301 S. Westfield Rd., Suite 250 Madison, WI See inside for information about our Endocrine Surgery Referral Program

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1 301 S. Westfield Rd., Suite 250 Madison, WI See inside for information about our Endocrine Surgery Referral Program

2 December 2017 Dear Colleague, Thank you for referring your patient(s) to UW Health Endocrine Surgery. We value our relationship with you and appreciate your confidence in our services and staff. Our goal is to work together to provide your patients with the highest quality of care. We know you have limited endocrine surgery referral resources in your region, so we developed a guide for working up patients with thyroid, parathyroid and adrenal conditions. Enclosed is a handheld version of this guide for your use. If you would like a poster version for your office, please call us at (608) and we will mail it to you. To make the referral process as easy as possible, we have included information about our Distance Referral Program a description of the program, contact information and referral checklists. We are happy to provide services for any patient with a thyroid, parathyroid or adrenal problem. If you have questions about our program or are interested in referring a patient, please contact our program coordinator, Cindy Shumway, at (608) or shumway@surgery.wisc.edu. We look forward to continuing to work with you and your patients. Rebecca Sippel, MD, FACS Chief of Endocrine Surgery On behalf of the UW Health Endocrine Surgery team Your privacy is our top priority. If you do not wish to receive communications from us, please send an with your name and address to uwhealthoptout@uwhealth.org or call us at (844) If you are a patient at UW Health, you will continue to receive information related to your care. Thank you. GS

3 UW HEALTH ENDOCRINE SURGERY The UW Health Endocrine Surgery Program has been providing nationally recognized care and innovative services to its patients for more than a decade. Our surgeons have performed thousands of endocrine operations to treat multiple parathyroid, thyroid and adrenal conditions. Our distance referral program is a convenient way for you to refer your patients with hyperparathyroidism, thyroid or adrenal problems to UW Health Endocrine Surgery. We offer your patients a consultation and surgery all in one trip. This usually requires a 2 3 day stay in Madison. If you have questions about our distance referral program or are interested in referring a patient, please contact our program coordinator, Cindy Shumway, at (608) or shumway@surgery.wisc.edu. UW Health endocrine surgeons (from left): David Schneider, MD, MS; Susan Pitt, MD, MPHS; Rebecca Sippel, MD; Kristin Long, MD For more information, visit GS Evaluating Thyroid, Parathyroid and Adrenal Conditions

4 Evaluating Thyroid, Parathyroid and Adrenal Conditions EVALUATION OF A NEW THYROID NODULE TSH Perform FNA of thyroid nodule(s) If US shows a nodule >1 cm or nodule with any suspicious characteristics*** Non-diagnostic (Not enough material to evaluate) Malignant Papillary thyroid cancer Medullary thyroid cancer Anaplastic thyroid cancer Repeat biopsy using U/S in 4 6 weeks (wait for inflammation to subside before repeating) Perform a H+P Compressive symptoms* Symptoms of hypo/hyperthyroidism Risk factors for cancer** Check a TSH Order a neck ultrasound TSH Suspicious/Indeterminant Suspicious for PTC Follicular/Hurthle cell/neoplasm Follicular lesion of undetermined significance (FLUS) Atypia of undetermined significance (AUS) Benign Work-up Hyperthyroidism Refer for surgical consultation Repeat U/S in mo Refer to Endocrine Surgery if: Compressive symptoms* Size >4 cm Family Hx of thyroid cancer or radiation exposure Growth >2 mm in 2 dimensions on follow-up imaging Check free T3 and T4, TRAb Order a NM thyroid uptake scan (distinguish between Graves disease, thyroiditis and toxic nodules) Refer to Endocrinology or Endocrine Surgery *Compressive symptoms: pressure, difficulty swallowing, voice changes SOB or snoring **Risks for cancer: family Hx, radiation exposure ***Suspicious U/S findings: microcalcifications, irregular margins, hypoechoic, hypervascular PRIMARY HYPERPARATHYROIDISM DIAGNOSTIC TOOL Patient presents with: Normal Calcium + PTH Check 25-OH Vitamin D and ionized calcium Hypercalcemia Repeat Calcium to confirm and check a PTH level Vitamin D Deficiency (<30 mg/dl) Supplement Vitamin D and recheck labs Vitamin D Sufficient (>30 mg/dl) Rule out other secondary causes of PTH elevation Check kidney function Check 24-hr urinary calcium Elevated PTH (>reference range) Primary HPT* Mildly elevated or inappropriately normal PTH (within reference range) Most Likely Primary HPT* Low PTH (<reference range) Not HPT Calcium rises and PTH remains elevated Primary HPT* Refer to Endocrinology or Endocrine Surgery Calcium doesn t rise and PTH normalizes Normal Response No further action Possibly Normocalcemic HPTH* Refer to Endocrinology or Endocrine Surgery Refer to Endocrinology or Endocrine Surgery Check 24-hour urinary calcium to rule out familial hypocalciuric hypercalcemia (urinary calcium will be very low, typically <50 mg/24 hr) Check medications (stop thiazide diuretics) Refer to Endocrinology or Endocrine Surgery Look for non-pth causes of Ca a. Check PTHrp b. Check Vitamin D status c. Check serum protein electrophoresis *If patient is diagnosed for PHPT: Refer to Endocrinology or Endocrine Surgery: Obtain a DEXA scan (include forearm) Check a 25-OH Vitamin D level Imaging will be ordered by surgeon if needed Will discuss with pt potential benefits of treatment: Improvement of BMD Reduction of kidney stones Improvement in cardiovascular mortality Improvement in QOL and symptoms (fatigue, memory, irritability, mood, insomnia, heartburn, hypertension, constipation, urinary symptoms, bone pain) ADRENAL INCIDENTALOMA DIAGNOSTIC TOOL Adrenal mass identified on imaging H+P (including age/risk appropriate cancer screening) Functional work-up* Cancer evaluation Functional Refer to Endocrinology or Endocrine Surgery <10 HU or >50% contrast washout or <4 cm on CT Likely Benign Repeat imaging and functional work-up in 1 year Non-functional Evaluate imaging characteristics >10 HU or <50% contrast washout or >4 cm on CT Concerning Imaging Features Refer to Endocrinology or Endocrine Surgery *How to do a functional work-up: Pheochromocytoma (all pts) Plasma metanephrines OR 24-hr urinary metanephrines Hypercortisolism (all pts) 1 mg dexamethasone suppression test 24-hr urinary cortisol Midnight salivary cortisol X2 Hyperaldosteronism (if HTN present) Serum K+ Aldosterone and renin levels To refer a patient, please call (608)

5 The UW Health Endocrine Surgery Program includes a multidisciplinary thyroid clinic of endocrinologists, endocrine surgeons, nuclear medicine specialists, pathologists, interventional radiologists, oncologists and nurse practitioners who manage our patients endocrine concerns. Patients play a crucial role in treatment, working side by side with physicians to determine an individualized treatment program. MEET OUR ENDOCRINE SURGERY PROVIDERS Our multidisciplinary care team consists of board-certified surgeons who work side by side with endocrinologists, pathologists, cytologists and interventional radiologists specialized to specific endocrine conditions. Our team of endocrine surgeons specializes in surgical treatment of the thyroid, parathyroid and adrenal glands. Multidisciplinary Care: Endocrine Surgery Program Our distance referral program is a convenient way for you to refer your patients with hyperparathyroidism, thyroid or adrenal problems to UW Health Endocrine Surgery. We offer your patients a consultation and surgery all in one trip. This usually requires a 2 3 day stay in Madison. WHAT SETS US APART Our team includes endocrine surgeons and endocrinologists, as well as numerous other specialists, depending on the case. This integrated approach determines the best course of treatment for each patient, whether that is medical therapy, surgery or both. Our endocrine surgeons have some of the highest surgical volumes in the U.S., which has led to superior outcomes and very low complication rates. Kristin Long, MD Dr. Long is particularly interested in the surgical treatment and management of thyroid carcinoma and hereditary endocrine disorders, such as multiple endocrine neoplasia syndromes. Her research focuses on global surgery and improving surgical access in low-resource countries. Susan Pitt, MD, MPHS Dr. Pitt focuses on treating patients with benign and malignant adrenal disease (incidentalomas, functioning tumors and adrenocortical cancer), thyroid nodules and primary hyperparathyroidism. Her research aims to improve the treatment decision-making process and decrease overtreatment. Our program is part of the UW Carbone Cancer Center, the only National Cancer Institute (NCI)-designated Comprehensive Cancer Center in the state. We offer a monthly multidisciplinary endocrine case conference. Referring providers are welcome to participate. In conference, we evaluate and discuss each patient to help formulate optimal treatment strategies. Our surgeons were the first in Wisconsin to use minimally invasive techniques in endocrine operations. Our endocrine surgeons continue to pioneer state-of-the-art techniques for patients. David Schneider, MD, MS Dr. Schneider has a particular interest in the diagnosis and treatment of all types of parathyroid disease and indeterminate thyroid nodules. His research uses electronic medical records data and computers to help patients and providers make personalized decisions. Rebecca Sippel, MD Dr. Sippel has extensive experience in re-operative parathyroid and thyroid surgery. She is particularly interested in the treatment of hyperparathyroidism and benign and malignant thyroid disease, such as thyroid cancer, Graves disease and goiter. Her research focuses on improving the surgical care of patients with endocrine diseases. If you have questions about our distance referral program or are interested in referring a patient, please contact our program coordinator, Cindy Shumway, at (608) or shumway@surgery.wisc.edu. GS

6 Stoughton Rd ENDOCRINE SURGERY PROGRAM Thyroidectomy Partial or total thyroidectomy involves small incisions using either open or endoscopic techniques. Our approach optimizes treatment for patients with complex, recurrent, metastatic or re-operative thyroid disease. Parathyroidectomy Parathyroidectomy is accomplished through small incisions with ultrasound, radioguidance and intraoperative parathyroid hormone monitoring. Advanced techniques, such as venous sampling, 4-D CT scans and measurement of parathyroid hormone in fine needle aspirates, allow us to treat even the most challenging cases of recurrent, reoperative and ectopic hyperparathyroidism. Adrenalectomy Adrenalectomy includes laparoscopic, retroperitoneoscopic or open techniques. Our multidisciplinary adrenal clinic addresses all phases of care from the initial workup to advanced imaging, hormonal testing and adrenal venous sampling, as well as surveillance of adrenal nodules. PATIENT-FOCUSED OUTCOMES UW Health endocrine surgeons take a patient-centered approach. Our team offers a tailored treatment plan for each patient, focused on improving quality of life, optimizing long-term outcomes and special consideration for patient preferences. Even mild or subclinical forms of endocrine disease can be successfully treated. NOVEL TREATMENTS AND TAILORED THERAPY We offer advanced techniques for diagnosis, treatment and prevention of endocrine disorders. Our approach matches the best technology to each patient s needs. Our goal is to provide quality care for even the most complex patients. This includes: Workup and management of incidentally discovered adrenal nodules Comprehensive management of initial and recurrent thyroid cancers Endoscopic surgery Minimally invasive radioguided parathyroidectomy Re-operative surgery for patients with persistent and recurrent primary hyperparathyroidism Integrated treatment for hyperthyroidism, Cushing syndrome, hyperaldosteronism, pheochromocytoma and all types of hyperparathyroidism Clinical trials for treatment-resistant thyroid cancer Minimally invasive surgery for large adrenal masses Coordinated two-day visit, including clinical consult with surgery the following day ADVANCED IMAGING Surgeon-performed ultrasound Intraoperative ultrasound Nuclear medicine scans 4-D parathyroid CT scans Adrenal venous sampling Selective venous sampling for parathyroid hormone RESEARCH Our team conducts many types of research aimed at improving the care of our patients. The results of this research are readily translated into best practices at UW Health, benefiting our patients and referring providers. Highland Ave Speedway Rd Campus Dr University Ave Regent St Monroe St. 113 Lake Mendota Lake Wingra Park St Gorham St John Nolen Dr Northport Dr Sherman Ave Johnson St E Washington Ave Williamson St UW Health 1 S. Park Clinic Packers Ave Lake Monona CV Dane County Airport Aberg Ave Atwood Ave Monona Dr 51 UW Health at The American Center E Washington Ave 30 American Pky Terrace Dr Cottage Grove Rd

7 Endocrine Surgery Distance Referral Program Our distance referral program is a convenient way for you to refer your patients with hyperparathyroidism, thyroid or adrenal problems to UW Health Endocrine Surgery. We offer your patients a consultation and surgery all in one trip. This usually requires a 2 3 day stay in Madison. How Our Program Works Fax your referral and additional information (see accompanying checklists) to our distance referral coordinator: Cindy Shumway, BS, LPN Fax: (608) Phone: (608) We will call patients, get them set up in our system and obtain additional information. Our endocrine surgeons will review patients records and make recommendations. We will call patients with the surgeons recommendations and coordinate the consultation, any additional testing, if needed, and the surgery. Patients will need to see their primary care physicians for a pre-operative exam within 30 days of the surgery date. We will fax the primary care physicians a pre-operative request letter with the information needed (labs, EKG, etc.) We will fax all of the records to you after the surgery. Patients usually have their post-op visits and lab tests done locally and we call them on the phone to follow up with results. It is not always safe or appropriate to proceed with the consult and surgery in one trip. If this is the case, we will work with your patient to create an alternative plan. GS

8 Endocrine Surgery Adrenal Referral Checklist Please fax the following information with your referral to (608) : Patient face sheet Referring doctor information (name, address, phone and fax) Recent office notes Lab tests, if available Metanephrines (plasma or urinary) Renin Aldosterone Cortisol (serum, salivary or urinary) Basic or comprehensive metabolic panel Any related imaging, if available (CT scans, MRI scans, nuclear scans, ultrasound, etc.) You do not need to order any imaging prior to referring the patient. GS

9 Endocrine Surgery Hyperparathyroidism Referral Checklist Please fax the following information with your referral to (608) : Patient face sheet Referring doctor information (name, address, phone and fax) Recent office notes Lab tests, if available Serum calcium PTH Total 25-OH vitamin D Basic or comprehensive metabolic panel 24-hour urine calcium and creatinine Any related imaging, if available (neck ultrasound, nuclear scans, CT scans, etc.) You do not need to order any imaging prior to referring the patient. Bone mineral density scans, if available GS

10 Endocrine Surgery Thyroid Referral Checklist Please fax the following information with your referral to (608) : Patient face sheet Referring doctor information (name, address, phone and fax) Recent office notes Lab tests, if available TSH, T4 Any other thyroid tests Thyroglobulin and/or antibody levels Any related imaging, if available (neck ultrasound, nuclear scans, CT scans, etc.) You do not need to order any imaging prior to referring the patient. Needle biopsies and pathology reports, if available GS

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