.25 with little variation in score over time. Almost all (96%) patients had a MACIS score of under 6. Bilateral lobar resection was done in 1,132 (95%) patients, with NT or TT comprising 80% of the cases. UL was done in only 202 (15%) cases. The use of TT skyrocketed from 3% of the cases done in the first 2 decades to 40% in the last 2 decades. Regional nodes were removed at surgery in 743 (55%) cases, either by “node picking” (23%) or compartmental dissection (32%).

Overall survival following surgery in PTM patients was similar to age- and gender-matched controls (397 deaths observed, 431 deaths expected; P = .16). Only four (0.3%) patients died of PTM. The rates of locoregional recurrence were similar for the unilateral and bilateral approaches (P = .90). In 1,148 patients with potentially curable PTM, defined as the absence of metastasis at diagnosis and no gross residual disease, the rates of tumor recurrence 10, 20, and 40 years after surgery were 6%, 7%, and 10%, respectively. In these 1,148 patients, the 30-year locoregional recurrence rates after UL alone were similar to those seen after NT or TT followed by RRA (P = .99).

UL did not result in permanent unilateral vocal cord paresis or permanent hypoparathyroidism. These adversities were more likely to develop following bilateral lobectomy.

“Since [UL] produces comparable recurrence results when compared to bilateral surgery and is not associated with either cord paresis or hypoparathyroidism, then perhaps it is overdue for institutions like Mayo to individualize our treatment policies and more often employ UL when surgery, and not observation or ultrasound-guided percutaneous ethanol ablation, is chosen to treat PTM,” said Dr. Hay.

Dr. Hay was adamant on the overuse of ultrasound in the detection of small-diameter carcinomas in the decision for bilateral surgery. “It’s embarrassing how much we are wasting resources and doing too much ultrasound too often,” he said in an interview.

Dr. Hay had no disclosures.

BOSTON – A study of over 60 years of patient data from the Mayo Clinic suggests a reconsideration of the routine use of unilateral thyroid lobectomy (UL) as the initial treatment for papillary thyroid microcarcinoma.

“Papillary thyroid microcarcinoma [PTM] patients have a normal life expectancy and typically are cured by adequate tumor resection. More than 99% of PTM patients are not at risk of either distant spread or mortality from cancer,” said Dr. Ian D. Hay of the Mayo Clinic, Rochester, Minn. Unilateral thyroid lobectomy is one treatment option for papillary thyroid microcarcinoma along with conventional bilateral nodal resection approaches of near-total thyroidectomy (NT) or total thyroidectomy (TT), or selective radioactive iodine remnant ablation (RRA).

Awareness of PTM is not new; examination of thyroid glands at autopsy going back decades has revealed their presence in 6%-36% of samples. A more recent development is the use of high-resolution ultrasound-guided biopsies of papillary thyroid carcinoma (PTC) lesions as small as 3 cm. For example, at the Mayo Clinic the diagnosis of PTM was about one annually from 1935 to 1944, while from 2005 to 2014 the average was close to one per day. “At Mayo, 34% of PTCs seen since 1995 are PTMs,” Dr. Hay said at the annual meeting of the Endocrine Society.

The best initial management of PTMs is disputed, with observation favored by some, TT and RRA favored by others, and ethanol ablation having been found to be effective by institutions including the Mayo Clinic. UL has been deemphasized, despite the 2015 American Thyroid Association Guidelines recommendation of UL as the usual surgical procedure for adults with PTM.

Dr. Hay and his colleagues sought to provide some clarity to the issue by taking advantage of the institute’s database of adult (18+ years) PTM patients who were consecutively treated from 1935 to 2014. The decades of data allowed a long-term look at patient outcomes. They examined data from 1,345 patients, 954 women and 391 men with a median age at surgery of 48 years. The mean follow-up was 15.4 years, representing almost 21,000 patient years. Data on tumor recurrence and cause-specific mortality were derived from a data base of over 4,300 PTC patients representing over 66,000 patient-years of observation.

Median tumor size was 7 mm (range, 0.08-1.0 cm). Extrathyroid invasion was evident in 18 (1.3%) cases and 298 tumors (26%) were multifocal. There were 399 (30%) node-positive tumors at diagnosis and 4 (0.3%) cases featuring initial distant metastases.

The mean MACIS (metastasis, age at presentation, completeness of surgical resection, invasion [extrathyroidal], size) score was 4.25 with little variation in score over time. Almost all (96%) patients had a MACIS score of under 6. Bilateral lobar resection was done in 1,132 (95%) patients, with NT or TT comprising 80% of the cases. UL was done in only 202 (15%) cases. The use of TT skyrocketed from 3% of the cases done in the first 2 decades to 40% in the last 2 decades. Regional nodes were removed at surgery in 743 (55%) cases, either by “node picking” (23%) or compartmental dissection (32%).

Overall survival following surgery in PTM patients was similar to age- and gender-matched controls (397 deaths observed, 431 deaths expected; P = .16). Only four (0.3%) patients died of PTM. The rates of locoregional recurrence were similar for the unilateral and bilateral approaches (P = .90). In 1,148 patients with potentially curable PTM, defined as the absence of metastasis at diagnosis and no gross residual disease, the rates of tumor recurrence 10, 20, and 40 years after surgery were 6%, 7%, and 10%, respectively. In these 1,148 patients, the 30-year locoregional recurrence rates after UL alone were similar to those seen after NT or TT followed by RRA (P = .99).

UL did not result in permanent unilateral vocal cord paresis or permanent hypoparathyroidism. These adversities were more likely to develop following bilateral lobectomy.

“Since [UL] produces comparable recurrence results when compared to bilateral surgery and is not associated with either cord paresis or hypoparathyroidism, then perhaps it is overdue for institutions like Mayo to individualize our treatment policies and more often employ UL when surgery, and not observation or ultrasound-guided percutaneous ethanol ablation, is chosen to treat PTM,” said Dr. Hay.

Dr. Hay was adamant on the overuse of ultrasound in the detection of small-diameter carcinomas in the decision for bilateral surgery. “It’s embarrassing how much we are wasting resources and doing too much ultrasound too often,” he said in an interview.

Dr. Hay had no disclosures.

BOSTON – A random morning serum cortisol above 11.1 mcg/dL safely rules out adrenal insufficiency in both inpatients and outpatients, according to a review of 3,300 adrenal insufficiency work-ups at the Edinburgh Centre for Endocrinology and Diabetes.

The finding could help eliminate the cost and hassle of unnecessary adrenocorticotropic hormone (ACTH) stimulation tests; the investigators estimated that the cut point would eliminate almost half of them without any ill effects. “You can be very confident that patients aren’t insufficient if they are above that line,” with more than 99% sensitivity. If they are below it, “they may be normal, and they may be abnormal.” Below 1.8 mcg/dL, adrenal insufficiency is almost certain, but between the cutoffs, ACTH stimulation is necessary, said lead investigator Dr. Scott Mackenzie, a trainee at the center.

In short, “basal serum cortisol as a screening test ... offers a convenient and accessible means of identifying patients who require further assessment,” he said at the annual meeting of the Endocrine Society.

Similar cut points have been suggested by previous studies, but the Scottish investigation is the first to validate its findings both inside and outside of the hospital.

The team arrived at the 11.1 mcg/dL morning cortisol cut point by comparing basal cortisol levels and synacthen results in 1,628 outpatients. They predefined a sensitivity of more than 99% for adrenal sufficiency to avoid missing anyone with true disease. The cut point’s predictive power was then validated in 875 outpatients and 797 inpatients. Morning basal cortisol levels proved superior to afternoon levels.

The investigators were thinking about cost-effectiveness, but they also wanted to increase screening. “We may be able to reduce the number of adrenal insufficiency cases we are missing because [primary care is] reluctant to send people to the clinic for synacthen tests” due to the cost and inconvenience. As with many locations in the United States, “our practice is to do [ACTH on] everyone.” If there was “a quick and easy 9 a.m. blood test” instead, it would help, Dr. Mackenzie said.

Adrenal insufficiency was on the differential for a wide variety of reasons, including hypogonadism, pituitary issues, prolactinemia, fatigue, hypoglycemia, postural hypotension, and hyponatremia. Most of the patients were middle aged, and they were about evenly split between men and women.

There was no outside funding for the work, and the investigators had no disclosures.

aotto@frontlinemedcom.com

BOSTON – A random morning serum cortisol above 11.1 mcg/dL safely rules out adrenal insufficiency in both inpatients and outpatients, according to a review of 3,300 adrenal insufficiency work-ups at the Edinburgh Centre for Endocrinology and Diabetes.

The finding could help eliminate the cost and hassle of unnecessary adrenocorticotropic hormone (ACTH) stimulation tests; the investigators estimated that the cut point would eliminate almost half of them without any ill effects. “You can be very confident that patients aren’t insufficient if they are above that line,” with more than 99% sensitivity. If they are below it, “they may be normal, and they may be abnormal.” Below 1.8 mcg/dL, adrenal insufficiency is almost certain, but between the cutoffs, ACTH stimulation is necessary, said lead investigator Dr. Scott Mackenzie, a trainee at the center.

In short, “basal serum cortisol as a screening test ... offers a convenient and accessible means of identifying patients who require further assessment,” he said at the annual meeting of the Endocrine Society.

Similar cut points have been suggested by previous studies, but the Scottish investigation is the first to validate its findings both inside and outside of the hospital.

The team arrived at the 11.1 mcg/dL morning cortisol cut point by comparing basal cortisol levels and synacthen results in 1,628 outpatients. They predefined a sensitivity of more than 99% for adrenal sufficiency to avoid missing anyone with true disease. The cut point’s predictive power was then validated in 875 outpatients and 797 inpatients. Morning basal cortisol levels proved superior to afternoon levels.

The investigators were thinking about cost-effectiveness, but they also wanted to increase screening. “We may be able to reduce the number of adrenal insufficiency cases we are missing because [primary care is] reluctant to send people to the clinic for synacthen tests” due to the cost and inconvenience. As with many locations in the United States, “our practice is to do [ACTH on] everyone.” If there was “a quick and easy 9 a.m. blood test” instead, it would help, Dr. Mackenzie said.

Adrenal insufficiency was on the differential for a wide variety of reasons, including hypogonadism, pituitary issues, prolactinemia, fatigue, hypoglycemia, postural hypotension, and hyponatremia. Most of the patients were middle aged, and they were about evenly split between men and women.

There was no outside funding for the work, and the investigators had no disclosures.

aotto@frontlinemedcom.com

BOSTON – A random morning serum cortisol above 11.1 mcg/dL safely rules out adrenal insufficiency in both inpatients and outpatients, according to a review of 3,300 adrenal insufficiency work-ups at the Edinburgh Centre for Endocrinology and Diabetes.

The finding could help eliminate the cost and hassle of unnecessary adrenocorticotropic hormone (ACTH) stimulation tests; the investigators estimated that the cut point would eliminate almost half of them without any ill effects. “You can be very confident that patients aren’t insufficient if they are above that line,” with more than 99% sensitivity. If they are below it, “they may be normal, and they may be abnormal.” Below 1.8 mcg/dL, adrenal insufficiency is almost certain, but between the cutoffs, ACTH stimulation is necessary, said lead investigator Dr. Scott Mackenzie, a trainee at the center.

In short, “basal serum cortisol as a screening test ... offers a convenient and accessible means of identifying patients who require further assessment,” he said at the annual meeting of the Endocrine Society.

Similar cut points have been suggested by previous studies, but the Scottish investigation is the first to validate its findings both inside and outside of the hospital.

The team arrived at the 11.1 mcg/dL morning cortisol cut point by comparing basal cortisol levels and synacthen results in 1,628 outpatients. They predefined a sensitivity of more than 99% for adrenal sufficiency to avoid missing anyone with true disease. The cut point’s predictive power was then validated in 875 outpatients and 797 inpatients. Morning basal cortisol levels proved superior to afternoon levels.

The investigators were thinking about cost-effectiveness, but they also wanted to increase screening. “We may be able to reduce the number of adrenal insufficiency cases we are missing because [primary care is] reluctant to send people to the clinic for synacthen tests” due to the cost and inconvenience. As with many locations in the United States, “our practice is to do [ACTH on] everyone.” If there was “a quick and easy 9 a.m. blood test” instead, it would help, Dr. Mackenzie said.

Adrenal insufficiency was on the differential for a wide variety of reasons, including hypogonadism, pituitary issues, prolactinemia, fatigue, hypoglycemia, postural hypotension, and hyponatremia. Most of the patients were middle aged, and they were about evenly split between men and women.

There was no outside funding for the work, and the investigators had no disclosures.

aotto@frontlinemedcom.com

BOSTON – Results of a population-based study involving more than 8,000 adults from the Netherlands who were diabetes free at baseline has implicated low thyroid function with a 13% increased likelihood of developing type 2 diabetes, and up to 40% higher in individuals with prediabetes.

The heightened risk exists even for individuals with subclinical hypothyroidism, in whom thyroid-stimulating hormone (TSH) in the blood is still in the normal concentration range.

“These findings suggest we should consider screening people with prediabetes for low thyroid function,” Dr. Layal Chaker of Erasmus Medical Center, Rotterdam, the Netherlands, said at the annual meeting of the Endocrine Society.

Thyroid screening is recommended for patients with type 1 diabetes, since they are at increased risk of thyroid disease. An association between thyroid dysfunction in the form of hypothyroidism and type 2 diabetes has been surmised, since type 2 diabetes and hypothyroidism tend to be more prevalent in older adults, and since hypothyroidism has been linked with weight gain and reduced sensitivity to insulin.

To further study the link between thyroid function and diabetes, Dr. Chaker and her colleagues studied data from 8,452 participants aged 45 years and above (mean age 62 years, 58% female) from the Rotterdam Study, a prospective, longitudinal cohort study in the Ommoord district of Rotterdam that was undertaken to investigate the risk factors of cardiovascular, neurological, ophthalmologic, and endocrine diseases in the elderly. The cohort was considered representative of the general population in the Netherlands. All participants had blood tests to measure blood glucose, TSH, and free thyroxine (FT4). Normal blood glucose was considered to be under 5.9 mmol/L, prediabetes as over 5.9 to less than 7.0 mmol/L glucose, and diabetes as above 7.0 mmol/L.

Prediabetes and type 2 diabetes developed in 1,100 and 798 subjects, respectively, during a mean follow-up of 7.9 years. Higher TSH levels increased the risk of development of type 2 diabetes risk (hazard ratio [HR] 1.13, 95% confidence interval [CI], 1.08-1.18, per logTSH). This risk held even for subjects whose TSH levels were at the lower end of the reference range of thyroid function (HR 1.24, CI, 1.06-1.45). The risk of diabetes was reduced in subjects with FT4 levels that were elevated (HR 0.96, CI, 0.93-0.99, per pmol/L) and for those whose FT4 levels were in the reference range (HR 0.96, CI, 0.92-0.99). Low thyroid function, even within the normal range, was associated with a 1.4 times risk of progression from prediabetes to type 2 diabetes (P = .002).

“Low and, surprisingly, low-normal thyroid function are risk factors for incident diabetes, especially in individuals with prediabetes,” said Dr. Chaker.

The data point to the need to clarify whether screening for and treatment of subclinical hypothyroidism can help curb the development of diabetes, she added.

Dr. Chaker had no disclosures.

BOSTON – Results of a population-based study involving more than 8,000 adults from the Netherlands who were diabetes free at baseline has implicated low thyroid function with a 13% increased likelihood of developing type 2 diabetes, and up to 40% higher in individuals with prediabetes.

The heightened risk exists even for individuals with subclinical hypothyroidism, in whom thyroid-stimulating hormone (TSH) in the blood is still in the normal concentration range.

“These findings suggest we should consider screening people with prediabetes for low thyroid function,” Dr. Layal Chaker of Erasmus Medical Center, Rotterdam, the Netherlands, said at the annual meeting of the Endocrine Society.

Thyroid screening is recommended for patients with type 1 diabetes, since they are at increased risk of thyroid disease. An association between thyroid dysfunction in the form of hypothyroidism and type 2 diabetes has been surmised, since type 2 diabetes and hypothyroidism tend to be more prevalent in older adults, and since hypothyroidism has been linked with weight gain and reduced sensitivity to insulin.

To further study the link between thyroid function and diabetes, Dr. Chaker and her colleagues studied data from 8,452 participants aged 45 years and above (mean age 62 years, 58% female) from the Rotterdam Study, a prospective, longitudinal cohort study in the Ommoord district of Rotterdam that was undertaken to investigate the risk factors of cardiovascular, neurological, ophthalmologic, and endocrine diseases in the elderly. The cohort was considered representative of the general population in the Netherlands. All participants had blood tests to measure blood glucose, TSH, and free thyroxine (FT4). Normal blood glucose was considered to be under 5.9 mmol/L, prediabetes as over 5.9 to less than 7.0 mmol/L glucose, and diabetes as above 7.0 mmol/L.

Prediabetes and type 2 diabetes developed in 1,100 and 798 subjects, respectively, during a mean follow-up of 7.9 years. Higher TSH levels increased the risk of development of type 2 diabetes risk (hazard ratio [HR] 1.13, 95% confidence interval [CI], 1.08-1.18, per logTSH). This risk held even for subjects whose TSH levels were at the lower end of the reference range of thyroid function (HR 1.24, CI, 1.06-1.45). The risk of diabetes was reduced in subjects with FT4 levels that were elevated (HR 0.96, CI, 0.93-0.99, per pmol/L) and for those whose FT4 levels were in the reference range (HR 0.96, CI, 0.92-0.99). Low thyroid function, even within the normal range, was associated with a 1.4 times risk of progression from prediabetes to type 2 diabetes (P = .002).

“Low and, surprisingly, low-normal thyroid function are risk factors for incident diabetes, especially in individuals with prediabetes,” said Dr. Chaker.

The data point to the need to clarify whether screening for and treatment of subclinical hypothyroidism can help curb the development of diabetes, she added.

Dr. Chaker had no disclosures.

BOSTON – Results of a population-based study involving more than 8,000 adults from the Netherlands who were diabetes free at baseline has implicated low thyroid function with a 13% increased likelihood of developing type 2 diabetes, and up to 40% higher in individuals with prediabetes.

The heightened risk exists even for individuals with subclinical hypothyroidism, in whom thyroid-stimulating hormone (TSH) in the blood is still in the normal concentration range.

“These findings suggest we should consider screening people with prediabetes for low thyroid function,” Dr. Layal Chaker of Erasmus Medical Center, Rotterdam, the Netherlands, said at the annual meeting of the Endocrine Society.

Thyroid screening is recommended for patients with type 1 diabetes, since they are at increased risk of thyroid disease. An association between thyroid dysfunction in the form of hypothyroidism and type 2 diabetes has been surmised, since type 2 diabetes and hypothyroidism tend to be more prevalent in older adults, and since hypothyroidism has been linked with weight gain and reduced sensitivity to insulin.

To further study the link between thyroid function and diabetes, Dr. Chaker and her colleagues studied data from 8,452 participants aged 45 years and above (mean age 62 years, 58% female) from the Rotterdam Study, a prospective, longitudinal cohort study in the Ommoord district of Rotterdam that was undertaken to investigate the risk factors of cardiovascular, neurological, ophthalmologic, and endocrine diseases in the elderly. The cohort was considered representative of the general population in the Netherlands. All participants had blood tests to measure blood glucose, TSH, and free thyroxine (FT4). Normal blood glucose was considered to be under 5.9 mmol/L, prediabetes as over 5.9 to less than 7.0 mmol/L glucose, and diabetes as above 7.0 mmol/L.

Prediabetes and type 2 diabetes developed in 1,100 and 798 subjects, respectively, during a mean follow-up of 7.9 years. Higher TSH levels increased the risk of development of type 2 diabetes risk (hazard ratio [HR] 1.13, 95% confidence interval [CI], 1.08-1.18, per logTSH). This risk held even for subjects whose TSH levels were at the lower end of the reference range of thyroid function (HR 1.24, CI, 1.06-1.45). The risk of diabetes was reduced in subjects with FT4 levels that were elevated (HR 0.96, CI, 0.93-0.99, per pmol/L) and for those whose FT4 levels were in the reference range (HR 0.96, CI, 0.92-0.99). Low thyroid function, even within the normal range, was associated with a 1.4 times risk of progression from prediabetes to type 2 diabetes (P = .002).

“Low and, surprisingly, low-normal thyroid function are risk factors for incident diabetes, especially in individuals with prediabetes,” said Dr. Chaker.

The data point to the need to clarify whether screening for and treatment of subclinical hypothyroidism can help curb the development of diabetes, she added.

Dr. Chaker had no disclosures.

Subclinical hyperthyroidism and hypothyroidism are both linked to higher mortality in the elderly, with the greatest mortality increases found in those with thyroid-stimulating hormone (TSH) values above 6.38 mIU/L, according to a retrospective cohort study.

Researchers analyzed medical records from 538 individuals with subclinical hyperthyroidism, 1,956 with subclinical hypothyroidism and 14,946 with normal thyroid-stimulating hormone levels, and found subclinical hyperthyroidism (TSH less than 0.35 mIU/L) was associated with an 80% greater risk of mortality over 10 years of follow-up, compared with normal TSH levels.

The study showed subclinical hypothyroidism (TSH greater than 4.2 mIU/L) was associated with a 68% greater mortality risk, even after adjustment for potential confounders such as age, sex, chronic kidney or lung disease, smoking, and hypertension.

The analysis also showed that when TSH values were stratified into quintiles for both subclinical hyperthyroidism and hypothyroidism, individuals with TSH levels above 6.38 mIU/L had the greatest excess of mortality, compared with other individuals with hypothyroidism, while there were no significant mortality differences between the quintiles in subclinical hyperthyroidism.

“Whether this should lead to less-restricted thyroid hormone replacement in elderly individuals with subclinical hypothyroidism is unclear, but these results certainly serve as preliminary evidence for the requirement for thyroid hormone replacement in the elderly with subclinical hypothyroidism, possibly with a higher thyroid-stimulating hormone threshold value,” wrote Dr. Alon Grossman from the Rabin Medical Center, Petah Tikva, Israel, and coauthors (Am J Med. 2016 Apr;129[4]:423-30).

No conflicts of interest were declared.

Subclinical hyperthyroidism and hypothyroidism are both linked to higher mortality in the elderly, with the greatest mortality increases found in those with thyroid-stimulating hormone (TSH) values above 6.38 mIU/L, according to a retrospective cohort study.

Researchers analyzed medical records from 538 individuals with subclinical hyperthyroidism, 1,956 with subclinical hypothyroidism and 14,946 with normal thyroid-stimulating hormone levels, and found subclinical hyperthyroidism (TSH less than 0.35 mIU/L) was associated with an 80% greater risk of mortality over 10 years of follow-up, compared with normal TSH levels.

The study showed subclinical hypothyroidism (TSH greater than 4.2 mIU/L) was associated with a 68% greater mortality risk, even after adjustment for potential confounders such as age, sex, chronic kidney or lung disease, smoking, and hypertension.

The analysis also showed that when TSH values were stratified into quintiles for both subclinical hyperthyroidism and hypothyroidism, individuals with TSH levels above 6.38 mIU/L had the greatest excess of mortality, compared with other individuals with hypothyroidism, while there were no significant mortality differences between the quintiles in subclinical hyperthyroidism.

“Whether this should lead to less-restricted thyroid hormone replacement in elderly individuals with subclinical hypothyroidism is unclear, but these results certainly serve as preliminary evidence for the requirement for thyroid hormone replacement in the elderly with subclinical hypothyroidism, possibly with a higher thyroid-stimulating hormone threshold value,” wrote Dr. Alon Grossman from the Rabin Medical Center, Petah Tikva, Israel, and coauthors (Am J Med. 2016 Apr;129[4]:423-30).

No conflicts of interest were declared.

Subclinical hyperthyroidism and hypothyroidism are both linked to higher mortality in the elderly, with the greatest mortality increases found in those with thyroid-stimulating hormone (TSH) values above 6.38 mIU/L, according to a retrospective cohort study.

Researchers analyzed medical records from 538 individuals with subclinical hyperthyroidism, 1,956 with subclinical hypothyroidism and 14,946 with normal thyroid-stimulating hormone levels, and found subclinical hyperthyroidism (TSH less than 0.35 mIU/L) was associated with an 80% greater risk of mortality over 10 years of follow-up, compared with normal TSH levels.

The study showed subclinical hypothyroidism (TSH greater than 4.2 mIU/L) was associated with a 68% greater mortality risk, even after adjustment for potential confounders such as age, sex, chronic kidney or lung disease, smoking, and hypertension.

The analysis also showed that when TSH values were stratified into quintiles for both subclinical hyperthyroidism and hypothyroidism, individuals with TSH levels above 6.38 mIU/L had the greatest excess of mortality, compared with other individuals with hypothyroidism, while there were no significant mortality differences between the quintiles in subclinical hyperthyroidism.

“Whether this should lead to less-restricted thyroid hormone replacement in elderly individuals with subclinical hypothyroidism is unclear, but these results certainly serve as preliminary evidence for the requirement for thyroid hormone replacement in the elderly with subclinical hypothyroidism, possibly with a higher thyroid-stimulating hormone threshold value,” wrote Dr. Alon Grossman from the Rabin Medical Center, Petah Tikva, Israel, and coauthors (Am J Med. 2016 Apr;129[4]:423-30).

No conflicts of interest were declared.