Day 1 of ATA begins with review of testing, guidelines at Trainees' Conference

CORONADO, Calif. — Wednesday, Oct. 29 marked the beginning of the 84th Annual American Thyroid Association meeting here in beautiful Coronado, Calif. The morning kicked off with the first full day of the ATA’s Trainees’ Conference.

Bryan R. Haugen, MD, of the University of Colorado, started off the series of lectures by asking grant recipients to remember E. Chester Ridgway, MD, who founded the endocrine fellows’ conference more than 20 years ago, before beginning his review on the biochemical breakdown of how thyroid hormone works.

Pavani Srimatkandada

Carol Spencer, PhD, MT, FACB, of University of Southern California, spoke next about what thyroid tests to order. Although NHANES quotes the normal range of TSH to be 0.4 to 4.1 mIU/L, practitioners should remember these values are not fixed but rather “patient specific,” with individual ranges varying slightly, perhaps higher based on age and increasing BMI and lower in women wanting to conceive.

The three methods to measure cancer screening markers thyroglobulin and thyroglobulin antibody include: immunometric assay, RAI and mass spectrometry analysis. Although rapid and automated, the immunometric thyroglobulin assay can be falsely low with the presence of thyroglobulin antibody. If antibodies are present, mass spectrometry is recommended given its high precision rate.

David S. Cooper, MD, of Johns Hopkins University, reviewed the ATA clinical guidelines in hyper- and hypothyroidism. Anti-thyroidal drugs including propylthiouracil and methimazole, surgery or radioactive iodine ablation are all plausible treatment options for Graves’ disease depending on clinical scenario. He reminded trainees that guidelines do not recommend routine monitoring of white counts and liver enzymes unless signs and symptoms of fever, pharyngitis, or liver disease are present. Eighty percent of patients are cured with a single dose of radioactive iodine ablation. Although 50% of these patients become hypothyroid 1 year post treatment, eye disease can worsen due to circulating thyroid-stimulating immunoglobulin antibodies post procedure. Therefore, if mild, active eye disease is present, consider using steroids if treating with radioactive iodine. If there is increased risk of worsening eye disease, such as a history of smoking or markedly elevated triiodothyronine, steroids should be used when treating with radioactive iodine.

Stephen H. LaFranchi, MD, of Oregon Health and Sciences University, discussed the origins of congenital hypothyroidism. Eighty-five percent of congenital hypothyroidism is caused by thyroid dysgenesis, while maternal autoimmune disease composes only 2% of these cases. Newborn screening varies from state to state and can include either TSH, total thyroxine with reflex TSH (if T4 is less than 10%), or combined TSH and T4. Some areas use a single test measuring values at 2-5 days after birth, while other areas employ a two-test approach, testing at 2-5 days post-birth and again 10-21 days post-birth. Although mandatory in the United States, only about 30% of newborns undergo thyroid screening worldwide.

Yuri Nikiforov, MD, PhD, of the University of Pittsburgh, spoke about the Afirma (Veracyte) gene classifier analysis and the 70-gene mutational panel as molecular markers for diagnosis of thyroid cancer. According to Nikiforov, the Afirma gene classifier method has up to 90% to 94% sensitivity for detection of AUS/FLUS, follicular neoplasms, lesions suspicious for follicular neoplasm and suspicious for malignancy. Its high negative predictive value make it an excellent test to rule out these lesions while the gene mutational panel has a much higher positive predictive value.

The closing of the first day of the Trainees’ conference was followed by the Opening Session of the 84th Annual Meeting of the ATA. The lecture included talks by Peter Kopp, MD, who reviewed the latest thyroid basic science research and Douglas S. Ross, MD, who reviewed recent literature in clinical endocrinology. Herbert Chen, MD, provided a surgeon's perspective on the need for well-trained thyroid surgeons to prevent post-op surgical complications, decreased length of stay and decreased financial costs.

Pavani Srimatkandada, MD, is a second-year fellow at the Boston University School of Medicine.

Disclosure: Srimatkandada reports no relevant financial disclosures.