Thyroid Update. Timothy C. Petersen, MD, ECNU
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1 Thyroid Update Timothy C. Petersen, MD, ECNU
2 TPMG Coastal Endocrinology Virginia Beach, VA About Me Board Certified Endocrinology, Diabetes, and Metabolism Internal Medicine ECNU Certified Endocrine Certification in Neck Ultrasound American Association of Clinical Endocrinologists EVMS Medical School Residency Fellowship
3 None Disclosures
4 Overview Objectives Discuss commonly encountered thyroid diseases Hypothyroidism Thyroid nodules Thyroid cancer Provide updates in diagnosis and management Scope: adults only (18 + years old)
5 Outline I. Hypothyroidism II. Thyroid Nodules III. Thyroid Cancer IV. References V. Questions
6 Outline I. Hypothyroidism II. Thyroid Nodules III. Thyroid Cancer IV. References V. Questions
7 McAninch and Bianco, Annals Int Med 2016
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16 NATURAL SYNTHETIC
17 Diagnosis Symptoms/signs Biochemical/lab Hypothyroidism Source: US National Library of Medicine
18 Source: endocrinenews.endocrine.org
19 Treatment Hypothyroidism Levothyroxine Liothyronine e.g. Cytomel Combination L-thyroxine + liothyronine Compounded Natural desiccated thyroid e.g. Armour, Nature-Throid e.g. Synthroid/Levoxyl/Tirosint Hennessey JV, Endocr Pr 2015 McAninch EA, AC Bianco. Ann Int Med 2016
20 Hypothyroidism Treatment Levothyroxine remains standard Generic vs brand? However.. Individualized therapy Thr92AlaD2 McAninch, Bianco AIM ATA 2014 Guidelines Wartofsky Curr Opin Diab Endo Obes 2013
21 Source: Jonklaas et al. Thyroid 2014
22 Source: Jonklaas et al. Thyroid 2014
23 Hypothyroidism Transplant
24 Hypothyroidism Transplant SC, IM, IV
25 Hypothyroidism PO Transplant SC, IM, IV
26 Hypothyroidism Desiccated PO Transplant SC, IM, IV
27 Hypothyroidism Desiccated PO Transplant Synthetic SC, IM, IV
28 Hypothyroidism Personalized? Desiccated PO Transplant Synthetic SC, IM, IV
29 Hypothyroidism PO Transplant SC, IM, IV
30 Hypothyroidism PO Transplant (stem cells) SC, IM, IV
31 Petersen, McAninch, Bianco. JCEM 2016
32 Petersen, McAninch, Bianco. JCEM 2016
33 Petersen, McAninch, Bianco. JCEM 2016
34 Thyroid 2016;12(26):
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37 Hypothyroidism Surgery? Ivar Guldvog, MD, PhD Prospective, randomized trial Groups Control: medical therapy Experimental: total thyroidectomy Outcomes Antibodies Symptoms
38 Hypothyroidism Surgery? Outcomes Medical Antibodies: Symptoms: 85% 75% Surgical
39 Surgery? Outcomes Hypothyroidism Medical Surgical Antibodies: <500 Symptoms: 85% 75% 84% 34%* * p < 0.001
40 Surgery? Outcomes Hypothyroidism Medical Surgical Antibodies: <500 Symptoms: 85% 75% 84% 34% Conclusion?
41 Surgery? Outcomes Hypothyroidism Medical Surgical Antibodies: <500 Symptoms: 85% 75% 84% 34% Conclusion? Hypothyroidism is a surgical illness.
42 Surgery? Outcomes Hypothyroidism Medical Surgical Antibodies: <500 Symptoms: 85% 75% 84% 34% Conclusion? Hypothyroidism is a surgical illness. Maybe.
43 Outline I. Hypothyroidism II. Thyroid Nodules III. Thyroid Cancer IV. References V. Questions
44 Thyroid Nodules Epidemiology 50-60% all adults > 50 years old 5% of all thyroid nodules = malignancy Increasing incidence Overdiagnosis? Gharib et al. Endocr Pr 2016
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51 Where s the Doppler??
52 Options FNA Observation Surgery Thyroid Nodules
53 Thyroid Nodules Options FNA Observation Surgery Referral to your friendly neighborhood endocrinologist
54 The Bethesda System for Reporting Thyroid Cytopathology Source: BMJ Best Practice
55 Source: BMJ Best Practice
56 Source: BMJ Best Practice
57 Source: BMJ Best Practice surgery
58 Thyroid Nodules Molecular Testing Bethesda III (AUS/FLUS) Bethesda IV (Follicular neoplasm/suspicious for FN)
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60 Outline I. Hypothyroidism II. Thyroid Nodules III. Thyroid Cancer IV. References V. Questions Source: PinMart.com
61 Thyroid Cancer Epidemiology 37,200 new cases of DTC ,000 ( 14) 1 Yearly incidence 4.9/100, /100,000 Almost entirely PTC Size matters New PTC < 1 cm : 25% : 39% Predicted to be 3 rd most common cancer dx in Haugen et al. Thyroid Aschebrook-Kilfoy Canc Epid Biomark Prev 2013
62 Ahn et al. NEJM 2014
63 Estimated New Cases Of Cancer 2017, Virginia Source: American Cancer Society
64 Estimated New Cases Of Cancer 2017, Virginia Source: American Cancer Society
65 Thyroid Cancer Shifts in Perspective Incidence increases; mortality doesn t Augmenting QOL, limiting damage: clinical judgment Adverse effects Surgery Radioactive iodine Likelihood for declaring bankruptcy All cancer: > 2.5x Thyroid cancer: 3.5x Aschebrook-Kilfoy Canc Epid Biomark Prev 2013
66 Thyroid Cancer Options Surgery Lobectomy vs total thyroidectomy
67 Thyroid Cancer Options Surgery Lobectomy vs total thyroidectomy Observation
68 Thyroid Cancer Options Surgery Lobectomy vs total thyroidectomy Observation Referral to your friendly neighborhood endocrinologist
69 Surgery, then what? Radioactive iodine Suppressive levothyroxine? Tyrosine kinase inhibitors Monitoring Thyroid Cancer
70 Types Differentiated Medullary Anaplastic Primary thyroid lymphoma Thyroid Cancer
71 Types Differentiated Papillary Follicular Hurthle cell Medullary Anaplastic Primary thyroid lymphoma Thyroid Cancer
72 Types Differentiated Papillary NIFTP Follicular Hurthle cell Thyroid Cancer
73 JAMA Oncol 2016
74 Thyroid Cancer
75 Thyroid Cancer
76 Thyroid Cancer
77 Summary Hypothyroidism Thyroid Nodules Thyroid Cancer
78 Outline I. Hypothyroidism II. Thyroid Nodules III. Thyroid Cancer IV. References V. Questions
79 References Haugen BR, EK Alexander et al ATA Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid Jan;26(1): Gharib H, E Papini et al. AACE, ACE, AME Medical Guidelines for Clinical Practice for the Diagnosis and Management of Thyroid Nodules 2016 Update. Endocr Practice. May 2016:Vol 22(1) Hennessey JV. Historical and Current Perspective in the Use of Thyroid Extracts for the Treatment of Hypothyroidism. Endocr Pract Oct;21(10): McAninch EA, AC Bianco. The History and Future of Treatment of Hypothyroidism. Ann Int Med. 2016;164:50-6. Wartofsky L. Combination L-T3 and L-T4 therapy for hypothyroidism. Curr Opin Endocrinol Diabetes Obes. 2013;20:460-6.
80 References Aschebrook-Kilfoy B, Schechter RB, Shih YC, Kaplan EL, Chiu BC, Angelos P, Grogan RH. The clinical and economic burden of a sustained increase in thyroid cancer incidence. Cancer Epidemiol Biomarkers Prev. 2013;22: Jonklaas J, AC Bianco, AJ Bauer et al. Guidelines for the Treatment of Hypothyroidism. Thyroid. 2014;24(12): Celi FS. A much-needed historic perspective on the therapeutic use of thyroid hormones. Endocr Practice Oct;21(10): Nikiforov Y et al. Impact of the Multi-Gene ThyroSeq Next-Generation Sequencing Assay on Cancer Diagnosis in Thyroid Nodules with Atypia of Undetermined Significance/Follicular Lesion of Undetermined Significance Cytology. Thyroid. Nov 2015;25(11):
81 References Nikiforov Y et al. Nomenclature Revision for Encapsulated Follicular Variant of Papillary Thyroid Carcinoma: A Paradigm Shift to Reduce Overtreatment of Indolent Tumors. JAMA Oncol. 2016;2(8): Wichman J et al. Selenium Supplementation Significantly Reduces Thyroid Autoantibody Levels in Patients with Chronic Autoimmune Thyroiditis: A Systematic Review and Meta-Analysis. Thyroid. 2016;12(26):
82 Questions?
83 Thank you.
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