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Endocrine Disease Treatments Changing

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Russell B. Smith, MD, leads a case-based session on decision-making for head and neck endocrine disease.

Russell B. Smith, MD, sees the American Thyroid Association’s (ATA) 2015 guidelines for the management of thyroid nodules and differentiated thyroid cancer in adults, released in January 2016, as a more conservative approach than what he saw in his training 20 years ago.

“Some things have come full circle. When I was in my residency, there was a lot of controversy about the extent of surgery for thyroid cancer. Then there was a shift, and it became well accepted that most patients needed a total thyroidectomy. With the current guidelines, the pendulum has started to shift back to where we started 20 plus years ago,” said Dr. Smith, a clinical professor of surgery at Creighton University and a staff surgeon in head and neck surgical oncology at Nebraska Methodist Hospital, Omaha.

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Salvatore M. Caruana, MD, takes part in the Tuesday head and neck endocrine disease panel.

Dr. Smith was the moderator of the Tuesday Miniseminar “Clinic-Based Decision-Making for Head and Neck Endocrine Disease.” Prior to the session, he shared his thoughts on the program. A panel of speakers looked at complex clinical scenarios encountered in the outpatient clinic. Factors critical in treatment planning are fine-needle aspiration for thyroid nodules including the role of molecular markers, treatment planning in well-differentiated thyroid cancer and surveillance of thyroid cancer patients in the context of the new ATA guidelines, and evaluation and decision-making for surgery in primary hyperparathyroidism.

“The ATA guidelines are much more comprehensive and in-depth to delineate how to approach the management of these patients,” Dr. Smith said.

The session’s case presentations focused on common, but potentially controversial dilemmas that surgeons face in preoperative and postoperative evaluations of patients with thyroid or parathyroid disease.

“There may be very small but nuanced details within their presentation or their diagnostic evaluation, which should cause surgeons to realize that these patients are potentially more complex,” Dr. Smith said. “On the other hand, there is a concern that there is this new thyroid cancer epidemic, and we’re diagnosing a host of very early and potentially non-life-threatening disease.”

He recommended that rather than testing to establish a diagnosis, some patients with 4 mm and 5 mm lesions probably should be observed rather than biopsied.

One scenario that the session focused on is evaluation of a thyroid nodule larger than 1 cm, which in the past surgeons biopsied. The new ATA guidelines recommend that surgeons look to ultrasound characteristics to determine which lesions are potentially high-risk versus low-risk.

“There is a concern about misdiagnosis as you become more conservative,” said Dr. Smith, noting that some fear medical-legal issues if you don’t diagnose a cancer with an early evaluation but a cancer diagnosis is made later because the lesion changed.

Presenters also dove into decision-making after thyroid cancer, including if treatment requires surgery alone, use of radioactive iodine therapy, and post-treatment surveillance.

One theme that came out in the guidelines for very low-risk patients calls for eliminating radioactive iodine from the treatment regimen and being relatively conservative with their surveillance, and—for the lowest risk patients—potentially using a neck exam and blood work and not performing routine ultrasounds on a long-term basis.

With regard to fine-needle biopsy for thyroid nodules, the pathology results provide what’s considered an indeterminate result, which means that their risk of cancer is somewhere between 15 percent and 30 percent, Dr. Smith said.

“Typically, the recommendation is a diagnostic surgery to remove the nodule and then determine whether it is or isn’t cancer,” Dr. Smith said. “If we do molecular testing, we can sometimes better stratify patients with a low or high likelihood of cancer. That allows us to consider observation versus therapeutic surgery instead of diagnostic surgery.”

The program also included evaluation and decision-making for surgery in primary hyperparathyroidism.

“It’s a very common diagnosis. It’s important to work through making a determination of which patients should just be treated with active medical surveillance versus which patients need surgery, but also how best to perform their preoperative evaluation,” Dr. Smith said. “We need to be very thoughtful and thorough as we think about doing our pre-op and post-op evaluations.”

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