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Nonsurgical option for more large thyroid nodule patients?
WASHINGTON – , compared with only those that were.
While more research is needed, “the risk of false negative FNA results for large nodules may not be as high as reported in previous studies if you include patients who do not have indication for surgery, such as compressive symptoms, suspicious ultrasound features, etc.,” senior author Tracy Tylee, MD, an associate professor of endocrinology at the University of Washington, Seattle, said in an interview.
The implication is that nonsurgical options such as radiofrequency ablation may be appropriate for more patients than realized, she added.
“Clinicians should consider following these patients more conservatively, either with a second FNA to confirm [the] nodule is benign or with ultrasound follow-up for 5 years with intervention only if [there are] significant changes on imaging,” she said.
The findings were presented at the annual meeting of the American Thyroid Association.
Concerns about nodules over 4 cm having high false negative rates
Management of large thyroid nodules over 4 cm that are classified as Bethesda II, indicative of being benign, is complicated by concerns of false negatives in such cases. While the false negative rate for thyroid nodules in general is approximately 3%, the rate for large nodules over 4 cm has been reported as high as 35%.
Importantly, however, most studies evaluating the issue only involve patients who have received thyroid surgery, whereas most benign nodules are not referred for surgery.
“This may overestimate the false negative FNA biopsy risk for this group,” first author Melbin Thomas, MD, also of the University of Washington, said in her talk.
To better assess the false negative rate in the broader context of large nodules that did and did not undergo surgery, Dr. Thomas and her colleagues conducted a retrospective chart review of all patients undergoing FNA biopsy at her center between 2008 and 2014 for thyroid nodules larger than 4 cm and initially classified as Bethesda II, or benign.
With a follow-up of up to 10 years, nodules were considered accurately benign if they showed benign pathology on surgical resection, if they remained benign based on repeat FNA biopsy with Bethesda II results, or if there were no changes on imaging characteristics on ultrasound after at least 2 years.
Overall, 47 nodules over 4 cm and Bethesda II cytology were included, with an average follow-up of 5 years (range 2.2-9.7 years).
Of the nodules, 23 were treated with surgery, two of which were determined to have been malignant (8.7%) and, hence, false negatives. Nine of the nodules had repeat FNA, with none found to be malignant, and 15 received repeat ultrasound, also with no malignancies.
Overall, the false negative rate including all patients was 4.3%.
“False negative FNA biopsy results were not markedly elevated if nodules greater than 4 cm are evaluated, but rates were considerably higher if limited to surgical patients,” Dr. Thomas said.
Clinicians may be compelled to perform more aggressive surgery on large but benign thyroid nodules for a number of reasons, Dr. Tylee noted.
“A concern is that we may discontinue follow-up on these larger nodules and fail to diagnose a cancer early on, before there has been extrathyroidal extension or lymph node metastases,” she said.
In such cases, patients could wind up presenting at a higher stage of disease and require more intensive therapy.
However, with a low false negative rate overall, “all of this can increase the long-term health care costs and anxiety for patients, so having a better understanding of the true benign rate for large nodules is important,” she concluded.
Commenting on the research, Rodis D. Paparodis, MD, chief of Endocrinology, Diabetes, and Metabolism Clinics, in Patras, Greece, said the findings underscore that, as a surgical procedure, “thyroidectomy should be used cautiously, only when the benefit outweighs the risk.”
In his own previous multicenter study, Dr. Paparodis conducted a review of nearly 2,500 thyroidectomies that were performed based on size or longterm slow growth despite preoperative benign FNA findings. The results showed that only 1.9% of patients had any form of thyroid cancer in the nodule that had led to surgery; however, multiple other significant cancers were often present in other locations in the gland.
“Therefore, we suggest that careful sonographic evaluation of all thyroid nodules is warranted prior to deciding and planning the extent of surgical management for multinodular goiter,” he told this news organization.
“In addition, FNA of all suspicious nodules is required as well, to avoid unnecessary surprises in surgical pathology.”
Dr. Tylee, Dr. Thomas, and Dr. Paparodis report no relevant financial relationships.
A version of this article first appeared on Medscape.com.
WASHINGTON – , compared with only those that were.
While more research is needed, “the risk of false negative FNA results for large nodules may not be as high as reported in previous studies if you include patients who do not have indication for surgery, such as compressive symptoms, suspicious ultrasound features, etc.,” senior author Tracy Tylee, MD, an associate professor of endocrinology at the University of Washington, Seattle, said in an interview.
The implication is that nonsurgical options such as radiofrequency ablation may be appropriate for more patients than realized, she added.
“Clinicians should consider following these patients more conservatively, either with a second FNA to confirm [the] nodule is benign or with ultrasound follow-up for 5 years with intervention only if [there are] significant changes on imaging,” she said.
The findings were presented at the annual meeting of the American Thyroid Association.
Concerns about nodules over 4 cm having high false negative rates
Management of large thyroid nodules over 4 cm that are classified as Bethesda II, indicative of being benign, is complicated by concerns of false negatives in such cases. While the false negative rate for thyroid nodules in general is approximately 3%, the rate for large nodules over 4 cm has been reported as high as 35%.
Importantly, however, most studies evaluating the issue only involve patients who have received thyroid surgery, whereas most benign nodules are not referred for surgery.
“This may overestimate the false negative FNA biopsy risk for this group,” first author Melbin Thomas, MD, also of the University of Washington, said in her talk.
To better assess the false negative rate in the broader context of large nodules that did and did not undergo surgery, Dr. Thomas and her colleagues conducted a retrospective chart review of all patients undergoing FNA biopsy at her center between 2008 and 2014 for thyroid nodules larger than 4 cm and initially classified as Bethesda II, or benign.
With a follow-up of up to 10 years, nodules were considered accurately benign if they showed benign pathology on surgical resection, if they remained benign based on repeat FNA biopsy with Bethesda II results, or if there were no changes on imaging characteristics on ultrasound after at least 2 years.
Overall, 47 nodules over 4 cm and Bethesda II cytology were included, with an average follow-up of 5 years (range 2.2-9.7 years).
Of the nodules, 23 were treated with surgery, two of which were determined to have been malignant (8.7%) and, hence, false negatives. Nine of the nodules had repeat FNA, with none found to be malignant, and 15 received repeat ultrasound, also with no malignancies.
Overall, the false negative rate including all patients was 4.3%.
“False negative FNA biopsy results were not markedly elevated if nodules greater than 4 cm are evaluated, but rates were considerably higher if limited to surgical patients,” Dr. Thomas said.
Clinicians may be compelled to perform more aggressive surgery on large but benign thyroid nodules for a number of reasons, Dr. Tylee noted.
“A concern is that we may discontinue follow-up on these larger nodules and fail to diagnose a cancer early on, before there has been extrathyroidal extension or lymph node metastases,” she said.
In such cases, patients could wind up presenting at a higher stage of disease and require more intensive therapy.
However, with a low false negative rate overall, “all of this can increase the long-term health care costs and anxiety for patients, so having a better understanding of the true benign rate for large nodules is important,” she concluded.
Commenting on the research, Rodis D. Paparodis, MD, chief of Endocrinology, Diabetes, and Metabolism Clinics, in Patras, Greece, said the findings underscore that, as a surgical procedure, “thyroidectomy should be used cautiously, only when the benefit outweighs the risk.”
In his own previous multicenter study, Dr. Paparodis conducted a review of nearly 2,500 thyroidectomies that were performed based on size or longterm slow growth despite preoperative benign FNA findings. The results showed that only 1.9% of patients had any form of thyroid cancer in the nodule that had led to surgery; however, multiple other significant cancers were often present in other locations in the gland.
“Therefore, we suggest that careful sonographic evaluation of all thyroid nodules is warranted prior to deciding and planning the extent of surgical management for multinodular goiter,” he told this news organization.
“In addition, FNA of all suspicious nodules is required as well, to avoid unnecessary surprises in surgical pathology.”
Dr. Tylee, Dr. Thomas, and Dr. Paparodis report no relevant financial relationships.
A version of this article first appeared on Medscape.com.
WASHINGTON – , compared with only those that were.
While more research is needed, “the risk of false negative FNA results for large nodules may not be as high as reported in previous studies if you include patients who do not have indication for surgery, such as compressive symptoms, suspicious ultrasound features, etc.,” senior author Tracy Tylee, MD, an associate professor of endocrinology at the University of Washington, Seattle, said in an interview.
The implication is that nonsurgical options such as radiofrequency ablation may be appropriate for more patients than realized, she added.
“Clinicians should consider following these patients more conservatively, either with a second FNA to confirm [the] nodule is benign or with ultrasound follow-up for 5 years with intervention only if [there are] significant changes on imaging,” she said.
The findings were presented at the annual meeting of the American Thyroid Association.
Concerns about nodules over 4 cm having high false negative rates
Management of large thyroid nodules over 4 cm that are classified as Bethesda II, indicative of being benign, is complicated by concerns of false negatives in such cases. While the false negative rate for thyroid nodules in general is approximately 3%, the rate for large nodules over 4 cm has been reported as high as 35%.
Importantly, however, most studies evaluating the issue only involve patients who have received thyroid surgery, whereas most benign nodules are not referred for surgery.
“This may overestimate the false negative FNA biopsy risk for this group,” first author Melbin Thomas, MD, also of the University of Washington, said in her talk.
To better assess the false negative rate in the broader context of large nodules that did and did not undergo surgery, Dr. Thomas and her colleagues conducted a retrospective chart review of all patients undergoing FNA biopsy at her center between 2008 and 2014 for thyroid nodules larger than 4 cm and initially classified as Bethesda II, or benign.
With a follow-up of up to 10 years, nodules were considered accurately benign if they showed benign pathology on surgical resection, if they remained benign based on repeat FNA biopsy with Bethesda II results, or if there were no changes on imaging characteristics on ultrasound after at least 2 years.
Overall, 47 nodules over 4 cm and Bethesda II cytology were included, with an average follow-up of 5 years (range 2.2-9.7 years).
Of the nodules, 23 were treated with surgery, two of which were determined to have been malignant (8.7%) and, hence, false negatives. Nine of the nodules had repeat FNA, with none found to be malignant, and 15 received repeat ultrasound, also with no malignancies.
Overall, the false negative rate including all patients was 4.3%.
“False negative FNA biopsy results were not markedly elevated if nodules greater than 4 cm are evaluated, but rates were considerably higher if limited to surgical patients,” Dr. Thomas said.
Clinicians may be compelled to perform more aggressive surgery on large but benign thyroid nodules for a number of reasons, Dr. Tylee noted.
“A concern is that we may discontinue follow-up on these larger nodules and fail to diagnose a cancer early on, before there has been extrathyroidal extension or lymph node metastases,” she said.
In such cases, patients could wind up presenting at a higher stage of disease and require more intensive therapy.
However, with a low false negative rate overall, “all of this can increase the long-term health care costs and anxiety for patients, so having a better understanding of the true benign rate for large nodules is important,” she concluded.
Commenting on the research, Rodis D. Paparodis, MD, chief of Endocrinology, Diabetes, and Metabolism Clinics, in Patras, Greece, said the findings underscore that, as a surgical procedure, “thyroidectomy should be used cautiously, only when the benefit outweighs the risk.”
In his own previous multicenter study, Dr. Paparodis conducted a review of nearly 2,500 thyroidectomies that were performed based on size or longterm slow growth despite preoperative benign FNA findings. The results showed that only 1.9% of patients had any form of thyroid cancer in the nodule that had led to surgery; however, multiple other significant cancers were often present in other locations in the gland.
“Therefore, we suggest that careful sonographic evaluation of all thyroid nodules is warranted prior to deciding and planning the extent of surgical management for multinodular goiter,” he told this news organization.
“In addition, FNA of all suspicious nodules is required as well, to avoid unnecessary surprises in surgical pathology.”
Dr. Tylee, Dr. Thomas, and Dr. Paparodis report no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM ATA 2023
Thyroid cancer increase observed in transgender female veterans
WASHINGTON – Experts urge a cautious interpretation of these recent study results.
“In our clinic of about 50 transgender women, we noticed that we had two diagnosed cases of thyroid cancer in a year,” first author John Christensen, MD, of UC Davis Health, division of endocrinology, diabetes & metabolism, Sacramento, said in an interivew. He presented their findings at the annual meeting of the American Thyroid Association.
Comparatively, the thyroid cancer prevalence among cisgender male veterans is estimated at about 0.19%; the rate among all those assigned male at birth in the general population is 0.13%, whereas the rate among those assigned female at birth, which has historically been higher for all thyroid cancer subtypes, is 0.44%, according to U.S. cancer statistics for 2020 from the National Cancer Institute.
“About one-third of our [veteran] patients had been receiving estrogen for an average of over 3 years before diagnosis, which could suggest estrogen gender‐affirming hormone therapy [GAHT] may be a potentially important risk factor,” Dr. Christensen said.
Sustained use of external estrogen, especially in cisgender women undergoing fertility treatments, has been linked to an increased risk for thyroid cancer. This is because it can lead to an increase in estrogen receptors in cancerous cells. But experts caution that many other factors also come into play.
“There is definitely an implication that if you give extra estrogen to someone assigned female at birth, you may have an increased risk of thyroid cancer,” Dr. Christensen said. “So, it would stand to reason that even in those who are not assigned female at birth, there may be a risk from exogenous estrogen that may lead to an increased risk of thyroid cancer down the line.”
To investigate the issue in a larger population, Dr. Christensen and colleagues evaluated data from the comprehensive, nationwide Veterans Affairs Informatics and Computing Infrastructure database, including approximately 9 million veterans who had outpatient visits between December 2017 and January 2022.
Of the veterans, 9,988 were determined to likely be transgender women, based on either having an ICD-10 diagnosis code for gender dysphoria or being assigned male at birth and having received an estrogen or estradiol prescription.
Of those patients, 76 had an ICD-10 code indicating thyroid cancer and 34 had verification of the thyroid cancer on chart review, representing a prevalence of 0.34% among transgender female veterans.
The average age at thyroid cancer diagnosis among the veterans was 53.8 years, and 29.4% (10 of 34) of those patients had extrathyroidal disease at the time of their thyroid cancer diagnosis. The median body mass index, available for 26 patients, was 32, which is indicative of obesity.
In terms of the patients’ thyroid cancer subtypes, 22 were papillary cancer, 5 were a follicular variant of papillary cancer, 5 were both papillary and follicular cancer, 4 were follicular cancer, 3 were a Hürthle cell variant of follicular cancer, and one was unknown.
Among 11 (32.3%) of the 34 veterans receiving estrogen GAHT at diagnosis, treatment began an average of 3.38 years prior to diagnosis at variable doses and using various routes of administration.
About half of the patients had a history of smoking; however, Dr. Christensen noted that the role of smoking as being a risk factor in estrogenic cancers has been debated. Though most patients were obese, obesity is both very common and not well established in terms of its quantitative impact on the risk for cancer development.
With the small size of the thyroid cancer cohort and omissions in the medical record among the study’s important limitations, Dr. Christensen urged a cautious interpretation of the findings.
“We are certainly suspicious that GAHT may be associated with an increased risk of thyroid cancer, but I would characterize the trends in our data as being potentially suggestive or hypothesis generating – not conclusive,” he added. “I would hate for any transgender women reading this to stop taking GAHT without talking to their doctors first.”
Commenting on the issue, Maurice Garcia, MD, a clinical associate professor of urology and director of the transgender surgery and health program at Cedars-Sinai Medical Center, Los Angeles, said that any definitive evidence of an increase in cancer risk among transgender people is lacking.
“With an estimated 1.5 [million] to 1.6 million people in the U.S. who are transgender, with many of them receiving GAHT, we haven’t observed a bump or high incidence of any kind of cancer among these people so far,” he said.
“There’s certainly a high potential that hormone therapy, whether it’s feminizing or masculinizing hormone therapy, can affect an individual’s cancer risk,” he added. “But we don’t know of any [definitive evidence] yet of an increase, and, there’s also even the question of whether there could be an opposite effect.”
Regarding the thyroid cancer data, Dr. Garcia agreed that the preliminary nature of the study is a key limitation. “It’s hard to tell if these were comparable groups, or whether those in the transgender group came in with higher risk factors for thyroid cancer.
“Until more statistical analysis is done, I think all that can be said is that it’s speculative.”
Dr. Garcia, who coauthored a review on cancer screening for transgender individuals, underscored that, despite a lack of data suggesting that transgender patients need cancer screening any more than their matched cisgender counterparts, “the point is that we cannot forget to screen them at all.”
Dr. Christensen and Dr. Garcia had no disclosures to report.
A version of this article first appeared on Medscape.com.
WASHINGTON – Experts urge a cautious interpretation of these recent study results.
“In our clinic of about 50 transgender women, we noticed that we had two diagnosed cases of thyroid cancer in a year,” first author John Christensen, MD, of UC Davis Health, division of endocrinology, diabetes & metabolism, Sacramento, said in an interivew. He presented their findings at the annual meeting of the American Thyroid Association.
Comparatively, the thyroid cancer prevalence among cisgender male veterans is estimated at about 0.19%; the rate among all those assigned male at birth in the general population is 0.13%, whereas the rate among those assigned female at birth, which has historically been higher for all thyroid cancer subtypes, is 0.44%, according to U.S. cancer statistics for 2020 from the National Cancer Institute.
“About one-third of our [veteran] patients had been receiving estrogen for an average of over 3 years before diagnosis, which could suggest estrogen gender‐affirming hormone therapy [GAHT] may be a potentially important risk factor,” Dr. Christensen said.
Sustained use of external estrogen, especially in cisgender women undergoing fertility treatments, has been linked to an increased risk for thyroid cancer. This is because it can lead to an increase in estrogen receptors in cancerous cells. But experts caution that many other factors also come into play.
“There is definitely an implication that if you give extra estrogen to someone assigned female at birth, you may have an increased risk of thyroid cancer,” Dr. Christensen said. “So, it would stand to reason that even in those who are not assigned female at birth, there may be a risk from exogenous estrogen that may lead to an increased risk of thyroid cancer down the line.”
To investigate the issue in a larger population, Dr. Christensen and colleagues evaluated data from the comprehensive, nationwide Veterans Affairs Informatics and Computing Infrastructure database, including approximately 9 million veterans who had outpatient visits between December 2017 and January 2022.
Of the veterans, 9,988 were determined to likely be transgender women, based on either having an ICD-10 diagnosis code for gender dysphoria or being assigned male at birth and having received an estrogen or estradiol prescription.
Of those patients, 76 had an ICD-10 code indicating thyroid cancer and 34 had verification of the thyroid cancer on chart review, representing a prevalence of 0.34% among transgender female veterans.
The average age at thyroid cancer diagnosis among the veterans was 53.8 years, and 29.4% (10 of 34) of those patients had extrathyroidal disease at the time of their thyroid cancer diagnosis. The median body mass index, available for 26 patients, was 32, which is indicative of obesity.
In terms of the patients’ thyroid cancer subtypes, 22 were papillary cancer, 5 were a follicular variant of papillary cancer, 5 were both papillary and follicular cancer, 4 were follicular cancer, 3 were a Hürthle cell variant of follicular cancer, and one was unknown.
Among 11 (32.3%) of the 34 veterans receiving estrogen GAHT at diagnosis, treatment began an average of 3.38 years prior to diagnosis at variable doses and using various routes of administration.
About half of the patients had a history of smoking; however, Dr. Christensen noted that the role of smoking as being a risk factor in estrogenic cancers has been debated. Though most patients were obese, obesity is both very common and not well established in terms of its quantitative impact on the risk for cancer development.
With the small size of the thyroid cancer cohort and omissions in the medical record among the study’s important limitations, Dr. Christensen urged a cautious interpretation of the findings.
“We are certainly suspicious that GAHT may be associated with an increased risk of thyroid cancer, but I would characterize the trends in our data as being potentially suggestive or hypothesis generating – not conclusive,” he added. “I would hate for any transgender women reading this to stop taking GAHT without talking to their doctors first.”
Commenting on the issue, Maurice Garcia, MD, a clinical associate professor of urology and director of the transgender surgery and health program at Cedars-Sinai Medical Center, Los Angeles, said that any definitive evidence of an increase in cancer risk among transgender people is lacking.
“With an estimated 1.5 [million] to 1.6 million people in the U.S. who are transgender, with many of them receiving GAHT, we haven’t observed a bump or high incidence of any kind of cancer among these people so far,” he said.
“There’s certainly a high potential that hormone therapy, whether it’s feminizing or masculinizing hormone therapy, can affect an individual’s cancer risk,” he added. “But we don’t know of any [definitive evidence] yet of an increase, and, there’s also even the question of whether there could be an opposite effect.”
Regarding the thyroid cancer data, Dr. Garcia agreed that the preliminary nature of the study is a key limitation. “It’s hard to tell if these were comparable groups, or whether those in the transgender group came in with higher risk factors for thyroid cancer.
“Until more statistical analysis is done, I think all that can be said is that it’s speculative.”
Dr. Garcia, who coauthored a review on cancer screening for transgender individuals, underscored that, despite a lack of data suggesting that transgender patients need cancer screening any more than their matched cisgender counterparts, “the point is that we cannot forget to screen them at all.”
Dr. Christensen and Dr. Garcia had no disclosures to report.
A version of this article first appeared on Medscape.com.
WASHINGTON – Experts urge a cautious interpretation of these recent study results.
“In our clinic of about 50 transgender women, we noticed that we had two diagnosed cases of thyroid cancer in a year,” first author John Christensen, MD, of UC Davis Health, division of endocrinology, diabetes & metabolism, Sacramento, said in an interivew. He presented their findings at the annual meeting of the American Thyroid Association.
Comparatively, the thyroid cancer prevalence among cisgender male veterans is estimated at about 0.19%; the rate among all those assigned male at birth in the general population is 0.13%, whereas the rate among those assigned female at birth, which has historically been higher for all thyroid cancer subtypes, is 0.44%, according to U.S. cancer statistics for 2020 from the National Cancer Institute.
“About one-third of our [veteran] patients had been receiving estrogen for an average of over 3 years before diagnosis, which could suggest estrogen gender‐affirming hormone therapy [GAHT] may be a potentially important risk factor,” Dr. Christensen said.
Sustained use of external estrogen, especially in cisgender women undergoing fertility treatments, has been linked to an increased risk for thyroid cancer. This is because it can lead to an increase in estrogen receptors in cancerous cells. But experts caution that many other factors also come into play.
“There is definitely an implication that if you give extra estrogen to someone assigned female at birth, you may have an increased risk of thyroid cancer,” Dr. Christensen said. “So, it would stand to reason that even in those who are not assigned female at birth, there may be a risk from exogenous estrogen that may lead to an increased risk of thyroid cancer down the line.”
To investigate the issue in a larger population, Dr. Christensen and colleagues evaluated data from the comprehensive, nationwide Veterans Affairs Informatics and Computing Infrastructure database, including approximately 9 million veterans who had outpatient visits between December 2017 and January 2022.
Of the veterans, 9,988 were determined to likely be transgender women, based on either having an ICD-10 diagnosis code for gender dysphoria or being assigned male at birth and having received an estrogen or estradiol prescription.
Of those patients, 76 had an ICD-10 code indicating thyroid cancer and 34 had verification of the thyroid cancer on chart review, representing a prevalence of 0.34% among transgender female veterans.
The average age at thyroid cancer diagnosis among the veterans was 53.8 years, and 29.4% (10 of 34) of those patients had extrathyroidal disease at the time of their thyroid cancer diagnosis. The median body mass index, available for 26 patients, was 32, which is indicative of obesity.
In terms of the patients’ thyroid cancer subtypes, 22 were papillary cancer, 5 were a follicular variant of papillary cancer, 5 were both papillary and follicular cancer, 4 were follicular cancer, 3 were a Hürthle cell variant of follicular cancer, and one was unknown.
Among 11 (32.3%) of the 34 veterans receiving estrogen GAHT at diagnosis, treatment began an average of 3.38 years prior to diagnosis at variable doses and using various routes of administration.
About half of the patients had a history of smoking; however, Dr. Christensen noted that the role of smoking as being a risk factor in estrogenic cancers has been debated. Though most patients were obese, obesity is both very common and not well established in terms of its quantitative impact on the risk for cancer development.
With the small size of the thyroid cancer cohort and omissions in the medical record among the study’s important limitations, Dr. Christensen urged a cautious interpretation of the findings.
“We are certainly suspicious that GAHT may be associated with an increased risk of thyroid cancer, but I would characterize the trends in our data as being potentially suggestive or hypothesis generating – not conclusive,” he added. “I would hate for any transgender women reading this to stop taking GAHT without talking to their doctors first.”
Commenting on the issue, Maurice Garcia, MD, a clinical associate professor of urology and director of the transgender surgery and health program at Cedars-Sinai Medical Center, Los Angeles, said that any definitive evidence of an increase in cancer risk among transgender people is lacking.
“With an estimated 1.5 [million] to 1.6 million people in the U.S. who are transgender, with many of them receiving GAHT, we haven’t observed a bump or high incidence of any kind of cancer among these people so far,” he said.
“There’s certainly a high potential that hormone therapy, whether it’s feminizing or masculinizing hormone therapy, can affect an individual’s cancer risk,” he added. “But we don’t know of any [definitive evidence] yet of an increase, and, there’s also even the question of whether there could be an opposite effect.”
Regarding the thyroid cancer data, Dr. Garcia agreed that the preliminary nature of the study is a key limitation. “It’s hard to tell if these were comparable groups, or whether those in the transgender group came in with higher risk factors for thyroid cancer.
“Until more statistical analysis is done, I think all that can be said is that it’s speculative.”
Dr. Garcia, who coauthored a review on cancer screening for transgender individuals, underscored that, despite a lack of data suggesting that transgender patients need cancer screening any more than their matched cisgender counterparts, “the point is that we cannot forget to screen them at all.”
Dr. Christensen and Dr. Garcia had no disclosures to report.
A version of this article first appeared on Medscape.com.
AT ATA 2023
Hold blood thinners during thyroid nodule biopsy?
WASHINGTON – The routine practice of holding use of blood-thinning medications at the time of an ultrasound-guided thyroid nodule fine needle aspiration (FNA) biopsy shows no significant safety benefit in preventing the risk of complications such as hematomas or nondiagnostic results; however, experts suggest using individualized decision-making with the practice.
first author Michelle Lundholm, MD, of the Cleveland Clinic said in an interview.
“[The practice] impacts neither the safety of the FNA procedure nor the adequacy of the sample,” she said.
The late-breaking research was presented at the annual meeting of the American Thyroid Association.
Key concerns in the use of anticoagulants and/or antiplatelet medications during thyroid nodule FNA biopsy include the increased risk of postprocedural hematoma or nondiagnostic results, with, for instance, one study showing higher rates of nondiagnostic results among patients remaining on aspirin therapy during the FNA biopsy.
However, holding the medically indicated therapies can have risks of its own, including concerns of thrombotic events such as deep vein thrombosis or stroke. However, evidence comparing the risks with each strategy in thyroid nodule FNA is lacking.
To investigate, Dr. Lundholm and colleagues conducted a review of data on 2,945 patients who had undergone a total of 4,741 thyroid nodule FNAs in the Cleveland Clinic’s diverse network of centers between 2010 and 2023. The patients had a mean age of 66.2; 69.6% were female and 75.7% were White.
All patients had an active prescription for an anticoagulant or antiplatelet medication up to 10 days prior to their thyroid nodule FNA biopsy. Specifically, 73.7% were on 81 mg aspirin, 8.5% were on 325 mg aspirin, 7.4% were taking other antiplatelet medication such as clopidogrel or ticagrelor; 7.0% were on warfarin, 8.2% were on a direct oral anticoagulant (DOAC); 6.3% were on heparin products; and 10.3% of patients were on two or more blood-thinning medications.
The results show that, overall, 13.0% (n = 614) of the thyroid nodule FNA biopsies had nondiagnostic results, which is within the average rates in the literature ranging from 6% to 36%, Dr. Lundholm noted.
Blood-thinning medications were held in 20.8% of the FNA biopsies, however, there were no differences in nondiagnostic results between those who had drugs held (12.2%) or who continued on the medications (13.2%; P = .41).
After multivariate adjustment for age and sex, the lack of significant differences in receiving nondiagnostic results among those who did or did not continue blood thinners was consistent overall (odds ratio, 1.10; P = .38), and in the specific groups of 81 mg aspirin (OR, 1.00; P = .99); 325 mg aspirin or clopidogrel/ticagrelor (OR, 1.50; P = .15); or warfarin, DOAC, or heparin/enoxaparin (OR, 1.27; P = .27).
In terms of hematoma risk, ED records within 48 hours of the FNA showed that such events were rare, with only one hematoma occurring overall, involving a patient who was on 81 mg of aspirin for secondary stroke prevention that was not interrupted for FNA biopsy. The patient was discharged and did not require medical intervention.
Four other hematomas occurred among patients who were not being treated with blood thinners, with none requiring intervention.
The findings indicate that “hematoma can happen in any patient, but rarely requires intervention,” Dr. Lundholm said.
However, while thrombotic events were also rare, serious events occurred in three patients within 48 hours of the thyroid nodule FNA biopsy when a blood thinner was withheld, including ischemic strokes among two patients who were on a DOAC and 81 mg of aspirin that were withheld, and one MI occurring in a patient on a DOAC that was held for the FNA.
Unlike hematomas, the thrombotic events each had significant long‐term sequelae, Dr. Lundholm noted.
“Having these ischemic strokes and heart attack really led to a change in these patients’ lives,” she said. “While we can never assume that [the events occurred] because the blood-thinner therapy was held, the timing within 48 hours is certainly very suspicious.”
There were no deep vein thrombosis or pulmonary embolism events.
Withholding practices vary
In a previous survey of 60 clinicians conducted by Dr. Lundholm and colleagues, wide variation was reported in the rates of withholding antiplatelet or anticoagulant medications prior to thyroid nodule FNA biopsy.
The survey of endocrinologists, interventional radiologists, and ear, nose, and throat providers showed rates of withholding 81 mg of aspirin prior to FNA biopsy of just 13.3%, withholding 325 mg of aspirin, 15%, other antiplatelets, 41.7%, warfarin, 73.3%, DOACs, 43.3%, and heparin, 43.3%.
“We found heterogeneity in withholding patterns even within the same department,” she said. “This is reflective of the fact that evidence is mixed.”
Guidelines on the issue from the Society of Interventional Radiology and the International Society on Thrombosis and Hemostasis recommend that providers consider the balance of the procedure and patient bleeding risk versus the clotting risk, Dr. Lundholm noted.
However, a caveat is that those recommendations are based on pooled data from similar minimal risk procedures, she explained.
“There is a lack of data on bleeding risks for individual interventions like thyroid biopsy, and, as such, there is no specific procedure-related risk determination.”
Meanwhile, Dr. Lundholm said that notable limitations regarding the current research include that the study may not have caught all patient cases that presented with complications to an outside ED.
Furthermore, the study results pertain to the safety of blood thinners in routine use, with key aspects that can influence complication rates, such as provider experience, needle size, and nodule features unavailable for analysis.
At MD Anderson, case-by-case
Commenting on the research, Anastasios Maniakas, MD, PhD, of the department of head and neck surgery, division of surgery, University of Texas MD Anderson Cancer Center, Houston, said the study is important, noting that, at his institution, the approach regarding holding blood-thinning medications is generally determined on an individual basis.
“I think this was a good study, but I don’t think it’s practice changing because these decisions may differ on a case-by-case basis,” Dr. Maniakas, who comoderated the session, said in an interview.
“At MD Anderson, we probably have one of the highest volumes in the country for thyroid nodule FNAs, and we do hold blood thinners because we often have to do more significant biopsies, with multiple passages and larger needles to be used,” Dr. Maniakas said.
“If you’re going to use perhaps the smallest possible gauge needle, then I think it is reasonable to not hold blood thinners, but if you’re going to be doing multiple passages and you need to do a core biopsy and use a large needle, then it is wiser to try to hold the medications for a day or 2.
“We haven’t had any complications, but I think there’s still a lot of apprehension to not hold blood thinners,” Dr. Maniakas said. “So, overall, I think the message is that it has to be on a case-by-case basis.”
Dr. Lundholm and Dr. Maniakas reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
WASHINGTON – The routine practice of holding use of blood-thinning medications at the time of an ultrasound-guided thyroid nodule fine needle aspiration (FNA) biopsy shows no significant safety benefit in preventing the risk of complications such as hematomas or nondiagnostic results; however, experts suggest using individualized decision-making with the practice.
first author Michelle Lundholm, MD, of the Cleveland Clinic said in an interview.
“[The practice] impacts neither the safety of the FNA procedure nor the adequacy of the sample,” she said.
The late-breaking research was presented at the annual meeting of the American Thyroid Association.
Key concerns in the use of anticoagulants and/or antiplatelet medications during thyroid nodule FNA biopsy include the increased risk of postprocedural hematoma or nondiagnostic results, with, for instance, one study showing higher rates of nondiagnostic results among patients remaining on aspirin therapy during the FNA biopsy.
However, holding the medically indicated therapies can have risks of its own, including concerns of thrombotic events such as deep vein thrombosis or stroke. However, evidence comparing the risks with each strategy in thyroid nodule FNA is lacking.
To investigate, Dr. Lundholm and colleagues conducted a review of data on 2,945 patients who had undergone a total of 4,741 thyroid nodule FNAs in the Cleveland Clinic’s diverse network of centers between 2010 and 2023. The patients had a mean age of 66.2; 69.6% were female and 75.7% were White.
All patients had an active prescription for an anticoagulant or antiplatelet medication up to 10 days prior to their thyroid nodule FNA biopsy. Specifically, 73.7% were on 81 mg aspirin, 8.5% were on 325 mg aspirin, 7.4% were taking other antiplatelet medication such as clopidogrel or ticagrelor; 7.0% were on warfarin, 8.2% were on a direct oral anticoagulant (DOAC); 6.3% were on heparin products; and 10.3% of patients were on two or more blood-thinning medications.
The results show that, overall, 13.0% (n = 614) of the thyroid nodule FNA biopsies had nondiagnostic results, which is within the average rates in the literature ranging from 6% to 36%, Dr. Lundholm noted.
Blood-thinning medications were held in 20.8% of the FNA biopsies, however, there were no differences in nondiagnostic results between those who had drugs held (12.2%) or who continued on the medications (13.2%; P = .41).
After multivariate adjustment for age and sex, the lack of significant differences in receiving nondiagnostic results among those who did or did not continue blood thinners was consistent overall (odds ratio, 1.10; P = .38), and in the specific groups of 81 mg aspirin (OR, 1.00; P = .99); 325 mg aspirin or clopidogrel/ticagrelor (OR, 1.50; P = .15); or warfarin, DOAC, or heparin/enoxaparin (OR, 1.27; P = .27).
In terms of hematoma risk, ED records within 48 hours of the FNA showed that such events were rare, with only one hematoma occurring overall, involving a patient who was on 81 mg of aspirin for secondary stroke prevention that was not interrupted for FNA biopsy. The patient was discharged and did not require medical intervention.
Four other hematomas occurred among patients who were not being treated with blood thinners, with none requiring intervention.
The findings indicate that “hematoma can happen in any patient, but rarely requires intervention,” Dr. Lundholm said.
However, while thrombotic events were also rare, serious events occurred in three patients within 48 hours of the thyroid nodule FNA biopsy when a blood thinner was withheld, including ischemic strokes among two patients who were on a DOAC and 81 mg of aspirin that were withheld, and one MI occurring in a patient on a DOAC that was held for the FNA.
Unlike hematomas, the thrombotic events each had significant long‐term sequelae, Dr. Lundholm noted.
“Having these ischemic strokes and heart attack really led to a change in these patients’ lives,” she said. “While we can never assume that [the events occurred] because the blood-thinner therapy was held, the timing within 48 hours is certainly very suspicious.”
There were no deep vein thrombosis or pulmonary embolism events.
Withholding practices vary
In a previous survey of 60 clinicians conducted by Dr. Lundholm and colleagues, wide variation was reported in the rates of withholding antiplatelet or anticoagulant medications prior to thyroid nodule FNA biopsy.
The survey of endocrinologists, interventional radiologists, and ear, nose, and throat providers showed rates of withholding 81 mg of aspirin prior to FNA biopsy of just 13.3%, withholding 325 mg of aspirin, 15%, other antiplatelets, 41.7%, warfarin, 73.3%, DOACs, 43.3%, and heparin, 43.3%.
“We found heterogeneity in withholding patterns even within the same department,” she said. “This is reflective of the fact that evidence is mixed.”
Guidelines on the issue from the Society of Interventional Radiology and the International Society on Thrombosis and Hemostasis recommend that providers consider the balance of the procedure and patient bleeding risk versus the clotting risk, Dr. Lundholm noted.
However, a caveat is that those recommendations are based on pooled data from similar minimal risk procedures, she explained.
“There is a lack of data on bleeding risks for individual interventions like thyroid biopsy, and, as such, there is no specific procedure-related risk determination.”
Meanwhile, Dr. Lundholm said that notable limitations regarding the current research include that the study may not have caught all patient cases that presented with complications to an outside ED.
Furthermore, the study results pertain to the safety of blood thinners in routine use, with key aspects that can influence complication rates, such as provider experience, needle size, and nodule features unavailable for analysis.
At MD Anderson, case-by-case
Commenting on the research, Anastasios Maniakas, MD, PhD, of the department of head and neck surgery, division of surgery, University of Texas MD Anderson Cancer Center, Houston, said the study is important, noting that, at his institution, the approach regarding holding blood-thinning medications is generally determined on an individual basis.
“I think this was a good study, but I don’t think it’s practice changing because these decisions may differ on a case-by-case basis,” Dr. Maniakas, who comoderated the session, said in an interview.
“At MD Anderson, we probably have one of the highest volumes in the country for thyroid nodule FNAs, and we do hold blood thinners because we often have to do more significant biopsies, with multiple passages and larger needles to be used,” Dr. Maniakas said.
“If you’re going to use perhaps the smallest possible gauge needle, then I think it is reasonable to not hold blood thinners, but if you’re going to be doing multiple passages and you need to do a core biopsy and use a large needle, then it is wiser to try to hold the medications for a day or 2.
“We haven’t had any complications, but I think there’s still a lot of apprehension to not hold blood thinners,” Dr. Maniakas said. “So, overall, I think the message is that it has to be on a case-by-case basis.”
Dr. Lundholm and Dr. Maniakas reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
WASHINGTON – The routine practice of holding use of blood-thinning medications at the time of an ultrasound-guided thyroid nodule fine needle aspiration (FNA) biopsy shows no significant safety benefit in preventing the risk of complications such as hematomas or nondiagnostic results; however, experts suggest using individualized decision-making with the practice.
first author Michelle Lundholm, MD, of the Cleveland Clinic said in an interview.
“[The practice] impacts neither the safety of the FNA procedure nor the adequacy of the sample,” she said.
The late-breaking research was presented at the annual meeting of the American Thyroid Association.
Key concerns in the use of anticoagulants and/or antiplatelet medications during thyroid nodule FNA biopsy include the increased risk of postprocedural hematoma or nondiagnostic results, with, for instance, one study showing higher rates of nondiagnostic results among patients remaining on aspirin therapy during the FNA biopsy.
However, holding the medically indicated therapies can have risks of its own, including concerns of thrombotic events such as deep vein thrombosis or stroke. However, evidence comparing the risks with each strategy in thyroid nodule FNA is lacking.
To investigate, Dr. Lundholm and colleagues conducted a review of data on 2,945 patients who had undergone a total of 4,741 thyroid nodule FNAs in the Cleveland Clinic’s diverse network of centers between 2010 and 2023. The patients had a mean age of 66.2; 69.6% were female and 75.7% were White.
All patients had an active prescription for an anticoagulant or antiplatelet medication up to 10 days prior to their thyroid nodule FNA biopsy. Specifically, 73.7% were on 81 mg aspirin, 8.5% were on 325 mg aspirin, 7.4% were taking other antiplatelet medication such as clopidogrel or ticagrelor; 7.0% were on warfarin, 8.2% were on a direct oral anticoagulant (DOAC); 6.3% were on heparin products; and 10.3% of patients were on two or more blood-thinning medications.
The results show that, overall, 13.0% (n = 614) of the thyroid nodule FNA biopsies had nondiagnostic results, which is within the average rates in the literature ranging from 6% to 36%, Dr. Lundholm noted.
Blood-thinning medications were held in 20.8% of the FNA biopsies, however, there were no differences in nondiagnostic results between those who had drugs held (12.2%) or who continued on the medications (13.2%; P = .41).
After multivariate adjustment for age and sex, the lack of significant differences in receiving nondiagnostic results among those who did or did not continue blood thinners was consistent overall (odds ratio, 1.10; P = .38), and in the specific groups of 81 mg aspirin (OR, 1.00; P = .99); 325 mg aspirin or clopidogrel/ticagrelor (OR, 1.50; P = .15); or warfarin, DOAC, or heparin/enoxaparin (OR, 1.27; P = .27).
In terms of hematoma risk, ED records within 48 hours of the FNA showed that such events were rare, with only one hematoma occurring overall, involving a patient who was on 81 mg of aspirin for secondary stroke prevention that was not interrupted for FNA biopsy. The patient was discharged and did not require medical intervention.
Four other hematomas occurred among patients who were not being treated with blood thinners, with none requiring intervention.
The findings indicate that “hematoma can happen in any patient, but rarely requires intervention,” Dr. Lundholm said.
However, while thrombotic events were also rare, serious events occurred in three patients within 48 hours of the thyroid nodule FNA biopsy when a blood thinner was withheld, including ischemic strokes among two patients who were on a DOAC and 81 mg of aspirin that were withheld, and one MI occurring in a patient on a DOAC that was held for the FNA.
Unlike hematomas, the thrombotic events each had significant long‐term sequelae, Dr. Lundholm noted.
“Having these ischemic strokes and heart attack really led to a change in these patients’ lives,” she said. “While we can never assume that [the events occurred] because the blood-thinner therapy was held, the timing within 48 hours is certainly very suspicious.”
There were no deep vein thrombosis or pulmonary embolism events.
Withholding practices vary
In a previous survey of 60 clinicians conducted by Dr. Lundholm and colleagues, wide variation was reported in the rates of withholding antiplatelet or anticoagulant medications prior to thyroid nodule FNA biopsy.
The survey of endocrinologists, interventional radiologists, and ear, nose, and throat providers showed rates of withholding 81 mg of aspirin prior to FNA biopsy of just 13.3%, withholding 325 mg of aspirin, 15%, other antiplatelets, 41.7%, warfarin, 73.3%, DOACs, 43.3%, and heparin, 43.3%.
“We found heterogeneity in withholding patterns even within the same department,” she said. “This is reflective of the fact that evidence is mixed.”
Guidelines on the issue from the Society of Interventional Radiology and the International Society on Thrombosis and Hemostasis recommend that providers consider the balance of the procedure and patient bleeding risk versus the clotting risk, Dr. Lundholm noted.
However, a caveat is that those recommendations are based on pooled data from similar minimal risk procedures, she explained.
“There is a lack of data on bleeding risks for individual interventions like thyroid biopsy, and, as such, there is no specific procedure-related risk determination.”
Meanwhile, Dr. Lundholm said that notable limitations regarding the current research include that the study may not have caught all patient cases that presented with complications to an outside ED.
Furthermore, the study results pertain to the safety of blood thinners in routine use, with key aspects that can influence complication rates, such as provider experience, needle size, and nodule features unavailable for analysis.
At MD Anderson, case-by-case
Commenting on the research, Anastasios Maniakas, MD, PhD, of the department of head and neck surgery, division of surgery, University of Texas MD Anderson Cancer Center, Houston, said the study is important, noting that, at his institution, the approach regarding holding blood-thinning medications is generally determined on an individual basis.
“I think this was a good study, but I don’t think it’s practice changing because these decisions may differ on a case-by-case basis,” Dr. Maniakas, who comoderated the session, said in an interview.
“At MD Anderson, we probably have one of the highest volumes in the country for thyroid nodule FNAs, and we do hold blood thinners because we often have to do more significant biopsies, with multiple passages and larger needles to be used,” Dr. Maniakas said.
“If you’re going to use perhaps the smallest possible gauge needle, then I think it is reasonable to not hold blood thinners, but if you’re going to be doing multiple passages and you need to do a core biopsy and use a large needle, then it is wiser to try to hold the medications for a day or 2.
“We haven’t had any complications, but I think there’s still a lot of apprehension to not hold blood thinners,” Dr. Maniakas said. “So, overall, I think the message is that it has to be on a case-by-case basis.”
Dr. Lundholm and Dr. Maniakas reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
AT ATA 2023