Daily Endocrinology Research Analysis
Analyzed 81 papers and selected 3 impactful papers.
Summary
Today's top endocrinology papers refine diagnostic and treatment pathways in thyroid and adrenal disorders. A large Hypertension study shows single-sided AV sampling metrics are unreliable for primary aldosteronism subtyping, while a JCEM prospective study demonstrates that adding elastography to ACR TI-RADS can halve FNAs without missing cancer. A JAMA Otolaryngology propensity-matched cohort suggests de-escalation to lobectomy is feasible for select N1b papillary thyroid carcinoma.
Research Themes
- Diagnostic accuracy and risk stratification in endocrine imaging
- Surgical de-escalation strategies in differentiated thyroid cancer
- Reliability of adrenal vein sampling metrics in primary aldosteronism
Selected Articles
1. Partially Successful Adrenal Vein Sampling With and Without Cross-Sectional Imaging in Primary Aldosteronism Subtyping.
In 460 PA patients, simulated single-vein RASI showed extensive overlap across lateralized and bilateral subtypes, misclassifying up to 74% and 64% of cases using prior thresholds. RASI failed to predict cure after adrenalectomy; combining with cross-sectional imaging improved lateralization only modestly, especially with cosyntropin-stimulated AVS.
Impact: This study provides strong negative evidence against using single-vein RASI to guide adrenalectomy, directly impacting decision-making in primary aldosteronism centers.
Clinical Implications: Do not rely on RASI from partially successful AVS to subtype PA or to select patients for adrenalectomy. Prioritize bilateral AVS success; if partial, incorporate high-quality cross-sectional imaging and consider repeating AVS or medical therapy.
Key Findings
- RASI from lateralized PA overlapped 98% (dominant AV) and 97% (nondominant AV) with bilateral PA RASI without cosyntropin.
- Previously proposed RASI thresholds misclassified up to 74% of lateralized PA and 64% of bilateral PA.
- RASI did not distinguish adrenalectomy patients with versus without biochemical cure.
- Cross-sectional imaging modestly improved lateralization when combined with cosyntropin-stimulated AVS.
Methodological Strengths
- Large single-center cohort (n=460) with bilateral AVS success enabling robust simulation of partial success.
- Evaluation both before and after cosyntropin stimulation and inclusion of postoperative outcomes.
Limitations
- Retrospective single-center design may limit generalizability.
- Partial success was simulated from bilateral successes rather than observed in real-time partial cannulations.
Future Directions: Prospective multicenter studies validating integrated algorithms (bilateral AVS success metrics plus imaging) and exploring repeat AVS strategies are needed.
BACKGROUND: Adrenal vein (AV) sampling (AVS) is used to guide therapy in primary aldosteronism (PA). When a single AV is successfully cannulated, the relative aldosterone secretion index (RASI), which compares the aldosterone/cortisol ratio in that AV versus the periphery, has been proposed as sufficient for PA subtyping, particularly when <1. Data on RASI reliability have, however, been inconsistent. METHODS: This retrospective cohort study included patients with PA who underwent AVS before and after cosyntropin stimulation at a referral center between January 2015 and December 2024. To simulate partially successful AVS, RASI was calculated from patients with successful bilateral AV cannulation and compared across PA subtypes and postoperative outcomes, with assessment of distributional overlap. RESULTS: Of 460 patients (mean age 53±12 years; 58% men), bilateral AVS was successful in 437 patients at baseline and in all patients after cosyntropin stimulation. Without cosyntropin, 98% of dominant AV and 97% of nondominant AV RASI from lateralized PA overlapped with bilateral PA RASI. Similar patterns were observed postcosyntropin. In adrenalectomized patients, RASI did not distinguish between those with and without PA cure. Previously proposed RASI thresholds misclassified up to 74% of lateralized PA and 64% of bilateral PA. When corroborated with cross-sectional imaging, the prediction of correct lateralization improved, particularly when using RASI from cosyntropin-stimulated AVS. CONCLUSIONS: Considering the substantial overlap of RASI across PA subtypes, partially successful AVS has limited utility and is unreliable in guiding adrenalectomy for PA.
2. Elastography enhances diagnostic accuracy of ACR TI-RADS in thyroid nodule evaluation.
In a prospective cohort of 556 thyroid nodules, adding strain elastography to ACR TI-RADS reduced FNAs from 501 to 260 without missing any cancers. Elastography showed outstanding discrimination in TI-RADS 3 nodules (AUC 0.994), supporting a refined, imaging-enhanced risk stratification.
Impact: Provides immediate, actionable imaging criteria that can halve biopsy burden without compromising cancer detection, addressing a common endocrine diagnostic bottleneck.
Clinical Implications: Incorporate strain elastography thresholds alongside TI-RADS to reduce unnecessary FNAs, particularly in TI-RADS 3 nodules; ensure protocol standardization and local validation.
Key Findings
- Adding elastography ratio thresholds (>1.60 for TI-RADS 3; >0.44 for 4; >0.54 for 5) reduced FNA procedures from 501 to 260.
- No malignant nodules were missed when elastography was used as an additional criterion.
- Elastography achieved AUC 0.994 and Youden index 0.994 in TI-RADS 3 nodules.
Methodological Strengths
- Prospective design with standardized ultrasound, CDUS, and strain elastography protocols.
- Use of Bethesda cytology and surgical pathology as reference standards when available.
Limitations
- Potential device- and operator-dependence of elastography thresholds limiting generalizability.
- Not all nodules had surgical pathology, risking verification bias.
Future Directions: Multicenter validation of elastography thresholds across vendors and integration into decision tools to optimize FNA triage.
CONTEXT: The American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS) incorporates conventional grayscale ultrasonography (US) as the only imaging technique without considering the clinical and demographic characteristics of patients. OBJECTIVE: This study assessed whether the addition of demographic information, color Doppler US (CDUS), and strain elastography could enhance malignancy risk stratification beyond the current ACR TI-RADS criteria. DESIGN AND OUTCOME MEASURES: This prospective study enrolled 556 adult patients with thyroid nodules ≥10 mm who were referred for fine-needle aspiration (FNA) according to the ACR TI-RADS recommendations. All nodules underwent standardized US evaluations and vascularity assessments using CDUS and strain elastography, with cytological analysis performed according to the Bethesda system. Surgical pathology was the gold standard for malignancy when available. RESULTS: Applying elastography ratio (ER) thresholds (>1.60, >0.44, and >0.54 for ACR TI-RADS categories 3, 4, and 5, respectively) as an additional criterion for FNA reduced the number of procedures from 501 to 260, without missing any malignant cases. Notably, elastography demonstrated an excellent discriminative performance in ACR TI-RADS 3 nodules (Youden index 0.994, AUC 0.994), supporting its value in improving risk stratification in this challenging, predominantly benign category. CONCLUSIONS: Integrating elastography into the ACR TI-RADS framework can optimize FNA utilization in the management of thyroid nodules by reducing the number of unnecessary aspiration biopsies.
3. Thyroid Lobectomy and Neck Dissection for N1b Papillary Thyroid Carcinoma.
In a propensity-matched cohort of unilateral N1b PTC with low-volume nodal disease, thyroid lobectomy plus neck dissection achieved similar 5-year OS, DSS, and RFS compared with total thyroidectomy plus RAI, with long median follow-up. This supports de-escalation in carefully selected patients without clinical extranodal extension.
Impact: Challenges a long-standing paradigm that mandates total thyroidectomy plus RAI for N1b PTC by providing matched long-term outcomes for lobectomy.
Clinical Implications: Consider lobectomy with neck dissection for unilateral N1b PTC with low-volume metastases and no clinical extranodal extension, after thorough multidisciplinary evaluation and patient counseling.
Key Findings
- 5-year OS: 96.9% (TL) vs 96.8% (TT+RAI); HR 0.2 (95% CI 0.03–1.58).
- 5-year DSS: 96.7% (TL) vs 100% (TT+RAI).
- 5-year RFS: 89.8% (TL) vs 88.9% (TT+RAI); HR 1.48 (95% CI 0.39–5.58).
- Survival rates remained stable from 5 to 10 years.
Methodological Strengths
- Propensity-matched cohort with long median follow-up (90–113 months).
- Single tertiary cancer center with consistent surgical and follow-up protocols.
Limitations
- Small matched TL cohort (n=37) limits power to detect small differences.
- Retrospective single-center design with potential residual confounding.
Future Directions: Prospective registries and multicenter studies to refine selection criteria for de-escalation and to quantify quality-of-life and complication differences.
IMPORTANCE: Patients with papillary thyroid carcinoma (PTC) with lateral neck metastases (N1b) are usually treated with total thyroidectomy (TT), neck dissection, and adjuvant radioactive iodine (RAI). This philosophy comes with higher risks of complications and sequela than thyroid lobectomy (TL) and neck dissection alone. There are no prior studies on patients from the Western hemisphere that compare survival and recurrence outcomes between these groups. OBJECTIVE: To compare recurrence and survival outcomes in propensity-matched TL vs TT + RAI patients who presented with ipsilateral N1b PTC at a tertiary cancer center in the US. DESIGN, SETTING, AND PARTICIPANTS: This cohort propensity-matched study was conducted at a single US tertiary cancer center included 37 TL patients and 37 of 561 TT + RAI patients (after excluding patients with M1 disease), with a median (IQR) follow-up of 113 (58-241) and 90 (48-185) months, respectively. Adult patients with PTC with lateral neck node metastases (N1b) were identified from a thyroid cancer database. The study included patients undergoing surgery at Memorial Sloan Kettering Cancer Center from 1986 to 2020, inclusive, and the study was conducted from 2024 to 2025. MAIN OUTCOMES AND MEASURES: Overall survival (OS), disease-specific survival (DSS), and recurrence-free survival (RFS). RESULTS: Of 598 total individuals, the median (IQR) age was 41 (33-55) years, and 341 (57%) were female. The 5-year OS was 96.9% in the TL group and 96.8% in the TT + RAI group (hazard ratio [HR], 0.2; 95% CI, 0.03-1.58). The 5-year DSS was 96.7% in the TL group and 100% in the TT +RAI group. The 5-year RFS was 89.8% in the TL group and 88.9% in the TT + RAI group (HR, 1.48; 95% CI, 0.39-5.58). The survival rates did not change between 5 and 10 years. CONCLUSIONS AND RELEVANCE: This cohort study found that a select group of patients with N1b PTC treated with TL had no important difference in survival and recurrence outcomes compared with patients treated with TT + RAI. Therefore, TL is an effective and safe treatment option in carefully selected and appropriately counselled patients with N1b PTC with unilateral tumors and low-volume regional lymph node metastases without clinical extranodal extension.