Pituitary, Thyroid & Adrenal Disorders

LAKE BUENA VISTA, FLA. – Levothyroxine therapy during pregnancy in women with subclinical hypothyroidism was associated with a decrease in low birth weight and low Apgar scores but not with a significant decrease in pregnancy loss in a large retrospective cohort study.

In 79 pregnant women with subclinical hypothyroidism (SCH) who received therapy with levothyroxine (LT4), and 285 with SCH who did not receive LT4 therapy, the frequency of low birth weight (less than 2,500 g) was 1.3% vs. 10%, respectively, and the frequency of Apgar scores of 7 or less at 5 minutes was 0% vs. 6.9%, Dr. S. Maraka reported at the International Thyroid Congress.

The rate of pregnancy loss was clinically, but not significantly, lower in the treated group (5.1% vs. 8.8%), and there was no difference between the groups with respect to 11 other maternal and neonatal outcomes, Dr. Maraka of the Mayo Clinic, Rochester, Minn., said at the meeting held by the American Thyroid Association, Asia-Oceania Thyroid Association, European Thyroid Association, and Latin American Thyroid Society.

Study subjects were women evaluated at the Mayo Clinic, Rochester, between January 2011 and December 2013, who had SCH during pregnancy. SCH was defined as thyroid stimulating hormone levels greater than 2.5 mIU/L during the first trimester, or greater than 3 mIU/L but no more than 10 mIU/L during the second and third trimesters. Those with a twin pregnancy or who used medications that might affect thyroid function were excluded.

The treated and untreated groups were similar with regard to age, history of pregnancy loss, and smoking status, but the treated group had higher body mass index and higher TSH levels, Dr. Maraka noted.

The findings that LT4 may improve pregnancy outcome in women with SCH are important because SCH has been associated with an increased risk of adverse pregnancy outcomes in some studies and it has been unclear whether LT4 therapy improves outcomes.

However, the association seen in the current study, which involves the largest cohort reporting pregnancy outcomes of women with SCH treated vs. untreated with LT4 therapy, requires confirmation in randomized trials before widespread use of LT4 therapy for SCH can be recommended, she concluded.

Dr. Maraka reported having no disclosures.

[email protected]

LAKE BUENA VISTA, FLA. – Levothyroxine therapy during pregnancy in women with subclinical hypothyroidism was associated with a decrease in low birth weight and low Apgar scores but not with a significant decrease in pregnancy loss in a large retrospective cohort study.

In 79 pregnant women with subclinical hypothyroidism (SCH) who received therapy with levothyroxine (LT4), and 285 with SCH who did not receive LT4 therapy, the frequency of low birth weight (less than 2,500 g) was 1.3% vs. 10%, respectively, and the frequency of Apgar scores of 7 or less at 5 minutes was 0% vs. 6.9%, Dr. S. Maraka reported at the International Thyroid Congress.

The rate of pregnancy loss was clinically, but not significantly, lower in the treated group (5.1% vs. 8.8%), and there was no difference between the groups with respect to 11 other maternal and neonatal outcomes, Dr. Maraka of the Mayo Clinic, Rochester, Minn., said at the meeting held by the American Thyroid Association, Asia-Oceania Thyroid Association, European Thyroid Association, and Latin American Thyroid Society.

Study subjects were women evaluated at the Mayo Clinic, Rochester, between January 2011 and December 2013, who had SCH during pregnancy. SCH was defined as thyroid stimulating hormone levels greater than 2.5 mIU/L during the first trimester, or greater than 3 mIU/L but no more than 10 mIU/L during the second and third trimesters. Those with a twin pregnancy or who used medications that might affect thyroid function were excluded.

The treated and untreated groups were similar with regard to age, history of pregnancy loss, and smoking status, but the treated group had higher body mass index and higher TSH levels, Dr. Maraka noted.

The findings that LT4 may improve pregnancy outcome in women with SCH are important because SCH has been associated with an increased risk of adverse pregnancy outcomes in some studies and it has been unclear whether LT4 therapy improves outcomes.

However, the association seen in the current study, which involves the largest cohort reporting pregnancy outcomes of women with SCH treated vs. untreated with LT4 therapy, requires confirmation in randomized trials before widespread use of LT4 therapy for SCH can be recommended, she concluded.

Dr. Maraka reported having no disclosures.

[email protected]

LAKE BUENA VISTA, FLA. – Levothyroxine therapy during pregnancy in women with subclinical hypothyroidism was associated with a decrease in low birth weight and low Apgar scores but not with a significant decrease in pregnancy loss in a large retrospective cohort study.

In 79 pregnant women with subclinical hypothyroidism (SCH) who received therapy with levothyroxine (LT4), and 285 with SCH who did not receive LT4 therapy, the frequency of low birth weight (less than 2,500 g) was 1.3% vs. 10%, respectively, and the frequency of Apgar scores of 7 or less at 5 minutes was 0% vs. 6.9%, Dr. S. Maraka reported at the International Thyroid Congress.

The rate of pregnancy loss was clinically, but not significantly, lower in the treated group (5.1% vs. 8.8%), and there was no difference between the groups with respect to 11 other maternal and neonatal outcomes, Dr. Maraka of the Mayo Clinic, Rochester, Minn., said at the meeting held by the American Thyroid Association, Asia-Oceania Thyroid Association, European Thyroid Association, and Latin American Thyroid Society.

Study subjects were women evaluated at the Mayo Clinic, Rochester, between January 2011 and December 2013, who had SCH during pregnancy. SCH was defined as thyroid stimulating hormone levels greater than 2.5 mIU/L during the first trimester, or greater than 3 mIU/L but no more than 10 mIU/L during the second and third trimesters. Those with a twin pregnancy or who used medications that might affect thyroid function were excluded.

The treated and untreated groups were similar with regard to age, history of pregnancy loss, and smoking status, but the treated group had higher body mass index and higher TSH levels, Dr. Maraka noted.

The findings that LT4 may improve pregnancy outcome in women with SCH are important because SCH has been associated with an increased risk of adverse pregnancy outcomes in some studies and it has been unclear whether LT4 therapy improves outcomes.

However, the association seen in the current study, which involves the largest cohort reporting pregnancy outcomes of women with SCH treated vs. untreated with LT4 therapy, requires confirmation in randomized trials before widespread use of LT4 therapy for SCH can be recommended, she concluded.

Dr. Maraka reported having no disclosures.

[email protected]

LAKE BUENA VISTA, FLA. – Rapidly enlarging thyroid masses with compressive symptoms may signal thyroid lymphoma, according to findings from a review of cases at the Mayo Clinic.

Radiologically, these masses tend to present as large, unilateral, thyroid-centered masses that are hypoechoic on ultrasound and that expand into adjacent soft tissue, Dr. Anu Sharma reported at the International Thyroid Congress.

The findings are based on a review of 75 patients with biopsy-proven thyroid lymphoma – a relatively rare disease, accounting for between 1% and 5% of all thyroid malignancies, and less than 1% of all lymphomas – who presented to the Mayo Clinic between 2000 and 2014.

“Thyroid lymphoma can sometimes present very similar to anaplastic carcinoma, and we wanted to see if there are any unique identification factors that you can use to increase your suspicion of thyroid lymphoma,” Dr. Sharma of the Mayo Clinic, Rochester, Minn., said.

Indeed, rapid enlargement and compressive symptoms are also common presenting features of anaplastic carcinoma, she said.

Of the 75 cases included in the review – compromising all cases presenting during the study period – 70.7% involved primary thyroid lymphoma. A neck mass was present in 88% of cases, dysphagia in 45%, and hoarseness in 37%.

The typical presentation included a solid, hypoechoic mass with mildly increased vascularity, no internal calcifications, and edge characteristics that ranged from well-defined (80%) to ill-defined (20%). Median tumor volume was 64 cm³, Dr. Sharma said.

This differs from anaplastic carcinoma in that most patients with anaplastic carcinoma have ill-defined edges, she noted.

Another difference between thyroid lymphoma and anaplastic carcinoma as noted in this study involves necrosis; none of the patients in the current study had areas of necrosis, whereas 78% of anaplastic carcinoma patients in another study had areas of necrosis, she explained.

The patients in the current study had a median age of 67 years, although the ages varied widely. About half (50.7%) were men, and 54.7% had a history of Hashimoto’s thyroiditis. Fifty-seven of the patients had an ultrasound before treatment.

The first diagnostic procedure performed was fine needle aspiration (FNA) in 65 subjects, and the FNA biopsies were abnormal in 69% of those, with 42% suggesting a specific lymphoma subtype. The subtype diagnosis was accurate, based on final tissue analysis, in 89% of those.

“While this is quite impressive, all patients who had FNA ended up having further tissue biopsy for subtype confirmation and for treatment, and this is important, because the subtype of the lymphoma is important in determining the type of treatment uses as well as determining prognosis,” she said.

The diagnosis was confirmed by core biopsy in 46.7% of cases, by incisional biopsy in 9.3%, by partial or total thyroidectomy in 25.3%, and by lymph node biopsy in 13.3%; percentages total 94.6% due to downward rounding. Histologic subtypes included diffuse large B-cell lymphoma (DLBCL) in 73.3% of cases, follicular lymphoma in 5.3%, mucosa-associated lymphoid tissue (MALT) in 10.7%, MALT/DLBCL in 2.6%, T-cell lymphoma in 2.6%, and Hodgkin’s lymphoma in 1.3%; percentages total 95.8% rather than 100% due to downward rounding.

In addition to rapid enlargement of a neck mass with compressive symptoms, findings that should raise suspicion of thyroid lymphoma include a history of Hashimoto’s thyroiditis and the ultrasound findings characterized by this study, Dr. Sharma said.

“Once you have that increased suspicion, you should move toward going to core biopsy rather than FNA to save the patient from having two diagnostic steps rather than one,” she concluded.

Dr. Sharma reported having no disclosures.

[email protected]

LAKE BUENA VISTA, FLA. – Rapidly enlarging thyroid masses with compressive symptoms may signal thyroid lymphoma, according to findings from a review of cases at the Mayo Clinic.

Radiologically, these masses tend to present as large, unilateral, thyroid-centered masses that are hypoechoic on ultrasound and that expand into adjacent soft tissue, Dr. Anu Sharma reported at the International Thyroid Congress.

The findings are based on a review of 75 patients with biopsy-proven thyroid lymphoma – a relatively rare disease, accounting for between 1% and 5% of all thyroid malignancies, and less than 1% of all lymphomas – who presented to the Mayo Clinic between 2000 and 2014.

“Thyroid lymphoma can sometimes present very similar to anaplastic carcinoma, and we wanted to see if there are any unique identification factors that you can use to increase your suspicion of thyroid lymphoma,” Dr. Sharma of the Mayo Clinic, Rochester, Minn., said.

Indeed, rapid enlargement and compressive symptoms are also common presenting features of anaplastic carcinoma, she said.

Of the 75 cases included in the review – compromising all cases presenting during the study period – 70.7% involved primary thyroid lymphoma. A neck mass was present in 88% of cases, dysphagia in 45%, and hoarseness in 37%.

The typical presentation included a solid, hypoechoic mass with mildly increased vascularity, no internal calcifications, and edge characteristics that ranged from well-defined (80%) to ill-defined (20%). Median tumor volume was 64 cm³, Dr. Sharma said.

This differs from anaplastic carcinoma in that most patients with anaplastic carcinoma have ill-defined edges, she noted.

Another difference between thyroid lymphoma and anaplastic carcinoma as noted in this study involves necrosis; none of the patients in the current study had areas of necrosis, whereas 78% of anaplastic carcinoma patients in another study had areas of necrosis, she explained.

The patients in the current study had a median age of 67 years, although the ages varied widely. About half (50.7%) were men, and 54.7% had a history of Hashimoto’s thyroiditis. Fifty-seven of the patients had an ultrasound before treatment.

The first diagnostic procedure performed was fine needle aspiration (FNA) in 65 subjects, and the FNA biopsies were abnormal in 69% of those, with 42% suggesting a specific lymphoma subtype. The subtype diagnosis was accurate, based on final tissue analysis, in 89% of those.

“While this is quite impressive, all patients who had FNA ended up having further tissue biopsy for subtype confirmation and for treatment, and this is important, because the subtype of the lymphoma is important in determining the type of treatment uses as well as determining prognosis,” she said.

The diagnosis was confirmed by core biopsy in 46.7% of cases, by incisional biopsy in 9.3%, by partial or total thyroidectomy in 25.3%, and by lymph node biopsy in 13.3%; percentages total 94.6% due to downward rounding. Histologic subtypes included diffuse large B-cell lymphoma (DLBCL) in 73.3% of cases, follicular lymphoma in 5.3%, mucosa-associated lymphoid tissue (MALT) in 10.7%, MALT/DLBCL in 2.6%, T-cell lymphoma in 2.6%, and Hodgkin’s lymphoma in 1.3%; percentages total 95.8% rather than 100% due to downward rounding.

In addition to rapid enlargement of a neck mass with compressive symptoms, findings that should raise suspicion of thyroid lymphoma include a history of Hashimoto’s thyroiditis and the ultrasound findings characterized by this study, Dr. Sharma said.

“Once you have that increased suspicion, you should move toward going to core biopsy rather than FNA to save the patient from having two diagnostic steps rather than one,” she concluded.

Dr. Sharma reported having no disclosures.

[email protected]

LAKE BUENA VISTA, FLA. – Rapidly enlarging thyroid masses with compressive symptoms may signal thyroid lymphoma, according to findings from a review of cases at the Mayo Clinic.

Radiologically, these masses tend to present as large, unilateral, thyroid-centered masses that are hypoechoic on ultrasound and that expand into adjacent soft tissue, Dr. Anu Sharma reported at the International Thyroid Congress.

The findings are based on a review of 75 patients with biopsy-proven thyroid lymphoma – a relatively rare disease, accounting for between 1% and 5% of all thyroid malignancies, and less than 1% of all lymphomas – who presented to the Mayo Clinic between 2000 and 2014.

“Thyroid lymphoma can sometimes present very similar to anaplastic carcinoma, and we wanted to see if there are any unique identification factors that you can use to increase your suspicion of thyroid lymphoma,” Dr. Sharma of the Mayo Clinic, Rochester, Minn., said.

Indeed, rapid enlargement and compressive symptoms are also common presenting features of anaplastic carcinoma, she said.

Of the 75 cases included in the review – compromising all cases presenting during the study period – 70.7% involved primary thyroid lymphoma. A neck mass was present in 88% of cases, dysphagia in 45%, and hoarseness in 37%.

The typical presentation included a solid, hypoechoic mass with mildly increased vascularity, no internal calcifications, and edge characteristics that ranged from well-defined (80%) to ill-defined (20%). Median tumor volume was 64 cm³, Dr. Sharma said.

This differs from anaplastic carcinoma in that most patients with anaplastic carcinoma have ill-defined edges, she noted.

Another difference between thyroid lymphoma and anaplastic carcinoma as noted in this study involves necrosis; none of the patients in the current study had areas of necrosis, whereas 78% of anaplastic carcinoma patients in another study had areas of necrosis, she explained.

The patients in the current study had a median age of 67 years, although the ages varied widely. About half (50.7%) were men, and 54.7% had a history of Hashimoto’s thyroiditis. Fifty-seven of the patients had an ultrasound before treatment.

The first diagnostic procedure performed was fine needle aspiration (FNA) in 65 subjects, and the FNA biopsies were abnormal in 69% of those, with 42% suggesting a specific lymphoma subtype. The subtype diagnosis was accurate, based on final tissue analysis, in 89% of those.

“While this is quite impressive, all patients who had FNA ended up having further tissue biopsy for subtype confirmation and for treatment, and this is important, because the subtype of the lymphoma is important in determining the type of treatment uses as well as determining prognosis,” she said.

The diagnosis was confirmed by core biopsy in 46.7% of cases, by incisional biopsy in 9.3%, by partial or total thyroidectomy in 25.3%, and by lymph node biopsy in 13.3%; percentages total 94.6% due to downward rounding. Histologic subtypes included diffuse large B-cell lymphoma (DLBCL) in 73.3% of cases, follicular lymphoma in 5.3%, mucosa-associated lymphoid tissue (MALT) in 10.7%, MALT/DLBCL in 2.6%, T-cell lymphoma in 2.6%, and Hodgkin’s lymphoma in 1.3%; percentages total 95.8% rather than 100% due to downward rounding.

In addition to rapid enlargement of a neck mass with compressive symptoms, findings that should raise suspicion of thyroid lymphoma include a history of Hashimoto’s thyroiditis and the ultrasound findings characterized by this study, Dr. Sharma said.

“Once you have that increased suspicion, you should move toward going to core biopsy rather than FNA to save the patient from having two diagnostic steps rather than one,” she concluded.

Dr. Sharma reported having no disclosures.

[email protected]

LAKE BUENA VISTA, FLA. – Observation is a reasonable option for managing patients with benign thyroid nodules that display initial low-suspicion ultrasound patterns.

Presented at the International Thyroid Congress, the American Thyroid Association’s new guidelines on the management of thyroid nodules offer specific ultrasound patterns that help distinguish benign nodules from developing malignancy (Thyroid. 2015 Oct. doi: 10.1089/thy.2015.0020]).

They reflect new data obtained from studies conducted in the years since 2009, when the last guidelines were issued, Dr. Susan Mandel said at the meeting, which was held by the American Thyroid Association, Asia-Oceania Thyroid Association , European Thyroid Association, and Latin American Thyroid Society.

“We now know that about 20% of cytologically benign thyroid nodules will grow,” said Dr. Mandel of the University of Pennsylvania, Philadelphia. But very few of those will become malignant. According to a newly published study of 553 patients, 200 must be followed to identify one cancer that would have been missed (Thyroid. 2015 Oct 25;10:1115-20).

The new guidelines reflect findings like these and attempt to balance sensible follow-up while avoiding overtreatment, Dr. Mandel said. Diagnosed thyroid cancers are on the rise in the United States, from about 37,000 in 2009 to about 63,000 last year. But this is not because the cancer itself is more prevalent. More likely, it is the result of the increasing use of sonography or other imaging studies, which allows for earlier diagnosis and treatment. These technologies have a downside as well, leading to overdiagnosis and overtreatment of benign nodules that, most likely, would never undergo malignant transformation, Dr. Mandel said.

Nodules are most likely to grow in younger patients and those with longer follow-up, “which makes sense, as thyroid nodules grow very slowly.” Predominately solid nodules are also more likely to grow than are cystic nodules. Size at baseline is a controversial topic. There is some evidence that subcentimeter nodules are more likely to grow, while larger nodules are less likely.

Worrisome initial ultrasound patterns, however, should throw up a red flag even if the nodule is cytologically negative at baseline, Dr. Mandel said. These patterns are:

• Marked hypoechogeniticy.

• Microcalcifications.

• Irregular, microlobulated margins.

• Taller-than-wide shape.

• Incomplete or peripheral calcification.

These nodules should undergo a repeat ultrasound and a repeat ultrasound-guided fine needle biopsy within 6-12 months of the initial assessment, the guidelines recommend.

For nodules of any state, if (1) there is sonographic evidence of growth (20% increase in at least 2 nodule dimensions with a minimal increase of 2 mm or (2) more than 50% change in volume) or (3) development of new suspicious sonographic features,  there should be an additional fine-needle biopsy. “Although the risk of malignancy after two benign cytology results is virtually zero, routine repeat biopsy is not a viable or cost-effective option because of the low false negative rate,” the document notes.

Small nodules (less than 1 cm) that have very low-suspicion ultrasound patterns (including spongiform nodules) don’t require routine follow-up sonograms. Nor do nodules larger than 5 mm without high-suspicion findings.

The guidelines also offer recommendations on treatment. There is no need to offer routine therapy with thyroid stimulating hormone (TSH) for benign nodules. “Though modest responses to therapy can be detected, the potential harm outweighs benefit for most patients,” the document states.

If benign nodules grow, surgery could be an option if they become large (greater than 4 cm), or cause compression or structural symptoms – or if there is clinical concern, although the document does not specify exactly what that could be.

Patients with growing nodules that are benign after a second biopsy should be regularly monitored. Most asymptomatic nodules demonstrating modest growth should be followed without intervention,” it says.

Recurrent benign cystic thyroid nodules may be treated surgically or with ethanol ablation, but asymptotic cystic nodules may be followed conservatively There are no data to guide the use of thyroid hormone treatment for benign nodules, even if they do grow.

The guidelines also offer recommendations for initial serum and molecular studies, and treatment for follicular and differentiated thyroid cancers.

Dr. Mandel had no financial disclosures.

[email protected]

LAKE BUENA VISTA, FLA. – Observation is a reasonable option for managing patients with benign thyroid nodules that display initial low-suspicion ultrasound patterns.

Presented at the International Thyroid Congress, the American Thyroid Association’s new guidelines on the management of thyroid nodules offer specific ultrasound patterns that help distinguish benign nodules from developing malignancy (Thyroid. 2015 Oct. doi: 10.1089/thy.2015.0020]).

They reflect new data obtained from studies conducted in the years since 2009, when the last guidelines were issued, Dr. Susan Mandel said at the meeting, which was held by the American Thyroid Association, Asia-Oceania Thyroid Association , European Thyroid Association, and Latin American Thyroid Society.

“We now know that about 20% of cytologically benign thyroid nodules will grow,” said Dr. Mandel of the University of Pennsylvania, Philadelphia. But very few of those will become malignant. According to a newly published study of 553 patients, 200 must be followed to identify one cancer that would have been missed (Thyroid. 2015 Oct 25;10:1115-20).

The new guidelines reflect findings like these and attempt to balance sensible follow-up while avoiding overtreatment, Dr. Mandel said. Diagnosed thyroid cancers are on the rise in the United States, from about 37,000 in 2009 to about 63,000 last year. But this is not because the cancer itself is more prevalent. More likely, it is the result of the increasing use of sonography or other imaging studies, which allows for earlier diagnosis and treatment. These technologies have a downside as well, leading to overdiagnosis and overtreatment of benign nodules that, most likely, would never undergo malignant transformation, Dr. Mandel said.

Nodules are most likely to grow in younger patients and those with longer follow-up, “which makes sense, as thyroid nodules grow very slowly.” Predominately solid nodules are also more likely to grow than are cystic nodules. Size at baseline is a controversial topic. There is some evidence that subcentimeter nodules are more likely to grow, while larger nodules are less likely.

Worrisome initial ultrasound patterns, however, should throw up a red flag even if the nodule is cytologically negative at baseline, Dr. Mandel said. These patterns are:

• Marked hypoechogeniticy.

• Microcalcifications.

• Irregular, microlobulated margins.

• Taller-than-wide shape.

• Incomplete or peripheral calcification.

These nodules should undergo a repeat ultrasound and a repeat ultrasound-guided fine needle biopsy within 6-12 months of the initial assessment, the guidelines recommend.

For nodules of any state, if (1) there is sonographic evidence of growth (20% increase in at least 2 nodule dimensions with a minimal increase of 2 mm or (2) more than 50% change in volume) or (3) development of new suspicious sonographic features,  there should be an additional fine-needle biopsy. “Although the risk of malignancy after two benign cytology results is virtually zero, routine repeat biopsy is not a viable or cost-effective option because of the low false negative rate,” the document notes.

Small nodules (less than 1 cm) that have very low-suspicion ultrasound patterns (including spongiform nodules) don’t require routine follow-up sonograms. Nor do nodules larger than 5 mm without high-suspicion findings.

The guidelines also offer recommendations on treatment. There is no need to offer routine therapy with thyroid stimulating hormone (TSH) for benign nodules. “Though modest responses to therapy can be detected, the potential harm outweighs benefit for most patients,” the document states.

If benign nodules grow, surgery could be an option if they become large (greater than 4 cm), or cause compression or structural symptoms – or if there is clinical concern, although the document does not specify exactly what that could be.

Patients with growing nodules that are benign after a second biopsy should be regularly monitored. Most asymptomatic nodules demonstrating modest growth should be followed without intervention,” it says.

Recurrent benign cystic thyroid nodules may be treated surgically or with ethanol ablation, but asymptotic cystic nodules may be followed conservatively There are no data to guide the use of thyroid hormone treatment for benign nodules, even if they do grow.

The guidelines also offer recommendations for initial serum and molecular studies, and treatment for follicular and differentiated thyroid cancers.

Dr. Mandel had no financial disclosures.

[email protected]

LAKE BUENA VISTA, FLA. – Observation is a reasonable option for managing patients with benign thyroid nodules that display initial low-suspicion ultrasound patterns.

Presented at the International Thyroid Congress, the American Thyroid Association’s new guidelines on the management of thyroid nodules offer specific ultrasound patterns that help distinguish benign nodules from developing malignancy (Thyroid. 2015 Oct. doi: 10.1089/thy.2015.0020]).

They reflect new data obtained from studies conducted in the years since 2009, when the last guidelines were issued, Dr. Susan Mandel said at the meeting, which was held by the American Thyroid Association, Asia-Oceania Thyroid Association , European Thyroid Association, and Latin American Thyroid Society.

“We now know that about 20% of cytologically benign thyroid nodules will grow,” said Dr. Mandel of the University of Pennsylvania, Philadelphia. But very few of those will become malignant. According to a newly published study of 553 patients, 200 must be followed to identify one cancer that would have been missed (Thyroid. 2015 Oct 25;10:1115-20).

The new guidelines reflect findings like these and attempt to balance sensible follow-up while avoiding overtreatment, Dr. Mandel said. Diagnosed thyroid cancers are on the rise in the United States, from about 37,000 in 2009 to about 63,000 last year. But this is not because the cancer itself is more prevalent. More likely, it is the result of the increasing use of sonography or other imaging studies, which allows for earlier diagnosis and treatment. These technologies have a downside as well, leading to overdiagnosis and overtreatment of benign nodules that, most likely, would never undergo malignant transformation, Dr. Mandel said.

Nodules are most likely to grow in younger patients and those with longer follow-up, “which makes sense, as thyroid nodules grow very slowly.” Predominately solid nodules are also more likely to grow than are cystic nodules. Size at baseline is a controversial topic. There is some evidence that subcentimeter nodules are more likely to grow, while larger nodules are less likely.

Worrisome initial ultrasound patterns, however, should throw up a red flag even if the nodule is cytologically negative at baseline, Dr. Mandel said. These patterns are:

• Marked hypoechogeniticy.

• Microcalcifications.

• Irregular, microlobulated margins.

• Taller-than-wide shape.

• Incomplete or peripheral calcification.

These nodules should undergo a repeat ultrasound and a repeat ultrasound-guided fine needle biopsy within 6-12 months of the initial assessment, the guidelines recommend.

For nodules of any state, if (1) there is sonographic evidence of growth (20% increase in at least 2 nodule dimensions with a minimal increase of 2 mm or (2) more than 50% change in volume) or (3) development of new suspicious sonographic features,  there should be an additional fine-needle biopsy. “Although the risk of malignancy after two benign cytology results is virtually zero, routine repeat biopsy is not a viable or cost-effective option because of the low false negative rate,” the document notes.

Small nodules (less than 1 cm) that have very low-suspicion ultrasound patterns (including spongiform nodules) don’t require routine follow-up sonograms. Nor do nodules larger than 5 mm without high-suspicion findings.

The guidelines also offer recommendations on treatment. There is no need to offer routine therapy with thyroid stimulating hormone (TSH) for benign nodules. “Though modest responses to therapy can be detected, the potential harm outweighs benefit for most patients,” the document states.

If benign nodules grow, surgery could be an option if they become large (greater than 4 cm), or cause compression or structural symptoms – or if there is clinical concern, although the document does not specify exactly what that could be.

Patients with growing nodules that are benign after a second biopsy should be regularly monitored. Most asymptomatic nodules demonstrating modest growth should be followed without intervention,” it says.

Recurrent benign cystic thyroid nodules may be treated surgically or with ethanol ablation, but asymptotic cystic nodules may be followed conservatively There are no data to guide the use of thyroid hormone treatment for benign nodules, even if they do grow.

The guidelines also offer recommendations for initial serum and molecular studies, and treatment for follicular and differentiated thyroid cancers.

Dr. Mandel had no financial disclosures.

[email protected]

LAKE BUENA VISTA, FLA. – Patients with low thyroid function may experience a “double whammy” of hypothyroidism and metabolic syndrome.

Even subclinical hypothyroidism affects many metabolic pathways that can contribute to deranged glucose and lipid metabolism, raising the risk of metabolic syndrome, according to Dr. Gabriela Brenta of the department of endocrinology at the Dr. Cesar Milstein Hospital in Buenos Aires. Though some mechanisms are incompletely understood, the association is clear enough to warrant screening all metabolic syndrome patients for hypothyroidism, she said.

Dr. Brenta described the recent work she and others have completed in the field. Basic science work revealed some early clues. For example, those who studied the effects of acute thyroid hormone withdrawal on patients with no thyroid gland found that these patients saw a rapid rise in insulin resistance. It’s known that even subclinical insulin resistance can lead to impaired glucose metabolism, making it logical to follow both normal and deranged metabolic pathways to help sort out the relationship between thyroid dysfunction and impaired glucose metabolism, she reported at the International Thyroid Congress.

Hypothyroidism can affect glucose homeostasis through multiple mechanisms, said Dr. Brenta. Firstly, hypothyroidism can lead to decreased hepatic gluconeogenesis and glycogenolysis. Hypothyroidism also can lead to reduced baseline plasma insulin levels and increased postglucose insulin secretion. In the peripheral tissues, hypothyroidism can interfere with glucose metabolism and disposal. All of these mechanisms can decrease hepatic glucose metabolism and lead to a postabsorptive hyperglycemia state, said Dr. Brenta, noting: “Insulin resistance is in some way the backbone of metabolic syndrome.”

Lipid metabolism is also affected by subclinical hypothyroidism, which can decrease expression of mRNA for LDL-C receptors, leading to LDL-C receptor down-regulation. With fewer receptors available, serum levels of LDL-C increase, with resultant increased susceptibility to oxidative effects and increased foam cell generation.

Dr. Brenta cited her earlier work showing that “triglyceride enrichment of LDL particles correlates with lower hepatic lipase activity” for individuals with subclinical hypothyroidism, with significantly lower hepatic lipase activity and a higher LDL-C to triglyceride ratio for those patients than for controls (Thyroid. 2007 May;17[5]:453-60). Overall, in hypothyroidism, “LDL particles are exposed to more substances that make them more atherogenic with decreased degradation and increased half-life,” said Dr. Brenta.

The increased risk for hypertension in both subclinical and overt hypothyroidism may be related, in part, to the fact that triiodothyronine deficiency can contribute to endothelial dysfunction. The relationship between subclinical hypothyroidism and hypertension was confirmed in a 2011 meta-analysis, said Dr. Brenta (Hypertens Res. 2011 Oct;34[10]:1098-105).

Though many factors contribute to obesity and thyroid function alone does not regulate body weight, a large population-based Danish study found that “even mild elevations of TSH are important for body weight,” said Dr. Brenta. The relationship is complex and bidirectional – a classic “chicken and egg” story – since obesity also may modulate TSH, she said; “however, we must not forget the ample literature on low levels of thyroid hormones reducing resting energy expenditure” (J Clin Endocrinol Metab. 2005 Jul;90[7]:4019-24).

Even though TSH tends to rise naturally through the lifespan, the association between elevated TSH and increased risk of metabolic syndrome held true even for older patients in one study, with “each one unit increase in TSH predicting a 3% increase in the odds of metabolic syndrome,” even after adjustment for age, BMI, and HOMA-IR status, among other variables, said Dr. Brenta (Clin Endocrinol [Oxf]. 2012 Jun;76[6]:911-8).

Advocating for universal screening for hypothyroidism among patients with metabolic syndrome, Dr. Brenta said that “hypothyroid disturbances are associated with an adverse metabolic profile, and even low normal TSH levels are associated with the metabolic traits of metabolic syndrome.”

The meeting was held by the American Thyroid Association, Asia-Oceania Thyroid Association, European Thyroid Association, and Latin American Thyroid Society. Dr. Brenta did not identify any conflicts of interest.

[email protected]

On Twitter @karioakes

LAKE BUENA VISTA, FLA. – Patients with low thyroid function may experience a “double whammy” of hypothyroidism and metabolic syndrome.

Even subclinical hypothyroidism affects many metabolic pathways that can contribute to deranged glucose and lipid metabolism, raising the risk of metabolic syndrome, according to Dr. Gabriela Brenta of the department of endocrinology at the Dr. Cesar Milstein Hospital in Buenos Aires. Though some mechanisms are incompletely understood, the association is clear enough to warrant screening all metabolic syndrome patients for hypothyroidism, she said.

Dr. Brenta described the recent work she and others have completed in the field. Basic science work revealed some early clues. For example, those who studied the effects of acute thyroid hormone withdrawal on patients with no thyroid gland found that these patients saw a rapid rise in insulin resistance. It’s known that even subclinical insulin resistance can lead to impaired glucose metabolism, making it logical to follow both normal and deranged metabolic pathways to help sort out the relationship between thyroid dysfunction and impaired glucose metabolism, she reported at the International Thyroid Congress.

Hypothyroidism can affect glucose homeostasis through multiple mechanisms, said Dr. Brenta. Firstly, hypothyroidism can lead to decreased hepatic gluconeogenesis and glycogenolysis. Hypothyroidism also can lead to reduced baseline plasma insulin levels and increased postglucose insulin secretion. In the peripheral tissues, hypothyroidism can interfere with glucose metabolism and disposal. All of these mechanisms can decrease hepatic glucose metabolism and lead to a postabsorptive hyperglycemia state, said Dr. Brenta, noting: “Insulin resistance is in some way the backbone of metabolic syndrome.”

Lipid metabolism is also affected by subclinical hypothyroidism, which can decrease expression of mRNA for LDL-C receptors, leading to LDL-C receptor down-regulation. With fewer receptors available, serum levels of LDL-C increase, with resultant increased susceptibility to oxidative effects and increased foam cell generation.

Dr. Brenta cited her earlier work showing that “triglyceride enrichment of LDL particles correlates with lower hepatic lipase activity” for individuals with subclinical hypothyroidism, with significantly lower hepatic lipase activity and a higher LDL-C to triglyceride ratio for those patients than for controls (Thyroid. 2007 May;17[5]:453-60). Overall, in hypothyroidism, “LDL particles are exposed to more substances that make them more atherogenic with decreased degradation and increased half-life,” said Dr. Brenta.

The increased risk for hypertension in both subclinical and overt hypothyroidism may be related, in part, to the fact that triiodothyronine deficiency can contribute to endothelial dysfunction. The relationship between subclinical hypothyroidism and hypertension was confirmed in a 2011 meta-analysis, said Dr. Brenta (Hypertens Res. 2011 Oct;34[10]:1098-105).

Though many factors contribute to obesity and thyroid function alone does not regulate body weight, a large population-based Danish study found that “even mild elevations of TSH are important for body weight,” said Dr. Brenta. The relationship is complex and bidirectional – a classic “chicken and egg” story – since obesity also may modulate TSH, she said; “however, we must not forget the ample literature on low levels of thyroid hormones reducing resting energy expenditure” (J Clin Endocrinol Metab. 2005 Jul;90[7]:4019-24).

Even though TSH tends to rise naturally through the lifespan, the association between elevated TSH and increased risk of metabolic syndrome held true even for older patients in one study, with “each one unit increase in TSH predicting a 3% increase in the odds of metabolic syndrome,” even after adjustment for age, BMI, and HOMA-IR status, among other variables, said Dr. Brenta (Clin Endocrinol [Oxf]. 2012 Jun;76[6]:911-8).

Advocating for universal screening for hypothyroidism among patients with metabolic syndrome, Dr. Brenta said that “hypothyroid disturbances are associated with an adverse metabolic profile, and even low normal TSH levels are associated with the metabolic traits of metabolic syndrome.”

The meeting was held by the American Thyroid Association, Asia-Oceania Thyroid Association, European Thyroid Association, and Latin American Thyroid Society. Dr. Brenta did not identify any conflicts of interest.

[email protected]

On Twitter @karioakes

LAKE BUENA VISTA, FLA. – Patients with low thyroid function may experience a “double whammy” of hypothyroidism and metabolic syndrome.

Even subclinical hypothyroidism affects many metabolic pathways that can contribute to deranged glucose and lipid metabolism, raising the risk of metabolic syndrome, according to Dr. Gabriela Brenta of the department of endocrinology at the Dr. Cesar Milstein Hospital in Buenos Aires. Though some mechanisms are incompletely understood, the association is clear enough to warrant screening all metabolic syndrome patients for hypothyroidism, she said.

Dr. Brenta described the recent work she and others have completed in the field. Basic science work revealed some early clues. For example, those who studied the effects of acute thyroid hormone withdrawal on patients with no thyroid gland found that these patients saw a rapid rise in insulin resistance. It’s known that even subclinical insulin resistance can lead to impaired glucose metabolism, making it logical to follow both normal and deranged metabolic pathways to help sort out the relationship between thyroid dysfunction and impaired glucose metabolism, she reported at the International Thyroid Congress.

Hypothyroidism can affect glucose homeostasis through multiple mechanisms, said Dr. Brenta. Firstly, hypothyroidism can lead to decreased hepatic gluconeogenesis and glycogenolysis. Hypothyroidism also can lead to reduced baseline plasma insulin levels and increased postglucose insulin secretion. In the peripheral tissues, hypothyroidism can interfere with glucose metabolism and disposal. All of these mechanisms can decrease hepatic glucose metabolism and lead to a postabsorptive hyperglycemia state, said Dr. Brenta, noting: “Insulin resistance is in some way the backbone of metabolic syndrome.”

Lipid metabolism is also affected by subclinical hypothyroidism, which can decrease expression of mRNA for LDL-C receptors, leading to LDL-C receptor down-regulation. With fewer receptors available, serum levels of LDL-C increase, with resultant increased susceptibility to oxidative effects and increased foam cell generation.

Dr. Brenta cited her earlier work showing that “triglyceride enrichment of LDL particles correlates with lower hepatic lipase activity” for individuals with subclinical hypothyroidism, with significantly lower hepatic lipase activity and a higher LDL-C to triglyceride ratio for those patients than for controls (Thyroid. 2007 May;17[5]:453-60). Overall, in hypothyroidism, “LDL particles are exposed to more substances that make them more atherogenic with decreased degradation and increased half-life,” said Dr. Brenta.

The increased risk for hypertension in both subclinical and overt hypothyroidism may be related, in part, to the fact that triiodothyronine deficiency can contribute to endothelial dysfunction. The relationship between subclinical hypothyroidism and hypertension was confirmed in a 2011 meta-analysis, said Dr. Brenta (Hypertens Res. 2011 Oct;34[10]:1098-105).

Though many factors contribute to obesity and thyroid function alone does not regulate body weight, a large population-based Danish study found that “even mild elevations of TSH are important for body weight,” said Dr. Brenta. The relationship is complex and bidirectional – a classic “chicken and egg” story – since obesity also may modulate TSH, she said; “however, we must not forget the ample literature on low levels of thyroid hormones reducing resting energy expenditure” (J Clin Endocrinol Metab. 2005 Jul;90[7]:4019-24).

Even though TSH tends to rise naturally through the lifespan, the association between elevated TSH and increased risk of metabolic syndrome held true even for older patients in one study, with “each one unit increase in TSH predicting a 3% increase in the odds of metabolic syndrome,” even after adjustment for age, BMI, and HOMA-IR status, among other variables, said Dr. Brenta (Clin Endocrinol [Oxf]. 2012 Jun;76[6]:911-8).

Advocating for universal screening for hypothyroidism among patients with metabolic syndrome, Dr. Brenta said that “hypothyroid disturbances are associated with an adverse metabolic profile, and even low normal TSH levels are associated with the metabolic traits of metabolic syndrome.”

The meeting was held by the American Thyroid Association, Asia-Oceania Thyroid Association, European Thyroid Association, and Latin American Thyroid Society. Dr. Brenta did not identify any conflicts of interest.

[email protected]

On Twitter @karioakes

LAKE BUENA VISTA, FLA. – High levels of free thyroxine (T4) can double the risk of sudden cardiac death, a large cohort study has determined.

Even people with free T4 in the upper range of normal may face an increased risk – up to 4% over 10 years, Dr. Layal Chaker said at the International Thyroid Conference.

The association remained significant, even when researchers controlled for independent cardiovascular risk factors, including hypertension and hyperlipidemia, said Dr. Chaker of Erasmus Medical Center, Rotterdam, the Netherlands.

The findings were based on a 9-year analysis of about 10,000 people included in the Rotterdam Elderly Study, conducted from 1990 to 2008. That study followed 15,000 people from middle age to old age, assessing cardiovascular and neurological diseases and their relationship to aging.

Dr. Chaker’s study comprised a subset of those who were without frank cardiovascular disease at baseline. She defined sudden cardiac death as a natural death from cardiac causes, heralded by an abrupt loss of consciousness within an hour of the onset of acute symptoms. Unwitnessed deaths were also included in the analysis. All of the death records were reviewed by two clinicians and a senior cardiologist.

The cohort comprised 10,318 subjects who had measurements of thyroid stimulating hormone (TSH) and free thyroxine (free T4); the mean age was 65 years.

Dr. Chaker stratified the group into tertiles based on the levels of these biomarkers. She conducted a multivariate analysis that controlled for age, sex, pulse, hypertension, cholesterol levels, diabetes, body mass index, smoking, and QT interval.

There were 261 sudden cardiac deaths by the end of follow-up.

There was no significant relationship between any level of TSH and sudden cardiac death. However, when she assessed the deaths by tertiles of free T4, she found a significant 40% increase in the risk among those whose levels ranged from 1.29 to 4 ng/L. The absolute 10-year risk rose from 1% at the lowest tertile to 7% in the highest.

Dr. Chaker then included only patients whose free T4 levels were in the euthyroid range of 0.85-1.95 ng/L. Among these, the risk of sudden cardiac death increased as free T4 increased (hazard ratio [HR], 2.25 for the highest level). The absolute 10-year risk rose from 1% at the lowest euthyroid level to 4% at 1.95 ng/L.

The reason for this finding isn’t completely clear, although other studies have shown a relationship between cardiac problems and thyroid function, she said.

“There may be some hemodynamic abnormalities that go along with even subclinical hyperthyroidism. High free T4 also has been associated with atrial fibrillation; both subclinical hyper- and hypothyroidism are associated with a prolongation of the QT interval.”

The meeting was held by the American Thyroid Association, Asia-Oceania Thyroid Association, European Thyroid Association, and Latin American Thyroid Society. Dr. Chaker had no financial disclosures.

[email protected]

On Twitter @Alz_Gal

LAKE BUENA VISTA, FLA. – High levels of free thyroxine (T4) can double the risk of sudden cardiac death, a large cohort study has determined.

Even people with free T4 in the upper range of normal may face an increased risk – up to 4% over 10 years, Dr. Layal Chaker said at the International Thyroid Conference.

The association remained significant, even when researchers controlled for independent cardiovascular risk factors, including hypertension and hyperlipidemia, said Dr. Chaker of Erasmus Medical Center, Rotterdam, the Netherlands.

The findings were based on a 9-year analysis of about 10,000 people included in the Rotterdam Elderly Study, conducted from 1990 to 2008. That study followed 15,000 people from middle age to old age, assessing cardiovascular and neurological diseases and their relationship to aging.

Dr. Chaker’s study comprised a subset of those who were without frank cardiovascular disease at baseline. She defined sudden cardiac death as a natural death from cardiac causes, heralded by an abrupt loss of consciousness within an hour of the onset of acute symptoms. Unwitnessed deaths were also included in the analysis. All of the death records were reviewed by two clinicians and a senior cardiologist.

The cohort comprised 10,318 subjects who had measurements of thyroid stimulating hormone (TSH) and free thyroxine (free T4); the mean age was 65 years.

Dr. Chaker stratified the group into tertiles based on the levels of these biomarkers. She conducted a multivariate analysis that controlled for age, sex, pulse, hypertension, cholesterol levels, diabetes, body mass index, smoking, and QT interval.

There were 261 sudden cardiac deaths by the end of follow-up.

There was no significant relationship between any level of TSH and sudden cardiac death. However, when she assessed the deaths by tertiles of free T4, she found a significant 40% increase in the risk among those whose levels ranged from 1.29 to 4 ng/L. The absolute 10-year risk rose from 1% at the lowest tertile to 7% in the highest.

Dr. Chaker then included only patients whose free T4 levels were in the euthyroid range of 0.85-1.95 ng/L. Among these, the risk of sudden cardiac death increased as free T4 increased (hazard ratio [HR], 2.25 for the highest level). The absolute 10-year risk rose from 1% at the lowest euthyroid level to 4% at 1.95 ng/L.

The reason for this finding isn’t completely clear, although other studies have shown a relationship between cardiac problems and thyroid function, she said.

“There may be some hemodynamic abnormalities that go along with even subclinical hyperthyroidism. High free T4 also has been associated with atrial fibrillation; both subclinical hyper- and hypothyroidism are associated with a prolongation of the QT interval.”

The meeting was held by the American Thyroid Association, Asia-Oceania Thyroid Association, European Thyroid Association, and Latin American Thyroid Society. Dr. Chaker had no financial disclosures.

[email protected]

On Twitter @Alz_Gal

LAKE BUENA VISTA, FLA. – High levels of free thyroxine (T4) can double the risk of sudden cardiac death, a large cohort study has determined.

Even people with free T4 in the upper range of normal may face an increased risk – up to 4% over 10 years, Dr. Layal Chaker said at the International Thyroid Conference.

The association remained significant, even when researchers controlled for independent cardiovascular risk factors, including hypertension and hyperlipidemia, said Dr. Chaker of Erasmus Medical Center, Rotterdam, the Netherlands.

The findings were based on a 9-year analysis of about 10,000 people included in the Rotterdam Elderly Study, conducted from 1990 to 2008. That study followed 15,000 people from middle age to old age, assessing cardiovascular and neurological diseases and their relationship to aging.

Dr. Chaker’s study comprised a subset of those who were without frank cardiovascular disease at baseline. She defined sudden cardiac death as a natural death from cardiac causes, heralded by an abrupt loss of consciousness within an hour of the onset of acute symptoms. Unwitnessed deaths were also included in the analysis. All of the death records were reviewed by two clinicians and a senior cardiologist.

The cohort comprised 10,318 subjects who had measurements of thyroid stimulating hormone (TSH) and free thyroxine (free T4); the mean age was 65 years.

Dr. Chaker stratified the group into tertiles based on the levels of these biomarkers. She conducted a multivariate analysis that controlled for age, sex, pulse, hypertension, cholesterol levels, diabetes, body mass index, smoking, and QT interval.

There were 261 sudden cardiac deaths by the end of follow-up.

There was no significant relationship between any level of TSH and sudden cardiac death. However, when she assessed the deaths by tertiles of free T4, she found a significant 40% increase in the risk among those whose levels ranged from 1.29 to 4 ng/L. The absolute 10-year risk rose from 1% at the lowest tertile to 7% in the highest.

Dr. Chaker then included only patients whose free T4 levels were in the euthyroid range of 0.85-1.95 ng/L. Among these, the risk of sudden cardiac death increased as free T4 increased (hazard ratio [HR], 2.25 for the highest level). The absolute 10-year risk rose from 1% at the lowest euthyroid level to 4% at 1.95 ng/L.

The reason for this finding isn’t completely clear, although other studies have shown a relationship between cardiac problems and thyroid function, she said.

“There may be some hemodynamic abnormalities that go along with even subclinical hyperthyroidism. High free T4 also has been associated with atrial fibrillation; both subclinical hyper- and hypothyroidism are associated with a prolongation of the QT interval.”

The meeting was held by the American Thyroid Association, Asia-Oceania Thyroid Association, European Thyroid Association, and Latin American Thyroid Society. Dr. Chaker had no financial disclosures.

[email protected]

On Twitter @Alz_Gal

LAKE BUENA VISTA, FLA. – Normalizing maternal thyroid function early in pregnancy may improve obstetric outcomes for women with subclinical hypothyroidism.

A high level of thyroid-stimulating hormone (TSH) was associated with increased stillbirth in women who didn’t receive prenatal levothyroxine, Peter N. Taylor, Ph.D., reported at the International Thyroid Congress.

And women who were untreated for low free thyroxine (T₄) were significantly more likely to need an early cesarean section than treated women, suggesting that levothyroxine could be reducing conditions leading to maternal-fetal distress.

“The good thing is that many physicians are already treating with levothyroxine anyway,” said Dr. Taylor of Cardiff (Wales) University. “There are no obvious adverse obstetric events associated with it. It seems relatively benign, and the accepted dose of 150 mcg per day seems adequate.”

He reported data from a subgroup analysis of the large Controlled Antenatal Thyroid Screening Study (N Eng J Med. 2012;366:493-501). That trial enrolled more than 21,000 mother-child pairs, and examined the effect of maternal levothyroxine treatment on the child’s IQ at 3 years. Among the children of women with hypothyroidism, the mean IQ scores were 99.2 and 100 in the treated and control groups – not significantly different. The proportions of children with an IQ of less than 85 were 12% in the treated group and 14% in the control group, also not significantly different.

Dr. Taylor’s cohort involved about 14,000 mother-child pairs from this study, all of whom were from Wales. Using national health care databases as well as study data, he was able to examine obstetric outcomes in women with low thyroid function (664) who received or did not receive levothyroxine early between 11 and 16 weeks’ gestation.

About half of the hypothyroid women (351) had TSH levels above 3.5 mU/L. The remainder had free T₄ levels below 10.9 pmol/L. Each of these groups was randomized to levothyroxine treatment or placebo. The rest of the cohort had normal thyroid status.

The study’s primary endpoint was the rate of stillbirth. Secondary endpoints were cesarean section rate (both overall and early); gestational age at birth; and macrosomia.

Among the euthyroid group, the rate of stillbirth was 0.34%, similar to the national background rate. There were no stillbirths among women with high TSH who were treated. Three (1.68%) occurred in the untreated group. The TSH levels in those women before treatment were 3.63 mU/L, 3.66 mU/L, and 4.58 mU/L – not dramatically high, Dr. Taylor noted. “But they could have risen later in pregnancy as stress on the thyroid increased.”

After adjusting for maternal age, weight, parity, birth year, and smoking, stillbirths were five times more likely among the untreated women than the treated women. However, Dr. Taylor cautioned, “This is a very small number of events. But it is quite seductive to think that stillbirths could be prevented by levothyroxine.”

There were no significant associations of high TSH with macrosomia or gestational age.

Untreated low free T₄ was not associated with stillbirth. However, Dr. Taylor said, it was very strongly associated with early C-section.

The overall C-section rate was similar between untreated and treated women (28%). But 5.6% of the untreated women had an early C-section, compared with none of the treated women. This hints strongly at a protective effect of levothyroxine, Dr. Taylor said. Early C-sections – between 26 and 32 weeks – are medically driven rather than driven by patient choice. This finding of fewer early interventions among treated women suggests that levothyroxine is exerting some protective effect, especially given the finding that infants of untreated mothers actually tended to be about 133 g lighter at birth.

“We would speculate this is probably due to a decrease in preeclampsia and gestational hypertension, which are more common among women with hypothyroidism.”

Infants of untreated mothers also were born slightly earlier – about half a week, he said at the meeting held by the American Thyroid Association, Asia-Oceania Thyroid Association, European Thyroid Association, and Latin American Thyroid Society.

Dr. Taylor had no financial disclosures.

[email protected]

LAKE BUENA VISTA, FLA. – Normalizing maternal thyroid function early in pregnancy may improve obstetric outcomes for women with subclinical hypothyroidism.

A high level of thyroid-stimulating hormone (TSH) was associated with increased stillbirth in women who didn’t receive prenatal levothyroxine, Peter N. Taylor, Ph.D., reported at the International Thyroid Congress.

And women who were untreated for low free thyroxine (T₄) were significantly more likely to need an early cesarean section than treated women, suggesting that levothyroxine could be reducing conditions leading to maternal-fetal distress.

“The good thing is that many physicians are already treating with levothyroxine anyway,” said Dr. Taylor of Cardiff (Wales) University. “There are no obvious adverse obstetric events associated with it. It seems relatively benign, and the accepted dose of 150 mcg per day seems adequate.”

He reported data from a subgroup analysis of the large Controlled Antenatal Thyroid Screening Study (N Eng J Med. 2012;366:493-501). That trial enrolled more than 21,000 mother-child pairs, and examined the effect of maternal levothyroxine treatment on the child’s IQ at 3 years. Among the children of women with hypothyroidism, the mean IQ scores were 99.2 and 100 in the treated and control groups – not significantly different. The proportions of children with an IQ of less than 85 were 12% in the treated group and 14% in the control group, also not significantly different.

Dr. Taylor’s cohort involved about 14,000 mother-child pairs from this study, all of whom were from Wales. Using national health care databases as well as study data, he was able to examine obstetric outcomes in women with low thyroid function (664) who received or did not receive levothyroxine early between 11 and 16 weeks’ gestation.

About half of the hypothyroid women (351) had TSH levels above 3.5 mU/L. The remainder had free T₄ levels below 10.9 pmol/L. Each of these groups was randomized to levothyroxine treatment or placebo. The rest of the cohort had normal thyroid status.

The study’s primary endpoint was the rate of stillbirth. Secondary endpoints were cesarean section rate (both overall and early); gestational age at birth; and macrosomia.

Among the euthyroid group, the rate of stillbirth was 0.34%, similar to the national background rate. There were no stillbirths among women with high TSH who were treated. Three (1.68%) occurred in the untreated group. The TSH levels in those women before treatment were 3.63 mU/L, 3.66 mU/L, and 4.58 mU/L – not dramatically high, Dr. Taylor noted. “But they could have risen later in pregnancy as stress on the thyroid increased.”

After adjusting for maternal age, weight, parity, birth year, and smoking, stillbirths were five times more likely among the untreated women than the treated women. However, Dr. Taylor cautioned, “This is a very small number of events. But it is quite seductive to think that stillbirths could be prevented by levothyroxine.”

There were no significant associations of high TSH with macrosomia or gestational age.

Untreated low free T₄ was not associated with stillbirth. However, Dr. Taylor said, it was very strongly associated with early C-section.

The overall C-section rate was similar between untreated and treated women (28%). But 5.6% of the untreated women had an early C-section, compared with none of the treated women. This hints strongly at a protective effect of levothyroxine, Dr. Taylor said. Early C-sections – between 26 and 32 weeks – are medically driven rather than driven by patient choice. This finding of fewer early interventions among treated women suggests that levothyroxine is exerting some protective effect, especially given the finding that infants of untreated mothers actually tended to be about 133 g lighter at birth.

“We would speculate this is probably due to a decrease in preeclampsia and gestational hypertension, which are more common among women with hypothyroidism.”

Infants of untreated mothers also were born slightly earlier – about half a week, he said at the meeting held by the American Thyroid Association, Asia-Oceania Thyroid Association, European Thyroid Association, and Latin American Thyroid Society.

Dr. Taylor had no financial disclosures.

[email protected]

LAKE BUENA VISTA, FLA. – Normalizing maternal thyroid function early in pregnancy may improve obstetric outcomes for women with subclinical hypothyroidism.

A high level of thyroid-stimulating hormone (TSH) was associated with increased stillbirth in women who didn’t receive prenatal levothyroxine, Peter N. Taylor, Ph.D., reported at the International Thyroid Congress.

And women who were untreated for low free thyroxine (T₄) were significantly more likely to need an early cesarean section than treated women, suggesting that levothyroxine could be reducing conditions leading to maternal-fetal distress.

“The good thing is that many physicians are already treating with levothyroxine anyway,” said Dr. Taylor of Cardiff (Wales) University. “There are no obvious adverse obstetric events associated with it. It seems relatively benign, and the accepted dose of 150 mcg per day seems adequate.”

He reported data from a subgroup analysis of the large Controlled Antenatal Thyroid Screening Study (N Eng J Med. 2012;366:493-501). That trial enrolled more than 21,000 mother-child pairs, and examined the effect of maternal levothyroxine treatment on the child’s IQ at 3 years. Among the children of women with hypothyroidism, the mean IQ scores were 99.2 and 100 in the treated and control groups – not significantly different. The proportions of children with an IQ of less than 85 were 12% in the treated group and 14% in the control group, also not significantly different.

Dr. Taylor’s cohort involved about 14,000 mother-child pairs from this study, all of whom were from Wales. Using national health care databases as well as study data, he was able to examine obstetric outcomes in women with low thyroid function (664) who received or did not receive levothyroxine early between 11 and 16 weeks’ gestation.

About half of the hypothyroid women (351) had TSH levels above 3.5 mU/L. The remainder had free T₄ levels below 10.9 pmol/L. Each of these groups was randomized to levothyroxine treatment or placebo. The rest of the cohort had normal thyroid status.

The study’s primary endpoint was the rate of stillbirth. Secondary endpoints were cesarean section rate (both overall and early); gestational age at birth; and macrosomia.

Among the euthyroid group, the rate of stillbirth was 0.34%, similar to the national background rate. There were no stillbirths among women with high TSH who were treated. Three (1.68%) occurred in the untreated group. The TSH levels in those women before treatment were 3.63 mU/L, 3.66 mU/L, and 4.58 mU/L – not dramatically high, Dr. Taylor noted. “But they could have risen later in pregnancy as stress on the thyroid increased.”

After adjusting for maternal age, weight, parity, birth year, and smoking, stillbirths were five times more likely among the untreated women than the treated women. However, Dr. Taylor cautioned, “This is a very small number of events. But it is quite seductive to think that stillbirths could be prevented by levothyroxine.”

There were no significant associations of high TSH with macrosomia or gestational age.

Untreated low free T₄ was not associated with stillbirth. However, Dr. Taylor said, it was very strongly associated with early C-section.

The overall C-section rate was similar between untreated and treated women (28%). But 5.6% of the untreated women had an early C-section, compared with none of the treated women. This hints strongly at a protective effect of levothyroxine, Dr. Taylor said. Early C-sections – between 26 and 32 weeks – are medically driven rather than driven by patient choice. This finding of fewer early interventions among treated women suggests that levothyroxine is exerting some protective effect, especially given the finding that infants of untreated mothers actually tended to be about 133 g lighter at birth.

“We would speculate this is probably due to a decrease in preeclampsia and gestational hypertension, which are more common among women with hypothyroidism.”

Infants of untreated mothers also were born slightly earlier – about half a week, he said at the meeting held by the American Thyroid Association, Asia-Oceania Thyroid Association, European Thyroid Association, and Latin American Thyroid Society.

Dr. Taylor had no financial disclosures.

[email protected]

LAKE BUENA VISTA, FLA. – More cases of thyroid cancer are being seen in Japanese youth after the Fukushima Daiichi nuclear power plant accident, but the increased incidence may be an artifact of heightened surveillance.

“The thyroid cancers appear to have already occurred prior to radiation exposure,” said Dr. Shinichi Suzuki of the department of thyroid and endocrinology at Fukushima (Japan) Medical University. Radiation-induced thyroid cancers take about 5 years to become detectable, so physicians should just now be seeing the earliest cases of thyroid cancer related to Fukushima radiation exposure, according to Dr. Suzuki. He presented interim results of Japan’s universal screening protocol for children potentially affected by the Fukushima incident at the International Thyroid Conference.

The protocol, designed to screen everyone residing in the Fukushima prefecture and aged 19 years or younger at the time of the 2011 incident, has been highly successful, with over 80% of those eligible receiving a baseline screening that included a thyroid ultrasound exam.

Screening consisted of an initial thyroid ultrasound exam performed with a portable ultrasound device. If no cyst or nodule was found, then the patient would be seen at the next scheduled thyroid ultrasound exam, 2 years later. Patients with cysts 20 mm or less in greatest diameter or nodules 5 mm or smaller also were deferred to the next scheduled examination. Patients with cysts larger than 20 mm or nodules larger than 5 mm received confirmatory examination by detailed ultrasound examination, blood work, and fine-needle aspiration.

Of the 300,476 patients who received the preliminary baseline survey, 2,294 (0.8%) had an abnormality that warranted confirmatory examination and 91.9% of patients went on to have the confirmatory exams. Of these, 113 were assessed as malignant or suspicious for malignancy. Ninety-nine patients had surgery, with findings of 98 cases of thyroid cancer and one benign tumor.

Patients examined after April 2014 were part of an expanded protocol. Under this protocol, 169,455 patients (44.7% participation) were examined and 1,223 patients (0.8%) had suspicious findings on thyroid ultrasound exam. Participation rate for confirmatory testing for this group was 62.7%, with 25 patients’ thyroids having malignant or potentially malignant findings. Six of these patients had surgery, and thyroid cancer was found in all six cases.

Pooling data from the 138 malignant or suspicious cases from the two groups, 105 patients in total have had surgery, 13 patients with small, noninvasive masses are being watched, and a further 20 are awaiting surgery, Dr. Suzuki said at the meeting held by the American Thyroid Association, Asia-Oceania Thyroid Association, European Thyroid Association, and Latin American Thyroid Society.

Of the 97 patients with thyroid cancer who were treated at Fukushima University, 61 were female. The mean patient age at the time of the disaster was 14.8 ± 2.7 years (range, 6-18 years), while the mean age at diagnosis was 17.4 ± 2.8 years (range, 9-22 years). All patients were asymptomatic.

Tumors were unilateral in all but two patients. Mean tumor size was 15.1 ± 0.8 mm (range, 5-53 mm). Nearly all of the tumors (94/97) were papillary thyroid carcinoma, with 86 of those being classical-type papillary thyroid carcinoma. Three patients had poorly differentiated thyroid carcinoma. Fifty-eight patients (60%) had some intraglandular spread, while 71 (73%) had calcifications.

Dr. Suzuki and his collaborators compared these 97 cases with 37 cases of pediatric thyroid cancer in an historical Japanese cohort and to the 26 cases seen in a cohort from Belarus following the Chernobyl disaster. The Fukushima patients were significantly older than either comparison group, with mean age of 11.9 years for the historical Japanese cohort and 10.6 years for the children from Belarus. Tumor size was smaller than the historical Japanese cohort’s mean of 4.1 cm but about the same as that seen in Belarus (1.4 cm). Pulmonary metastases were more common in the historical Japanese cohort (19% vs. 4% in Belarus and 2% in Fukushima).

To have reference data that use similar techniques on a similar population, Japanese researchers are conducting thyroid ultrasound examsaccording to the Fukushima protocol concurrently in three other Japanese prefectures. This is especially important, Dr. Suzuki said, because rapid technological advances in ultrasound imaging mean that screening is much more likely to detect small abnormalities in the thyroid than would have been the case even a few years ago. For this reason, and also because much more radiation was released at the site of the Chernobyl nuclear disaster, only limited comparisons can be made between pediatric thyroid cancer rates from the two nuclear accidents.

Thyroid ultrasound exam “has the ability to detect a lot of thyroid cancers,” he said, so care must be taken to avoid overdiagnosis and overtreatment in this group of young people. Information to date from the Fukushima surveillance project does not yet “give us the clear view about the influence of radiation exposure after the accident on thyroid cancer occurrence,” he said.

Dr. Suzuki reported no relevant disclosures.

[email protected]

On Twitter @karioakes

LAKE BUENA VISTA, FLA. – More cases of thyroid cancer are being seen in Japanese youth after the Fukushima Daiichi nuclear power plant accident, but the increased incidence may be an artifact of heightened surveillance.

“The thyroid cancers appear to have already occurred prior to radiation exposure,” said Dr. Shinichi Suzuki of the department of thyroid and endocrinology at Fukushima (Japan) Medical University. Radiation-induced thyroid cancers take about 5 years to become detectable, so physicians should just now be seeing the earliest cases of thyroid cancer related to Fukushima radiation exposure, according to Dr. Suzuki. He presented interim results of Japan’s universal screening protocol for children potentially affected by the Fukushima incident at the International Thyroid Conference.

The protocol, designed to screen everyone residing in the Fukushima prefecture and aged 19 years or younger at the time of the 2011 incident, has been highly successful, with over 80% of those eligible receiving a baseline screening that included a thyroid ultrasound exam.

Screening consisted of an initial thyroid ultrasound exam performed with a portable ultrasound device. If no cyst or nodule was found, then the patient would be seen at the next scheduled thyroid ultrasound exam, 2 years later. Patients with cysts 20 mm or less in greatest diameter or nodules 5 mm or smaller also were deferred to the next scheduled examination. Patients with cysts larger than 20 mm or nodules larger than 5 mm received confirmatory examination by detailed ultrasound examination, blood work, and fine-needle aspiration.

Of the 300,476 patients who received the preliminary baseline survey, 2,294 (0.8%) had an abnormality that warranted confirmatory examination and 91.9% of patients went on to have the confirmatory exams. Of these, 113 were assessed as malignant or suspicious for malignancy. Ninety-nine patients had surgery, with findings of 98 cases of thyroid cancer and one benign tumor.

Patients examined after April 2014 were part of an expanded protocol. Under this protocol, 169,455 patients (44.7% participation) were examined and 1,223 patients (0.8%) had suspicious findings on thyroid ultrasound exam. Participation rate for confirmatory testing for this group was 62.7%, with 25 patients’ thyroids having malignant or potentially malignant findings. Six of these patients had surgery, and thyroid cancer was found in all six cases.

Pooling data from the 138 malignant or suspicious cases from the two groups, 105 patients in total have had surgery, 13 patients with small, noninvasive masses are being watched, and a further 20 are awaiting surgery, Dr. Suzuki said at the meeting held by the American Thyroid Association, Asia-Oceania Thyroid Association, European Thyroid Association, and Latin American Thyroid Society.

Of the 97 patients with thyroid cancer who were treated at Fukushima University, 61 were female. The mean patient age at the time of the disaster was 14.8 ± 2.7 years (range, 6-18 years), while the mean age at diagnosis was 17.4 ± 2.8 years (range, 9-22 years). All patients were asymptomatic.

Tumors were unilateral in all but two patients. Mean tumor size was 15.1 ± 0.8 mm (range, 5-53 mm). Nearly all of the tumors (94/97) were papillary thyroid carcinoma, with 86 of those being classical-type papillary thyroid carcinoma. Three patients had poorly differentiated thyroid carcinoma. Fifty-eight patients (60%) had some intraglandular spread, while 71 (73%) had calcifications.

Dr. Suzuki and his collaborators compared these 97 cases with 37 cases of pediatric thyroid cancer in an historical Japanese cohort and to the 26 cases seen in a cohort from Belarus following the Chernobyl disaster. The Fukushima patients were significantly older than either comparison group, with mean age of 11.9 years for the historical Japanese cohort and 10.6 years for the children from Belarus. Tumor size was smaller than the historical Japanese cohort’s mean of 4.1 cm but about the same as that seen in Belarus (1.4 cm). Pulmonary metastases were more common in the historical Japanese cohort (19% vs. 4% in Belarus and 2% in Fukushima).

To have reference data that use similar techniques on a similar population, Japanese researchers are conducting thyroid ultrasound examsaccording to the Fukushima protocol concurrently in three other Japanese prefectures. This is especially important, Dr. Suzuki said, because rapid technological advances in ultrasound imaging mean that screening is much more likely to detect small abnormalities in the thyroid than would have been the case even a few years ago. For this reason, and also because much more radiation was released at the site of the Chernobyl nuclear disaster, only limited comparisons can be made between pediatric thyroid cancer rates from the two nuclear accidents.

Thyroid ultrasound exam “has the ability to detect a lot of thyroid cancers,” he said, so care must be taken to avoid overdiagnosis and overtreatment in this group of young people. Information to date from the Fukushima surveillance project does not yet “give us the clear view about the influence of radiation exposure after the accident on thyroid cancer occurrence,” he said.

Dr. Suzuki reported no relevant disclosures.

[email protected]

On Twitter @karioakes

LAKE BUENA VISTA, FLA. – More cases of thyroid cancer are being seen in Japanese youth after the Fukushima Daiichi nuclear power plant accident, but the increased incidence may be an artifact of heightened surveillance.

“The thyroid cancers appear to have already occurred prior to radiation exposure,” said Dr. Shinichi Suzuki of the department of thyroid and endocrinology at Fukushima (Japan) Medical University. Radiation-induced thyroid cancers take about 5 years to become detectable, so physicians should just now be seeing the earliest cases of thyroid cancer related to Fukushima radiation exposure, according to Dr. Suzuki. He presented interim results of Japan’s universal screening protocol for children potentially affected by the Fukushima incident at the International Thyroid Conference.

The protocol, designed to screen everyone residing in the Fukushima prefecture and aged 19 years or younger at the time of the 2011 incident, has been highly successful, with over 80% of those eligible receiving a baseline screening that included a thyroid ultrasound exam.

Screening consisted of an initial thyroid ultrasound exam performed with a portable ultrasound device. If no cyst or nodule was found, then the patient would be seen at the next scheduled thyroid ultrasound exam, 2 years later. Patients with cysts 20 mm or less in greatest diameter or nodules 5 mm or smaller also were deferred to the next scheduled examination. Patients with cysts larger than 20 mm or nodules larger than 5 mm received confirmatory examination by detailed ultrasound examination, blood work, and fine-needle aspiration.

Of the 300,476 patients who received the preliminary baseline survey, 2,294 (0.8%) had an abnormality that warranted confirmatory examination and 91.9% of patients went on to have the confirmatory exams. Of these, 113 were assessed as malignant or suspicious for malignancy. Ninety-nine patients had surgery, with findings of 98 cases of thyroid cancer and one benign tumor.

Patients examined after April 2014 were part of an expanded protocol. Under this protocol, 169,455 patients (44.7% participation) were examined and 1,223 patients (0.8%) had suspicious findings on thyroid ultrasound exam. Participation rate for confirmatory testing for this group was 62.7%, with 25 patients’ thyroids having malignant or potentially malignant findings. Six of these patients had surgery, and thyroid cancer was found in all six cases.

Pooling data from the 138 malignant or suspicious cases from the two groups, 105 patients in total have had surgery, 13 patients with small, noninvasive masses are being watched, and a further 20 are awaiting surgery, Dr. Suzuki said at the meeting held by the American Thyroid Association, Asia-Oceania Thyroid Association, European Thyroid Association, and Latin American Thyroid Society.

Of the 97 patients with thyroid cancer who were treated at Fukushima University, 61 were female. The mean patient age at the time of the disaster was 14.8 ± 2.7 years (range, 6-18 years), while the mean age at diagnosis was 17.4 ± 2.8 years (range, 9-22 years). All patients were asymptomatic.

Tumors were unilateral in all but two patients. Mean tumor size was 15.1 ± 0.8 mm (range, 5-53 mm). Nearly all of the tumors (94/97) were papillary thyroid carcinoma, with 86 of those being classical-type papillary thyroid carcinoma. Three patients had poorly differentiated thyroid carcinoma. Fifty-eight patients (60%) had some intraglandular spread, while 71 (73%) had calcifications.

Dr. Suzuki and his collaborators compared these 97 cases with 37 cases of pediatric thyroid cancer in an historical Japanese cohort and to the 26 cases seen in a cohort from Belarus following the Chernobyl disaster. The Fukushima patients were significantly older than either comparison group, with mean age of 11.9 years for the historical Japanese cohort and 10.6 years for the children from Belarus. Tumor size was smaller than the historical Japanese cohort’s mean of 4.1 cm but about the same as that seen in Belarus (1.4 cm). Pulmonary metastases were more common in the historical Japanese cohort (19% vs. 4% in Belarus and 2% in Fukushima).

To have reference data that use similar techniques on a similar population, Japanese researchers are conducting thyroid ultrasound examsaccording to the Fukushima protocol concurrently in three other Japanese prefectures. This is especially important, Dr. Suzuki said, because rapid technological advances in ultrasound imaging mean that screening is much more likely to detect small abnormalities in the thyroid than would have been the case even a few years ago. For this reason, and also because much more radiation was released at the site of the Chernobyl nuclear disaster, only limited comparisons can be made between pediatric thyroid cancer rates from the two nuclear accidents.

Thyroid ultrasound exam “has the ability to detect a lot of thyroid cancers,” he said, so care must be taken to avoid overdiagnosis and overtreatment in this group of young people. Information to date from the Fukushima surveillance project does not yet “give us the clear view about the influence of radiation exposure after the accident on thyroid cancer occurrence,” he said.

Dr. Suzuki reported no relevant disclosures.

[email protected]

On Twitter @karioakes

LAKE BUENA VISTA, FLA. – An outpatient procedure may represent an efficacious and safe alternative to surgery for those patients with small papillary thyroid cancers who prefer definitive treatment over the “wait and watch” approach. Further, at one institution, the cost-effective alternative to surgery saved almost $40,000 per patient.

Ultrasound-guided percutaneous ethanol injection (UPEA) of small (cT1N0) intrathyroidal papillary thyroid cancer (SIPC) successfully reduced tumor volume by a median of 92%, eliminated tumor blood flow, and was very well tolerated by a series of 13 patients who received UPEA at the Mayo Clinic, Rochester, Minn.

Dr. Ian D. Hay, a consultant in Mayo’s division of endocrinology, diabetes, metabolism, and nutrition, presented the findings during a poster session at the International Thyroid Congress.

Dr. Hay and his colleagues treated 13 patients with a total of 15 tumors with injections of percutaneous ethanol. The first patient received just one injection; the remaining patients received one injection to each tumor site on each of 2 consecutive days. Five of the tumor foci had less than a 50% reduction in tumor volume at the first follow-up visit, so those tumors were injected a third time.

Patients in the series ranged from 38 to 86 years old (median 45), and five patients had significant comorbidities: one had congestive heart failure and the other four had concomitant unrelated cancers. Tumors were a median 8 mm in size, with volumes ranging from 25 to 676 mm³ (median 140 mm³).

All of the injections were performed under ultrasound guidance, and a median of 0.9 cc of ethanol was injected into each tumor. Ultrasound examination was performed at each follow-up visit to evaluate tumor volume and blood flow. Dr. Hay reported that the procedure was well tolerated: Local neck tenderness resolved within a day or two, and there were no reports of hoarseness or laryngeal nerve palsy.

Patients were followed for a mean 2.0 years (range, 0.4-5.7 years), with a median tumor reduction of 92% (range 46%-100%). For the nine tumors that were still identifiable on ultrasound at the time of reporting, the mean volume had decreased by 73%. Six tumor foci had completely disappeared, and no tumor had detectable blood flow on Doppler exam. Tumor thyroglobulin levels remained stable in all patients, and no nodal metastases were identified, Dr. Hay reported at the meeting, which was held by the American Thyroid Association, Asia-Oceania Thyroid Association, European Thyroid Association, and Latin American Thyroid Society.

Internationally, the approach to managing SIPC varies from lobectomy to near-total thyroidectomy to active surveillance. For patients who prefer definitive management of their tumors but are reluctant to have surgery or who may have significant comorbidities, UPEA may represent a safe alternative, and at significant cost savings compared to surgery: Dr. Hay and his colleagues reported that they estimated the average cost savings at their institution to be over $38,000 per patient. “If prospective trials of observation vs. surgery for SIPC are to occur in the USA, perhaps it could be included as a ‘third arm’ in such trials,” Dr. Hay and his colleagues said.

[email protected]

On Twitter @karioakes

LAKE BUENA VISTA, FLA. – An outpatient procedure may represent an efficacious and safe alternative to surgery for those patients with small papillary thyroid cancers who prefer definitive treatment over the “wait and watch” approach. Further, at one institution, the cost-effective alternative to surgery saved almost $40,000 per patient.

Ultrasound-guided percutaneous ethanol injection (UPEA) of small (cT1N0) intrathyroidal papillary thyroid cancer (SIPC) successfully reduced tumor volume by a median of 92%, eliminated tumor blood flow, and was very well tolerated by a series of 13 patients who received UPEA at the Mayo Clinic, Rochester, Minn.

Dr. Ian D. Hay, a consultant in Mayo’s division of endocrinology, diabetes, metabolism, and nutrition, presented the findings during a poster session at the International Thyroid Congress.

Dr. Hay and his colleagues treated 13 patients with a total of 15 tumors with injections of percutaneous ethanol. The first patient received just one injection; the remaining patients received one injection to each tumor site on each of 2 consecutive days. Five of the tumor foci had less than a 50% reduction in tumor volume at the first follow-up visit, so those tumors were injected a third time.

Patients in the series ranged from 38 to 86 years old (median 45), and five patients had significant comorbidities: one had congestive heart failure and the other four had concomitant unrelated cancers. Tumors were a median 8 mm in size, with volumes ranging from 25 to 676 mm³ (median 140 mm³).

All of the injections were performed under ultrasound guidance, and a median of 0.9 cc of ethanol was injected into each tumor. Ultrasound examination was performed at each follow-up visit to evaluate tumor volume and blood flow. Dr. Hay reported that the procedure was well tolerated: Local neck tenderness resolved within a day or two, and there were no reports of hoarseness or laryngeal nerve palsy.

Patients were followed for a mean 2.0 years (range, 0.4-5.7 years), with a median tumor reduction of 92% (range 46%-100%). For the nine tumors that were still identifiable on ultrasound at the time of reporting, the mean volume had decreased by 73%. Six tumor foci had completely disappeared, and no tumor had detectable blood flow on Doppler exam. Tumor thyroglobulin levels remained stable in all patients, and no nodal metastases were identified, Dr. Hay reported at the meeting, which was held by the American Thyroid Association, Asia-Oceania Thyroid Association, European Thyroid Association, and Latin American Thyroid Society.

Internationally, the approach to managing SIPC varies from lobectomy to near-total thyroidectomy to active surveillance. For patients who prefer definitive management of their tumors but are reluctant to have surgery or who may have significant comorbidities, UPEA may represent a safe alternative, and at significant cost savings compared to surgery: Dr. Hay and his colleagues reported that they estimated the average cost savings at their institution to be over $38,000 per patient. “If prospective trials of observation vs. surgery for SIPC are to occur in the USA, perhaps it could be included as a ‘third arm’ in such trials,” Dr. Hay and his colleagues said.

[email protected]

On Twitter @karioakes

LAKE BUENA VISTA, FLA. – An outpatient procedure may represent an efficacious and safe alternative to surgery for those patients with small papillary thyroid cancers who prefer definitive treatment over the “wait and watch” approach. Further, at one institution, the cost-effective alternative to surgery saved almost $40,000 per patient.

Ultrasound-guided percutaneous ethanol injection (UPEA) of small (cT1N0) intrathyroidal papillary thyroid cancer (SIPC) successfully reduced tumor volume by a median of 92%, eliminated tumor blood flow, and was very well tolerated by a series of 13 patients who received UPEA at the Mayo Clinic, Rochester, Minn.

Dr. Ian D. Hay, a consultant in Mayo’s division of endocrinology, diabetes, metabolism, and nutrition, presented the findings during a poster session at the International Thyroid Congress.

Dr. Hay and his colleagues treated 13 patients with a total of 15 tumors with injections of percutaneous ethanol. The first patient received just one injection; the remaining patients received one injection to each tumor site on each of 2 consecutive days. Five of the tumor foci had less than a 50% reduction in tumor volume at the first follow-up visit, so those tumors were injected a third time.

Patients in the series ranged from 38 to 86 years old (median 45), and five patients had significant comorbidities: one had congestive heart failure and the other four had concomitant unrelated cancers. Tumors were a median 8 mm in size, with volumes ranging from 25 to 676 mm³ (median 140 mm³).

All of the injections were performed under ultrasound guidance, and a median of 0.9 cc of ethanol was injected into each tumor. Ultrasound examination was performed at each follow-up visit to evaluate tumor volume and blood flow. Dr. Hay reported that the procedure was well tolerated: Local neck tenderness resolved within a day or two, and there were no reports of hoarseness or laryngeal nerve palsy.

Patients were followed for a mean 2.0 years (range, 0.4-5.7 years), with a median tumor reduction of 92% (range 46%-100%). For the nine tumors that were still identifiable on ultrasound at the time of reporting, the mean volume had decreased by 73%. Six tumor foci had completely disappeared, and no tumor had detectable blood flow on Doppler exam. Tumor thyroglobulin levels remained stable in all patients, and no nodal metastases were identified, Dr. Hay reported at the meeting, which was held by the American Thyroid Association, Asia-Oceania Thyroid Association, European Thyroid Association, and Latin American Thyroid Society.

Internationally, the approach to managing SIPC varies from lobectomy to near-total thyroidectomy to active surveillance. For patients who prefer definitive management of their tumors but are reluctant to have surgery or who may have significant comorbidities, UPEA may represent a safe alternative, and at significant cost savings compared to surgery: Dr. Hay and his colleagues reported that they estimated the average cost savings at their institution to be over $38,000 per patient. “If prospective trials of observation vs. surgery for SIPC are to occur in the USA, perhaps it could be included as a ‘third arm’ in such trials,” Dr. Hay and his colleagues said.

[email protected]

On Twitter @karioakes