American Thyroid Association 89th Annual Meeting:

Thyroid Disease Advances in Care: Key Insights from ATA Attendees

with Mohammad Shaear, MD, Malini Gupta, MD, and Adina Alazraki, MD

As has become a custom when attending endorine-focused meetings, rather than report only on the headlining presentations, EndocrineWeb seeks to learn what advances in care strike those in attendence. In this way, you will benefit from the practice pointers that were singled out by your peers.

At this year's ATA annual meeting, many sessions focused on thyroid management, particularly when consideration turns to the pros and cons of surgury.

Attendees at an ATA presentation on advanced thyroid care management.

For Patients' Sake, Benefits of Active Surveillance Need to Permeate Clinical Practice

Standing outside the session hall, Mohammad Shaear, MD, a postdoctoral research fellow in endocrine surgery at Johns Hopkins School of Medicine in Baltimore, Maryland, told EndocrineWeb that the discussion that most caught his attention revolved around the implementation less invasive interventions as well as the need for surgeons to advocate for active surveillance when appropriate for the patient.

“In my practice group, under the mentorship of Ralph P Tufano, MD, MBA, Charles W. Cummings MD Endowed Professor and director of the Division of Head and Neck Endocrine Surgery at Johns Hopkins, we have been exploring the efficiency and safety of the radio frequency ablation (RFA) in treating microcarcinomas of the thyroid,” said Dr. Shaear.

“We’ve seen that once you tell any patient that she has cancer, whether it’s a microadenoma or a large tumor, she starts to get anxious. A lot of patients, at this point, will then respond with: Please just do the surgery, I want you to take this out’ even though we know that the surgery carries higher risks that must be considered in each individual,” he said.

“Even though I am in a surgical practice, we are recognizing that a lot of patients would be better off if they understood the  important role that their thyroid gland plays, particularly in producing essential hormones—T4 and T3—that are involved in metabolic processes and other important functions such as bone homeostasis, gastrointestinal function, and muscle control,” said Dr. Shaear.

More patients should be counseled regarding the advantages of active surveillance and encouraged to stay this route for as long as possible. However, having more options for surgical intervention once the time is right is also important.

“That’s why we are interested in exploring thermal techniques, especially radiofrequency ablation. At John Hopkins, we started using this procedure for benign thyroid nodules and now we’re really interested in using this surgical intervention for microcarcinomas,” he said.

Endocrine Side Effects Rising with Wider Use of Checkpoint Inhibitors Endocrine

Several attendees, including Malini Gupta, MD, founder and director of G2Endo, a private practice in endocrinology, diabetes, and metabolism, in Memphis, Tennessee, mentioned gaining valuable insights regarding endocrine adverse events that occur following use of combination immune system checkpoint inhibition therapy with cytotoxic T-lymphocyte-associated proteins (CTLA-4, also known as CD analog), that downregulates the thyroid immune response and programmed cell death protein-1 (PD-1), inhibitory receptors expressed by T cells.1

Bhavana Konda, MD, MPH, an oncologist at the Ohio State University Wexner Medical Center in Columbus and Ramona Dadu, MD, assistant professor of medicine at MD Anderson Cancer Center, department of endocrine neoplasia and hormonal disorders led a workshop session on the side effects affecting the thyroid in patients receiving checkpoint inhibition therapy.1

These monoclonal antibodies (ie, pembrolizumab [Keytruda], nivolumab [Opdivo], cemiplimab [Libtayo]), have been found to produce a durable response in patients with metastatic cancers that has not been achieved with traditional chemotherapy.2. As such, this checkpoint inhibition cocktail appears particularly effective in targeting chemotherapy resistant cancers as melanoma, HER-2/neu breast cancer, Hodgkin’s lymphoma, and more recently, head and neck cancers, said the researchers.

“It is important to anticipate that these checkpoint inhibitors, when given to a patient to treat other forms of cancer may result in an adverse effect to their thyroid, which often is irreversible,” Dr. Gupta told EndocrineWeb; this proved to be a major takeaway when mulling the many sessions she attended. Given the growing use of checkpoint inhibitors, as clinicians, we should be on the alert for common endocrine-related side effects that may arise following treatment with these drugs that include fatigue, a persistent cough, nausea and a loss of appetite, a skin rash and itching.

“An increase in antithyroid antibodies after [checkpoint inhibition] treatment has been observed such that clinicians should be aware of the array of endocrinopathies that may arise, necessitating that these patients be referred for treatment to endocrinologists,” she recounted.

Of particular note is the increase in the relative risk of both hypothyroidism (ie, Hashimoto’s thyroidits) and hyperthyroidism secondary to anti-CTLA-4 (ipilimumab, tremelimumab) or anti-PD-1 (nivolumab, pembrolizumab) therapy as well as hypophysitis (pituitary inflammation).1

For more on the side effects of Checkpoint Inhibitors:

There’s a Time and Place for Specialty Care in Thyroid Cancer Management

In speaking with Adina Alazraki, MD, pediatric radiologist at Emory University Medical School in Atlanta, Georgia, told EndocrineWeb that there is a strong push for clinicians to subspecialize in academic institutions, and the advantage of this for patients is that they are provided greater assurance of having imaging assessments from highly trained thyroid radiologists and treatment from high volume surgeons.

The significant downside is the great major of patients are treated in community settings where radiology and surgery are most often in the hands of generalists who do not have focused training and experience in identifying and managing thyroid cancer.  Thus, “while thyroid tumors remain a rare occurrence in the pediatric population, in adults, high volume surgeons are often faced with having to ‘clean up’ the problems that arise with failed and incomplete surgeries,” Dr. Alzraki said, which is not a very good proposition for the majority of patients who must be referred for management particularly for advanced thyroid cancer.

Many patients are worry about having neck scars, and it is not just about vanity. Research shows that when there is a visible scare, the eyes are drawn to the neck, and not to person’s face, producing conscious and unconscious emotional distress.

“While it would seem obvious, thyroid surgery should be done by surgeons with sufficient familiarly with thyroid specific pathophysiology,” to avoid failed or incomplete results, said Micheal C. Singer, MD, an endocrine surgeon specializing in minimally invasive thyroid and parathyriod surgery at the Henry Ford Cancer Institute in Detroit, Michigan, adding his concerns to this discussion.

“Yes, and we may have arrived at the point in which there is a need to consider incorporating a recommendation into future guidelines such that for treatment of advanced thyroid carcinomas, patients should be directed for treatment exclusively by high volume thyroid oncology surgeons,” Dr. Turfano told EndocrineWeb. Dr. Singer pushed—why not make that the case for all thyroid cancer cases?—to which Dr. Turfano suggested that it would be most effective to begin this mandate with the most urgent cases, in trying to establish a new management norm.

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