The Year 2016 in Thyroidology

Transcription

1 The Year 2016 in Thyroidology Gerasimos Sykiotis, MD PhD Médecin associé; Service EDM, CHUV Privat-docent, MER clin.; FMB, UNIL

2 Nodules et cancer (y.c. recommandations ATA 2015) Dysthyroïdies pendant la grossesse Recommendations ATA sur l hyperthyroïdie

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4 Publications et citations par sujet

5 Tendances par sujet

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11 Why NIFTP matters for us clinicians?

12 The Bethesda system B.N. (before NIFTP)

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14 Reclassification decreases the malignancy rate of nodules with architectural atypia in CNB «avant NIFPT» (NIFTP=malin) «avec NIFPT» (NIFTP=bénin)

15 Similar impact on the Bethesda system

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17 Not possible to diagnose NIFTP pre-operatively

18 Or is it?

19 Bethesda VI Bethesda V

20 And then there are also «ethics» to consider

21 Réexaminer les EFVPTC pour trouver les NIFTP Informer les patients concernés Modifier l attitude si indiqué

22 What about «real» thyroid cancer?

23 2016: The year when the war began Why the European Association of Nuclear Medicine has declined to endorse the 2015 American Thyroid Association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer. Eur J Nucl Med Mol Imaging Jun;43(6): The 2015 Revised American Thyroid Association guidelines for the management of medullary thyroid carcinoma: the "evidence-based" refusal to endorse them by EANM due to the "not evidence-based" marginalization of the role of Nuclear Medicine. Eur J Nucl Med Mol Imaging Jul;43(8):

24 What to do for the epidemic of microptc

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26 Surveillance: no worse oncological outcomes

27 Surveillance: better non-oncological outcomes

28 Which patients opt for surgery vs. surveillance?

29 How should physicians choose between surgery and active surveillance?

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31 surveillance possible surveillance non-recommandée surveillance non-recommandée

32 Risk of progression decreases with age Surveillance is not prohibited in patients <40 years old but the progression risk must be considered in the decision

33 And what to do for cancers 1-4 cm?

34 If lobectomy is chosen, when is reoperation required? What percentage of patients will be affected?

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37 Nearly half of the patients would require reoperation among T1b tumors: 36% BRAF V600E not tested

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39 Do low risk DTC patients need RAI-131 treatment? Low risk (of recurrent disease): <5% or <10%

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42 57 months: US + months: (WBS + Tg) months: US + months: (WBS + Tg) /rtsh followed for months

43 No patient relapsed (36-84 months of follow up) No need for stimulated Tg measurements No need for diagnostic WBS But some patients had slightly higher final Tg longer follow-up needed?

44 How we should follow patients not treated by RAI-131?

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49 Excellent response predicts 0% risk of structural disease regardless of the initial risk estimate

50 Best response to therapy is the best predictor of structural disease

51 «Salvage therapy» for structural disease is effective

52 Conclusions The recognition of NIFTP as a separate clinical entity has implications for the performance of diagnostic tests and for the initial treatment decisions (favoring lobectomy in many cases). Active surveillance of low-risk microptc can be considered and discussed with the patient. Expertise in cervical ultrasonography is critical for this strategy. Lobectomy can be considered for 1-4 cm DTC without high-risk features and discussed with the patient in light of a 30-50% risk of completion thyroidectomy. DTC treated with lobectomy or total thyroidectomy without RAI- 131 can be reliably followed according to current guidelines.

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54 Hypothyroïdie

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56 A: n=198, TPO(+), +T4 B: n=195, TPO(+), no T4 C: n=197, TPO(-), no T4 T4 treatment has no effect!

57 Hyperthyroïdie

58 Can we predict agra?

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62 Heterozygote pour 3 SNPs: risque d agra 30% (!) Number need to test: 283 ( )

63 Synthetic biology to treat Graves?

64 Designer cells secreting a TSHR antagonist under control of T3

65 TSHR antagonist circulates to prevent TSHR stimulation by auto-antibodies

66 Implantation of designer cells normalizes the thyroid hormone profile in Graves mice

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