AACE 28th Annual Scientific & Clinical Congress:

Better Disease Management—Thyroid, Adrenal, Pituitary Gland Disorders

With Quan-Yang Duh, MD, Anand Vaidya, MD, MMSc, John Carmichael, MD, Gabriel Zada, MD,  Jonathan LoPresti, MD, PhD, Dennis Maceri, MD, and Jeffrey R. Garber, MD

The concept of collaborative efforts among physicians is nothing new, of course, but attention to its value in patient care delivery has become a necessary focal point for all involved parties. So much so that a four-hour session was held during the 28th American Association of Clinical Endocrinologists Annual Scientific &  Clinical Congress, in Los Angeles, California.

While there has been ongoing discussion regarding the benefts of improved patient-physicain communication, this program was initiated based on the favorable reception and strong attendance at similarily held forums, Jeffrey R. Garber, MD, FACP, FACE, the session chair, told EndocrineWeb. Dr. Garber is chief of endocrinology at Atrius Health, in Boston, Massachusetts, and a past president of AACE and the American College of Endocrinology.  

When endocrinologist and surgeon work closely with patient, outcome improves.

Forming a Collaborative Approach Between Endocrine Specialists

In a recent perspective in the AMA Journal of Ethics, the authors cited: "Teams offer the promise to improve clinical care because they can aggregate, modify, combine, and apply a greater amount and variety of knowledge in order to make decisions, solve problems, generate ideas, and execute tasks more effectively and efficiently than any individual working alone.”1

The potential of clinical gains for both practitioners and patients, of course, does not materialize without its challenges. To discuss all aspects of the collaborative model of patient management, a panel of experts addressed the topic covering the benefits and obstacles in a precongress program at AACE 2019—in this case, focusing specifically on the collaborative relationship between endocrinologists and surgeons.2

Three teams of endocrinologists and surgeons, some who have worked together, some who did not, tackled a variety of questions that arise striving for the best approach to effective management of endocrine disorders, and presented their views on how a collaboration approach between an endocrinologist and a surgeon should work.

High points from each of the three endocrinologist/surgeon team discussions about strategies to enhance this clinical model is provided with some perspective from Quan-Yang Duh, MD, professor and chief of endocrine surgery, University of California, San Francisco.

Touchpoints in the Collaborative Approach to Care Surrounding Adrenal Surgery

Dr. Duh and Anand Vaidya, MD, MMSc, director of the Center for Adrenal Disorders at Brigham and Women's Hospital and assistant professor at Harvard Medical School, discussed issues that are likely to arise in adrenal patients.

One highlighted case involved a 65-year-old female who had had a computerized tomography (CT) scan for diverticulitis, during which a 4.5 cm right adrenal mass was detected. The mass was heterogeneous and less than a 50% absolute washout was found. A biopsy was performed and interpreted as ''benign."

A repeat CT scan conducted six years later showed similar features and no change in size. However, three years later—now 9 years after the baseline scan—showed tumor grown to 5.4 cm. Laparoscopic surgery was done with disruption of the tumor capsule and spilling of contents. The diagnosis was high-grade stage II adrenocortical carcinoma.2

"You almost never stick a needle in an adrenal tumor," Dr. Duh said.  He cited a study from the Mayo Clinic looking at 20 fine needle aspiration biopsies resulting in 14 complications, six hematomas, five incorrect diagnoses, and detection of tumor recurrence in two cases.3

"You have reason enough to take the tumor out at the beginning," Dr. Duh said, ''when the adrenal tumor was first identified.” Waiting so long, and to find it was growing presents a problem. "When an adrenal tumor gets beyond 6 cm, it is harder to remove. If you have good surgical people to help you, it's much easier."

Dr. Vaidya responded: "I would have referred this patient to you at the first scan."  He cited a paper he authored about managing incidentally discovered adrenal masses.4 "You should ask yourself, 'Is there evidence of malignancy? Is there adrenal hormone excess?"  In the case of this patient, he said, there were no symptoms or signs to suggest hypercortisolism, pheochromocytoma, hyperaldosteronism, or hirsutism, he said. Nor was there evidence of weight loss or abdominal distention to suggest metastatic cancer or hyperfunctioning adrenocortical carcinoma.

However, Dr. Vaidya said, the radiologic characteristics were suspicious, which should have triggered concern for malignancy.The woman's mass had an irregular shape, heterogeneous content, a rate of growth 1 cm/year or more, a HU score of 10 or higher, all of which pointed to potential malignancy, as well as an absolute contact washout on CT protocol at 15 minutes of 60% or less. The size, more than 4-6 cm, should have raised greater concern, and at least discussion about surgery.

Among his other take-home messages, clinicians will want to consider the following screenings2:

  • All adrenal masses for cortisol excess given the higher incidence in these types of tumors.
  • For catecholamine excess
  • Aldosterone screening for those with hypertension and/or hypokalemia. Benign sex-producing tumors are rare, he said.2

Strategies to Enhance Collaborative Care in Considering Pituitary Surgery

Pituitary disorders were addressed by Gabriel Zada, MD, associate professor of neurological surgery at the Keck School of Medicine at the University of Southern California in Los Angeles, and John Carmichael, MD, associate professor of clinical medicine, an endocrinologist also at the Keck.

They described their USC Pituitary Center collaborative model.2 It helps that the clinic for neuroendocrinology and neurosurgery are in the same office, they said. "Scheduling is done by the same person, and we try to see the patient on the same day," Dr. Carmichael said.

Like the other speakers, they reviewed several cases, but gave many gems of advice about collaboration in a system in which team members live it every day. Among the most salient suggestions regarding pituitary tumor management:2

  • For postoperative care, surgeons and endocrinologists should recognize that escalation of surveillance may be crucial to adequately treat these patients.
  • Communication beyond the endocrinologist/endo surgeon must extend to physicians and other team members as a necessary and important ongoing requirement.
  • Preoperative management will rely heavily on attention to a hormonal assessment to avoid diagnostic pitfall
  • Peri-operative management will require a clear delineation of duties, which should be clarified and confirmed by both specialists.2

Approaches to Enhance the Collaborative Care of Patients with Thyroid Cancer

Differentiated thyroid cancer (DTC) was the topic discussed by Dennis Maceri, MD, professor of otolaryngology and Jonathan S. LoPresti, MD, PhD, associate professor of clinical medicine, both at the Keck School of Medicine of USC.

This endo team presented a 31-year-old female referred by her gynecologist after detecting a thyroid nodule during a routine health maintenance exam. The patient had not noticed it; she denied experiencing any neck pain, swallowing problems, intolerance to heat or cold, weight changes, or other relevant symptoms. A family history revealed a mother with hypothyroidism who was taking levothyroxine replacement therapy and a father who was under treatment for hypertension.2  The patient’s laboratory findings: free T4-1.24 nd/dl, TSH 2.3 uIU/ml, TPO, 32 IU/ml.  On ultrasound, a 3.2x17x2.9 nodule was discovered; it was hypoechoic with shaggy borders, microcalcifications; TIRADS 5.

The FNA biopsy results reflected enlarged follicular cells in papillary clusters consistent with a diagnosis of papillary thyroid carcinoma, Bethesda category VI.2

The endocrine team determined that the best recommendation for this patient was a thyroidectomy followed by T4 therapy, who was told about the potential risks, including voice nerve damage and a low serum calcium that would increase her risk of osteoporosis. The patient did some internet research and came back with a request to entertain a lobectomy instead.

While the American Thyroid Association Guidelines introduce lobectomy as an option for initial therapy,3 Dr. LoPresti explained to her patient that this approach would require management with serial ultrasounds as well as Tg measurements. If a new nodule appear, a repeat FNA would be needed; if the Tg rose above 30, a second surgery might be needed.4,5

Dr. LoPresti offered a word of caution: "Unfortunately, what happens with age is that the thyroid develops nodules. If you continue to do ultrasounds, you are going to find [additional] thyroid nodules.''

Dr. Maceri added: "It's hard for me to comprehend doing a lobectomy when there is a more than 30% chance of leaving microscopic disease behind in that thyroid." The nodule size points to the need for a total thyroidectomy so the patient was referred to the thyroid surgeon to talk about the surgery.

A total thyroidectomy, for this patient, was the correct course, both the endocrinologist and endocrine surgeon agreed. "I think the completeness of the surgical resection is probably the most important aspect for this patient," Dr. Maceri said.

All the panels agreed that for surgery, experience counted, citing Surveillance, Epidemiology and End Results (SEER) Program data.6 While survival is the same whether surgery is done by a low-volume or high-volume surgeon, complication rates are higher with a low-volume surgeon—reaching 24.1% for a total thyroidectomy done by low-volume, compared to 14.5% done by high-volume surgeons.6

This patient did well post-surgery, taking a suppressive dose of L-T4 and returned at six weeks to discuss her long-term management. She was unsure about considering postop radioactive iodine (RAI). She was told that the need for RAI was evaluated based on a pre- and post-op Tg (87 ng/dl, 0.21 ng, respectively) meaning she could be reassured that it was reasonable to defer RAI, in her case. 

A post-op Tg  <0.5, in the face of TSH suppression, was consistent with tumor removal and likely represented residual normal tissue, the USC physicians concur. "The surgeon had done his job well," Dr. LoPresti said.

Thoughts from a Collaborator to Future Endocrine Collaborators

Collaboration should not be viewed as daunting or as difficult as some may think,2 Dr. Duh told EndocrineWeb in a post-meeting interview. Multidisciplinary sessions, he said, involving an endocrinologist, a surgeon, and possibility other team members, are generally more efficient than sending a patient from one doctor to another for consultations.

"Most of the time, at these multidisciplinary meetings, there are few surprises." A common ground on decisions is generally met by everyone involved in the patients care, he said. In effect, there is a huge time-savings, which may come as a surprise to many.

When he considers a collaborative approach, he doesn't think just about what occurs at a formal meeting, rather he finds that once you work with another health care provider for a period of time, ''you get to know how they think." So the collaboration going on in those discussions might be nearly effortless.

Dr. Duh has nothing to disclose. Dr. Vaidya is on advisory boards or consults for Selenity, HRA, Orphagen, Ionis, Corcept; Dr. Carmichael is PI for research grants to USC from Chiasma, Strongbridge, Millendo, Novartis, Novo Nordisk, Pfizer; and Dr. Zada, Dr. Maceri and Dr. LoPresti have no relevant disclosures.

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