Consideration of Early Dynamic Risk Stratification to Guide Discharge from Oncologic Follow-up in Patients with Differentiated Thyroid Cancer.

BACKGROUND: The current dogma is a life-long follow-up for patients treated for follicular-derived differentiated thyroid cancers (DTC). Our primary objective was to determine the time to recurrence in a series of DTC patients with an excellent response to therapy 6 months after total thyroidectomy and radioiodine therapy. The secondary objectives were to determine the time to suspicion of recurrence and to identify factors associated with recurrence. METHODS: This retrospective cohort study included patients treated for DTC between 2008 and 2012 and in remission 6 months after total thyroidectomy and radioiodine treatment. The criteria for remission were negative imaging and suppressed thyroglobulin (Tg) < 0.2 ng/mL or rh-TSH-(recombinant human TSH) stimulated Tg < 1 ng/mL according to the 2015 ATA (American Thyroid Association) guidelines. Recurrence was defined by cytologically and/or histologically proven cervical lymph node metastasis or the administration of a second radioiodine treatment. RESULTS: Among 721 patients treated for DTC, 158 were excluded because of persistent disease at 6 months and 71 because of missing follow-up data and 492 were included. The mean and median follow-up time were 7.0 and 7.9 years [IQR 2.1-11.3]. Recurrence occurred for 7 patients (1.4%), 1 initially classified as high recurrence risk, 3 as intermediate and 3 as low risk according to the 2015 ATA guidelines. All relapses occurred within 10 years after initial management (4 within the first 5 years). For patients with recurrence, rise in Tg and/or suspicious lymph node were detected in 6 out of 7 cases in the first 8 years, and for the last case 10 years after initial surgery. CONCLUSION: Low and intermediate recurrence risk DTC patients with excellent response 6 months after total thyroidectomy and radioiodine and in remission 10 years later have an extremely low recurrence risk. Follow-up might be undertaken by primary care providers from this time point. These discharge recommendations should be confirmed by further prospective studies.

Discordance Between Glycated Hemoglobin A1c and the Glucose Management Indicator in People With Diabetes and Chronic Kidney Disease.

INTRODUCTION: Assessment of glucose exposure via glycated hemoglobin A1c (HbA1c) has limitations for interpretation in individuals with diabetes and chronic kidney disease (CKD). The glucose management indicator (GMI) derived from continuous glucose monitoring (CGM) data could be an alternative. However, the concordance between HbA1c measured in laboratory and GMI (HbA1c-GMI) is uncertain in individuals with CKD. The purpose of this study is to analyze this discrepancy. MATERIAL AND METHOD: We performed a multicentric, retrospective, observational study. A group of individuals with diabetes and CKD (n = 170) was compared with a group of individuals with diabetes without CKD (n = 185). All individuals used an intermittently scanned continuous glucose monitoring (isCGM). A comparison of 14-day and 90-day glucose data recorded by the isCGM was performed to calculate GMI and the discordance between lab HbA1c and GMI was analyzed by a Bland-Altman method and linear regression. RESULTS: HbA1c-GMI discordance was significantly higher in the CKD group versus without CKD group (0.78 ± 0.57 [0.66-0.90] vs 0.59 ± 0.44 [0.50-0.66]%, P < .005). An absolute difference >0.5% was found in 68.2% of individuals with CKD versus 42.2% of individuals without CKD. We suggest a new specific formula to estimate HbA1c from the linear regression between HbA1c and mean glucose CGM, namely CKD-GMI = 0.0261 × 90-day mean glucose (mg/L) + 3.5579 (r2 = 0.59). CONCLUSIONS: HbA1c-GMI discordance is frequent and usually in favor of an HbA1c level higher than the GMI value, which can lead to errors in changes in glucose-lowering therapy, especially for individuals with CKD. This latter population should benefit from the CGM to measure their glucose exposure more precisely.

Ectopic localization of CYP11B1 and CYP11B2-expressing cells in the normal human adrenal gland.

The sharp line of demarcation between zona glomerulosa (ZG) and zona fasciculata (ZF) has been recently challenged suggesting that this interface is no longer a compartment boundary. We have used immunohistochemical analyses to study the steroid 11ß-hydroxylase (CYP11B1) and aldosterone synthase (CYP11B2) pattern of expression and investigate the remodeling of the adrenal cortex in relation to aging. We analyzed human adrenal glands prepared from 47 kidney donors. No aldosterone-producing micronodules (APMs) were detectable in the younger donors aged between 22-39 but the functional ZG depicted by positive CYP11B2 staining demonstrated a lack of continuity. In contrast, the development of APMs was found in samples from individuals aged 40-70. Importantly, the progressive replacement of CYP11B2-expressing cells in the histological ZG by CYP11B1-expressing cells highlights the remodeling capacity of the adrenal cortex. In 70% of our samples, immunofluorescence studies revealed the presence of isolated or clusters of CYP11B2 positive cells in the ZF and zona reticularis. Our data emphasize that mineralocorticoid- and glucocorticoid-producing cells are distributed throughout the cortex and the medulla making the determination of the functional status of a cell or group of cells a unique tool in deciphering the changes occurring in adrenal gland particularly during aging. They also suggest that, in humans, steroidogenic cell phenotype defined by function is a stable feature and thus, the functional zonation might be not solely maintained by cell lineage conversion/migration.

Using 18F-FDG-PET/CT Metrics to Predict Survival in Ra-Dio-Iodine Refractory Thyroid Cancers.

Radio-iodine refractory (RAI-R) differentiated thyroid cancer (DTC) is a rare disease with a poor prognosis and limited therapeutic resources. Therefore, identifying prognostic factors is essential in order to select patients who could benefit from an early start of treatment. The aim of this study is to identify positron emission tomography with 18F-fluorodeoxyglucose with integrated computed tomography (18F-FDG-PET/CT) parameters to predict overall survival (OS) in patients with RAI-R DTC. In this single-center retrospective study, we analyze the 18F-FDG-PET/CT parameters of 34 patients with RAI-R DTC between April 2007 and December 2019. The parameters collected are MTV, SUVmax and progression for each site of metastasis (neck, mediastinum, lungs, liver, bone) and total sites. ROC curves, Kaplan-Meier survival analysis curves, univariate and multivariate Cox analyses determine prognostic factors for 1-year and 5-year OS. The parameters for mediastinum, liver and total sites are significantly associated with worse 1-year and 5-year OS by both ROC curve analysis and Kaplan-Meier survival analysis. Univariate Cox analysis confirms significance of mediastinum SUVmax (HR 1.08; 95% CI [1.02-1.15]; p = 0.014) and total SUVmax (HR 1.06; 95% CI [1-1.12]; p = 0.042) for worse 1-year OS; of mediastinum SUVmax (HR 1.06; 95% CI [1.02-1.10]; p = 0.003), liver SUVmax (HR 1.04; 95% CI [1.01-1.08]; p = 0.02), liver MTV (HR 2.56; 95% CI [1.13-5.82]; p = 0.025), overall SUVmax (HR 1.05; 95% CI [1.02-1.08]; p = 0.001) and total MTV (HR 1.41; 95% CI [1.07-1.86]; p = 0.016) for worse 5-year OS. Multivariate Cox analysis confirms a significant association between liver MTV (HR 1.02; 95% CI [1-1.04]; p = 0.042) and decrease 1-year OS. In this study, we demonstrate that in RAI-R DTC, 18F-FDG-PET/CT parameters of the mediastinum, liver and overall tumor burden were prognostic factors of poor 1-year and 5-year OS. Identifying these criteria could allow early therapeutic intervention in order to improve patients' survival.

Surgery for 'asymptomatic' mild primary hyperparathyroidism improves some clinical symptoms postoperatively.

OBJECTIVE AND BACKGROUND: Most primary hyperparathyroidism (pHPT) patients do not conform to the guidelines for parathyroidectomy established by an international panel of specialists and have a mild pHPT. This group is typically defined as 'asymptomatic'. The primary aim of this study was to determine symptom improvement in this 'asymptomatic' group after parathyroidectomy. Secondly, we aimed to create a preoperative clinical score predicting postoperative symptom resolution. DESIGN: A prospective nonrandomized study included patients with mild pHPT. METHODS: A questionnaire (22 items) was given to 'asymptomatic' patients preoperatively and at 3, 6, and 12 postoperative months. A logistic regression was performed to create a preoperative clinical score. RESULTS: One hundred and sixteen patients were included. Postoperatively, HPT was resolved in 98% of patients. Twelve of 22 nonspecific symptoms were improved at 1 year. Subgroups analysis showed a greater improvement in patients <70 years and those with a serum calcium level ≥2.6 mmol/l preoperatively. A clinical score, based on age and five symptoms, was established to predict the clinical improvement after surgery in mild pHPT patients with a positive predictive value of 81%. CONCLUSION: Patients with asymptomatic pHPT have clinical improvement of their symptoms postoperatively even after 1 year. Younger patients and those with higher preoperative calcium levels show the best improvement.