Day 2 of ATA highlights fellow lectures, start of Meet-the-Professor sessions

CORONADO, Calif. — Day 2 of the American Thyroid Association Annual Meeting consisted of lectures for fellows participating in the Trainees’ grant program and the first session of the Meet-the-Professor lectures.

Erik A. Alexander, MD, of Brigham and Women's Hospital and Stephanie L. Lee, MD, PhD, of Boston University School of Medicine, served as discussants for a series of questions submitted by fellows in attendance about thyroid nodules. The lecture reviewed Bethesda categories for thyroid fine needle aspiration (FNA) cytology; it can be difficult to know what to do with FLUS/AUS (Bethesda category 3) cytology. The use of molecular markers can be made in this case – however, if it is not an option financially – repeat biopsy is warranted.

Multiple cases focused on thyroid cancer. The degree of extrathyroidal extension and lymphovascular invasion plays a significant role in determining if postoperative radioactive iodine (RAI) treatment should be considered. Finally, although guidelines recommend against biopsying nodules <1 cm, subcentimeter flurodeoxyglucose (FDG) PET-positive thyroid nodules should be biopsied, given 35% to 45% of these nodules can be malignant.

Pavani Srimatkandada

Meet the Professors

The first series of the Meet-the-Professor lectures also started. R.P. Peeters, MD, PhD, from Rotterdam Medical Center reviewed current guidelines in thyroid disease in pregnancy. It is important to calculate population-based trimester-specific thyroid stimulating hormone reference ranges based on optimal iodine intake in your area of practice. The upper limit of TSH 2.5 mIU/L in the first trimester and 3.0 mIU/L in the second and third trimesters should only be used if trimester-specific ranges for your area are not available. The decision to treat or not to treat subclinical hypothyroidism (SCH) during pregnancy is controversial. ATA guidelines acknowledge there is an association with SCH and adverse maternal and fetal outcomes, but state there is insufficient evidence to treat thyroid autoantibodies (TOAb) negative women. The majority recommend treating SCH if TPOAb is positive, however, Endocrine Society guidelines note the potential benefit of treatment outweighs the risks so they recommend treating SCH if TPOAb is positive or negative.

Ultrasound, FNA Workshops

The remainder of the afternoon consisted of a thyroid ultrasound and FNA biopsy workshop for Trainees. Andrew G. Gianoukakis, MD, of Harbor UCLA Medical Center reviewed worrisome ultrasound features found in nodules including hypoechoic echotexture, punctate calcifications, taller-than-wider dimensions, intranodular vascular flow and irregular borders. These characteristics have increased specificity but low sensitivity for detection of thyroid malignancy, making them a less than ideal screening test. Sixty-six percent of benign nodules have at least one of these features.

Stephanie A. Fish, MD, of Memorial Sloan-Kettering Cancer Center, noted that FNA by palpation has a high false negative rate (0.5%-2.3%) compared with ultrasound-guided FNA biopsy (0%-0.6%). Worrisome lymph node features include: rounded large lymph nodes, hyperechoic texture, absence of a hilum, cystic changes, microcalcifications and increased peripheral vascular flow. Parathyroid ultrasound and indications for surgery were also reviewed. Parathyroidectomy for primary hyperparathyroidism is recommended if calcium is 1 unit above upper limits of normal, 24-hour urine creatinine is >400mg/d, creatinine clearance is <60 cc/ml, presence of nephrolithiasis, T score of less than -2.5 at any site or age is <50 years.

Nicole Massoll, MD, of the University of Arkansas for Medical Sciences, reviewed the proper technique for making cytology slides including direct smear, use of cytospin, cell-block and liquid-based slide preparations. Alcohol-fixed slides are better compared with air drying slides when evaluating nuclear features. The session ended with fellows being able to practice thyroid ultrasounds, prepare slides and perform FNA on turkey breasts!

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

Disclosure: Srimatkandada reports no relevant financial disclosures.