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Sezer H, Yazıcı D, Terzioğlu T, Tezelman S, Canbaz HB, Yerlikaya A, Demirkol MO, Kapran Y, Çolakoğlu B, Çilingiroğlu EN, Alagöl F. Early Post-operative Stimulated Serum Thyroglobulin: Role in Preventing Unnecessary Radioactive Iodine Treatment in Low to Intermediate Risk Papillary Thyroid Cancer. Am Surg 2023; 89:5996-6004. [PMID: 37309609 DOI: 10.1177/00031348231157816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
AIM The aims of the study are to evaluate the predictive value of early post-operative stimulated thyroglobulin (sTg) analysis on the recurrence risk, and to define a cut-off value that is related to recurrence risk in low to intermediate risk papillary thyroid cancer (PTC). METHODS This retrospective cohort study included individuals who were diagnosed with PTC aged 18 years or older and had been operated by experienced surgeons of a tertiary university hospital between the years 2011 and 2021. The American Thyroid Association thyroid cancer guidelines version 2015 was used as the risk stratification system. Early sTg measurement obtained at 3-4 weeks after surgery when TSH >30 µIU/mL. Data was collected from the hospital database. A total of 328 patients who had post-operative early sTg values with negative anti-Tg antibodies were included. RESULTS The median age was 44 years. Of the 328 patients, 223 (68%) were women. The median tumor diameter was 11 mm. One hundred ninety-one patients (58.2%) had low risk and 137 (41.8%) had intermediate risk for recurrent disease. Of the 328 patients, 4.0% had recurrent disease. In multivariate Cox regression, post-operative early sTg value [OR: 1.070 (1.038-1.116), P = .000], and the pre-operative malign cytology [OR: 1.483 (1.080-2.245), P = .042] were independent risk factors for recurrence. On the ROC curve analysis, the cut-off value of early sTg was 4.1 ng/mL for those with recurrent disease. CONCLUSION This study demonstrated that early sTg could predict recurrent disease in patients with low to intermediate risk PTC. A cut-off of 4.1 ng/mL was identified with a high negative predictive value.
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Affiliation(s)
- Havva Sezer
- Department of Endocrinology and Medicine, Koç University, Istanbul, Turkey
| | - Dilek Yazıcı
- Department of Endocrinology and Medicine, Koç University, Istanbul, Turkey
| | - Tarık Terzioğlu
- Department of General Surgery, American Hospital, Istanbul, Turkey
| | - Serdar Tezelman
- Department of General Surgery, American Hospital, Istanbul, Turkey
| | | | - Aslıhan Yerlikaya
- Department of Internal Medicine, Yale New Haven Health Bridgeport Hospital, USA
| | | | - Yersu Kapran
- Department of Pathology, Koc University, Istanbul, Turkey
| | | | | | - Faruk Alagöl
- Department of Endocrinology and Medicine, Koç University, Istanbul, Turkey
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Sparano C, Moog S, Hadoux J, Dupuy C, Al Ghuzlan A, Breuskin I, Guerlain J, Hartl D, Baudin E, Lamartina L. Strategies for Radioiodine Treatment: What’s New. Cancers (Basel) 2022; 14:cancers14153800. [PMID: 35954463 PMCID: PMC9367259 DOI: 10.3390/cancers14153800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/29/2022] [Accepted: 08/02/2022] [Indexed: 11/16/2022] Open
Abstract
Radioiodine treatment (RAI) represents the most widespread and effective therapy for differentiated thyroid cancer (DTC). RAI goals encompass ablative (destruction of thyroid remnants, to enhance thyroglobulin predictive value), adjuvant (destruction of microscopic disease to reduce recurrences), and therapeutic (in case of macroscopic iodine avid lesions) purposes, but its use has evolved over time. Randomized trial results have enabled the refinement of RAI indications, moving from a standardized practice to a tailored approach. In most cases, low-risk patients may safely avoid RAI, but where necessary, a simplified protocol, based on lower iodine activities and human recombinant TSH preparation, proved to be just as effective, reducing overtreatment or useless impairment of quality of life. In pediatric DTC, RAI treatments may allow tumor healing even at the advanced stages. Finally, new challenges have arisen with the advancement in redifferentiation protocols, through which RAI still represents a leading therapy, even in former iodine refractory cases. RAI therapy is usually well-tolerated at low activities rates, but some concerns exist concerning higher cumulative doses and long-term outcomes. Despite these achievements, several issues still need to be addressed in terms of RAI indications and protocols, heading toward the RAI strategy of the future.
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Affiliation(s)
- Clotilde Sparano
- Endocrinology Unit, Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Florence, 50139 Florence, Italy
- Service d’oncologie Endocrinienne, Département d’Imagerie Médicale, Gustave Roussy, 112 rue Edouard Vaillant, 94805 Villejuif, France
| | - Sophie Moog
- Service d’oncologie Endocrinienne, Département d’Imagerie Médicale, Gustave Roussy, 112 rue Edouard Vaillant, 94805 Villejuif, France
| | - Julien Hadoux
- Service d’oncologie Endocrinienne, Département d’Imagerie Médicale, Gustave Roussy, 112 rue Edouard Vaillant, 94805 Villejuif, France
| | - Corinne Dupuy
- UMR 9019 CNRS, Université Paris-Saclay, Gustave Roussy, 94800 Villejuif, France
| | - Abir Al Ghuzlan
- Département de Biologie et Pathologie Médicales, Gustave Roussy, 112 rue Edouard Vaillant, 94805 Villejuif, France
| | - Ingrid Breuskin
- Département Anesthésie Chirurgie et Interventionnel, Gustave Roussy, 112 rue Edouard Vaillant, 94805 Villejuif, France
| | - Joanne Guerlain
- Département Anesthésie Chirurgie et Interventionnel, Gustave Roussy, 112 rue Edouard Vaillant, 94805 Villejuif, France
| | - Dana Hartl
- Département Anesthésie Chirurgie et Interventionnel, Gustave Roussy, 112 rue Edouard Vaillant, 94805 Villejuif, France
| | - Eric Baudin
- Service d’oncologie Endocrinienne, Département d’Imagerie Médicale, Gustave Roussy, 112 rue Edouard Vaillant, 94805 Villejuif, France
| | - Livia Lamartina
- Service d’oncologie Endocrinienne, Département d’Imagerie Médicale, Gustave Roussy, 112 rue Edouard Vaillant, 94805 Villejuif, France
- Correspondence:
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Matrone A, Faranda A, Latrofa F, Gambale C, Stefani Donati D, Molinaro E, Agate L, Viola D, Piaggi P, Torregrossa L, Basolo F, Elisei R. Thyroglobulin Changes are Highly Dependent on TSH in Low-risk DTC Patients not Treated with Radioiodine. J Clin Endocrinol Metab 2020; 105:5845992. [PMID: 32453405 DOI: 10.1210/clinem/dgaa297] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 05/22/2020] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Low-risk differentiated thyroid cancer (DTC) is currently rarely treated with radioiodine (131I) to ablate the postoperative remnant. Therefore, the interpretation of the serum thyroglobulin (Tg) values should be reconsidered. The aim of our study was to evaluate the changes in Tg values during follow-up with regard to the changing values in thyroid stimulating hormone (TSH). MATERIALS AND METHODS We evaluated 271 low-risk DTC patients, treated with total thyroidectomy but not 131I. To be included, patients had to be negative for Tg antibodies and have at least 3 evaluations in our department. All patients were on levothyroxine (L-T4) therapy. RESULTS After a median follow-up of 73 months, the overall Tg values were stable, while TSH values slightly increased. Therefore, we pooled data of Tg and TSH from all evaluations and a significant positive correlation was demonstrated (R = 0.2; P < 0.01), and was also demonstrated when we performed the analysis using time-weighted values (R = 0.14; P = 0.02). Moreover, when dividing patients into 3 groups according to first postoperative Tg (Group A [Tg < 0.2 ng/ml], Group B [Tg 0.2-1 ng/ml], and Group C [Tg > 1 ng/ml]) most patients showed stable values of Tg at the end of follow-up but TSH variations had a clear impact on the changes in Tg among the groups. CONCLUSION We demonstrated that in low-risk DTC not treated with 131I, serum Tg remains substantially stable over time, and the variations observed were correlated with the concomitant variations of TSH levels, mainly due to the modification of LT-4 therapy performed according to the ongoing risk stratification.
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Affiliation(s)
- Antonio Matrone
- Department of Clinical and Experimental Medicine, Unit of Endocrinology, University Hospital of Pisa, Pisa, Italy
| | - Alessio Faranda
- Department of Clinical and Experimental Medicine, Unit of Endocrinology, University Hospital of Pisa, Pisa, Italy
| | - Francesco Latrofa
- Department of Clinical and Experimental Medicine, Unit of Endocrinology, University Hospital of Pisa, Pisa, Italy
| | - Carla Gambale
- Department of Clinical and Experimental Medicine, Unit of Endocrinology, University Hospital of Pisa, Pisa, Italy
| | - Delio Stefani Donati
- Department of Clinical and Experimental Medicine, Unit of Endocrinology, University Hospital of Pisa, Pisa, Italy
| | - Eleonora Molinaro
- Department of Clinical and Experimental Medicine, Unit of Endocrinology, University Hospital of Pisa, Pisa, Italy
| | - Laura Agate
- Department of Clinical and Experimental Medicine, Unit of Endocrinology, University Hospital of Pisa, Pisa, Italy
| | - David Viola
- Department of Clinical and Experimental Medicine, Unit of Endocrinology, University Hospital of Pisa, Pisa, Italy
| | - Paolo Piaggi
- Phoenix Epidemiology and Clinical Research Branch National Institute of Diabetes and Digestive and Kidney Disease, National Institutes of Health, Phoenix, Arizona
| | - Liborio Torregrossa
- Department of Surgical, Medical, Molecular Pathology and Critical Area, Anatomic Pathology Section, University Hospital of Pisa, Pisa, Italy
| | - Fulvio Basolo
- Department of Surgical, Medical, Molecular Pathology and Critical Area, Anatomic Pathology Section, University Hospital of Pisa, Pisa, Italy
| | - Rossella Elisei
- Department of Clinical and Experimental Medicine, Unit of Endocrinology, University Hospital of Pisa, Pisa, Italy
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Bueno F, Falcone MGG, Peñaloza MA, Abelleira E, Pitoia F. Dynamics of serum antithyroglobulin antibodies in patients with differentiated thyroid cancer. Endocrine 2020; 67:387-396. [PMID: 31650394 DOI: 10.1007/s12020-019-02112-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 10/02/2019] [Indexed: 01/21/2023]
Abstract
PURPOSE Serum antithyroglobulin antibodies (sTgAb) affect the reliability of Tg measurement in patients with thyroid cancer. We compared the outcome of patients with detectable and undetectable sTgAb, stratified according to the initial risk of recurrence (RR); also the response to treatment in patients with detectable sTgAb treated with total thyroidectomy (TT) with and without radioiodine remnant ablation (RA) and the sTgAb trend in the long-term follow-up according to the initial response. METHODS We included 432 patients submitted to TT, with or without RA; 106 patients had detectable sTgAb levels. Median follow-up was 53 months. RESULTS There were no statistically significant differences considering presentation between negative or positive sTgAb subjects. The frequency of structural incomplete response (SIR) in low, intermediate, and high RR was similar. Undetectable sTgAb in patients was achieved in a median of 16 months in ablated patients compared with 11 months in those without RA (p = 0.0232). Patients without RA had a higher rate of undetectable sTgAb during the first 12 months. A SIR was observed in 3% of patients with declining sTgAb, in 19% of those with stable levels, and in 43% with increasing sTgAb (p = 0.004). The status of no evidence of disease was achieved more frequently in patients with initial sTgAb levels < 200 mUI/l, independently of the initial RR. CONCLUSIONS There was no impact of sTgAb on the initial clinical presentation and the response to therapy in low-risk patients treated with or without RA. sTgAb trend is more useful than an absolute value to predict a SIR.
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Affiliation(s)
- Fernanda Bueno
- Division of Endocrinology, Hospital de Clínicas-University of Buenos Aires, Buenos Aires, Argentina
| | | | - Mirna Angela Peñaloza
- Division of Endocrinology, Hospital de Clínicas-University of Buenos Aires, Buenos Aires, Argentina
| | - Erika Abelleira
- Division of Endocrinology, Hospital de Clínicas-University of Buenos Aires, Buenos Aires, Argentina
| | - Fabián Pitoia
- Division of Endocrinology, Hospital de Clínicas-University of Buenos Aires, Buenos Aires, Argentina.
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Matrone A, Latrofa F, Torregrossa L, Piaggi P, Gambale C, Faranda A, Ricci D, Agate L, Molinaro E, Basolo F, Vitti P, Elisei R. Changing Trend of Thyroglobulin Antibodies in Patients With Differentiated Thyroid Cancer Treated With Total Thyroidectomy Without 131I Ablation. Thyroid 2018; 28:871-879. [PMID: 29860933 DOI: 10.1089/thy.2018.0080] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Thyroglobulin (Tg) antibodies (TgAb) can interfere with Tg measurement and can be used as "Tg surrogate" in patients with differentiated thyroid cancer (DTC) treated with total thyroidectomy (TTx) and radioiodine remnant ablation (RRA). In contrast, few data, and in patients usually followed for a short-term follow-up, have been reported about the changes of TgAb levels in patients treated with TTx but without RRA. The aims of this study were to evaluate the changes of TgAb levels in DTC patients treated with TTx but not RRA and to identify the factors that influence these changes. METHODS The change in TgAb levels in 107 DTC (<1 cm) patients submitted to TTx but not RRA was evaluated. Patients were followed for a median of 6.3 years, and all had at least three determinations of TgAb and neck ultrasound (nUS). RESULTS TgAb levels showed a progressive decrease during follow-up. Initial TgAb levels and degree of lymphocytic infiltration influenced the time but not the rate of TgAb disappearance. No influence on time and rate of the decrease in TgAb was observed when the association with thyroperoxidase antibodies (TPOAb) levels were considered. A TgAb cutoff value of 61.9 IU/mL at first postoperative evaluation was a good indicator for disappearance of the TgAb within six years. No tumor recurrence was observed in the series. In one case, the progressive increase in TgAb anticipated the reappearance of benign thyroid tissue with lymphocytic infiltration. CONCLUSIONS TgAb levels decline in the majority of DTC patients treated with TTx but not ablated with radioiodine. The levels decrease rapidly after the surgical treatment and continue to decrease over time. The time of disappearance is influenced by the initial TgAb levels and the degree of lymphocytic infiltration. No influence of the actual TPOAb levels has been observed. An increase in TgAb levels should not be overlooked, since it can indicate the presence or reappearance of either normal thyroid tissue or tumor recurrence.
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Affiliation(s)
- Antonio Matrone
- 1 Department of Clinical and Experimental Medicine, Unit of Endocrinology, University of Pisa , Pisa, Italy
| | - Francesco Latrofa
- 1 Department of Clinical and Experimental Medicine, Unit of Endocrinology, University of Pisa , Pisa, Italy
| | - Liborio Torregrossa
- 2 Department of Surgical, Medical, Molecular Pathology and Critical Area, Anatomic Pathology Section, University of Pisa , Pisa, Italy
| | - Paolo Piaggi
- 3 Phoenix Epidemiology and Clinical Research Branch National Institute of Diabetes and Digestive and Kidney Disease, National Institutes of Health , Phoenix, Arizona
| | - Carla Gambale
- 1 Department of Clinical and Experimental Medicine, Unit of Endocrinology, University of Pisa , Pisa, Italy
| | - Alessio Faranda
- 1 Department of Clinical and Experimental Medicine, Unit of Endocrinology, University of Pisa , Pisa, Italy
| | - Debora Ricci
- 1 Department of Clinical and Experimental Medicine, Unit of Endocrinology, University of Pisa , Pisa, Italy
| | - Laura Agate
- 1 Department of Clinical and Experimental Medicine, Unit of Endocrinology, University of Pisa , Pisa, Italy
| | - Eleonora Molinaro
- 1 Department of Clinical and Experimental Medicine, Unit of Endocrinology, University of Pisa , Pisa, Italy
| | - Fulvio Basolo
- 2 Department of Surgical, Medical, Molecular Pathology and Critical Area, Anatomic Pathology Section, University of Pisa , Pisa, Italy
| | - Paolo Vitti
- 1 Department of Clinical and Experimental Medicine, Unit of Endocrinology, University of Pisa , Pisa, Italy
| | - Rossella Elisei
- 1 Department of Clinical and Experimental Medicine, Unit of Endocrinology, University of Pisa , Pisa, Italy
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Doubleday A, Sippel RS. Surgical options for thyroid cancer and post-surgical management. Expert Rev Endocrinol Metab 2018; 13:137-148. [PMID: 30058897 DOI: 10.1080/17446651.2018.1464910] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 04/11/2018] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Differentiated thyroid cancer (DTC), which includes papillary and follicular, is the most common type of thyroid cancer and the incidence is rising. Survival rates of DTC are excellent, so the focus of management should be to optimize the initial oncological surgical resection, while providing follow up and adjunct therapies to improve long-term outcomes. AREAS COVERED It is important for providers to be aware of the most recent guidelines for DTC management, as practices have changed in recent years. In this review, we will highlight some of the updates in the American Thyroid Association (ATA) guidelines and the American Joint Committee on Cancer (AJCC) edition changes in order to better guide practitioners in the management of the evolving treatment strategies. Management of DTC includes diagnosis of thyroid nodules, defining the best operative or non-operative treatment for patients using a multidisciplinary approach, and surveillance of DTC to optimize patients in terms of both clinical and quality of life outcomes. EXPERT COMMENTARY As the rate of DTC rises yet the mortality remains stable, management focuses on disease-free follow up and optimal long-term outcomes. Current controversies in management of DTC include proper oncological surgery depending on the nature and size of the DTC, the cytopathology nomenclature, management of lymph node disease, and appropriate surveillance strategies. Preoperative risk stratification is key. We have many modalities to aid in that stratification, such as identifying known concerning features of nodules with expert-performed ultrasound, thyroglobulin (Tg) levels, molecular testing, and evidence based outcomes data for recurrence rates. However, many individual cases still present with multiple management options, thus highlighting the importance of patient discussion and a multidisciplinary approach. It is important for providers to recognize that the short and long-term follow up must be guided by surveillance studies, and patients need to be re-risk stratified in order to optimize detection of recurrence yet sustain quality of life.
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Affiliation(s)
- Amanda Doubleday
- a Division of Endocrine Surgery , University of Wisconsin School of Medicine and Public Health , Madison , Wisconsin , USA
| | - Rebecca S Sippel
- a Division of Endocrine Surgery , University of Wisconsin School of Medicine and Public Health , Madison , Wisconsin , USA
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Back so soon? Is early recurrence of papillary thyroid cancer really just persistent disease? Surgery 2017; 163:118-123. [PMID: 29128176 DOI: 10.1016/j.surg.2017.05.028] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 04/30/2017] [Accepted: 05/26/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Papillary thyroid carcinoma has excellent survival, yet recurrence remains a challenge. We sought to determine the proportion of reoperations performed for persistent, rather than truly recurrent, disease. METHODS We conducted a retrospective review of a prospectively maintained database. Patients with papillary thyroid carcinoma who underwent reoperation for disease from 2000-2016 were included. We defined recurrence as disease that developed after a patient had an undetectable thyroglobulin and a negative ultrasonography within 1 year of operation. RESULTS A total of 69 patients underwent 92 reoperations. On initial pathology, mean tumor size was 2.6 cm, 51% were multifocal, and 42% had extrathyroidal extension. Half (46%) of the patients underwent a central/lateral neck dissection at the initial operation, and 77% were treated with postoperative radioactive iodine. The median time to first reoperation was 21 months (range, 1-292), and 42% occurred within 1 year. Only 3 operations met criteria for true "recurrence," while 71 operations were categorized as persistent disease. CONCLUSION Many reoperations for papillary thyroid carcinoma are for management of persistent disease. More than half of the patients required reoperation within the first 2 years, which suggests strongly that improvements in the preoperative assessment and adequacy of initial operative therapy need to be made to improve the care of patients with thyroid cancer.
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Haymart MR, Esfandiari NH, Stang MT, Sosa JA. Controversies in the Management of Low-Risk Differentiated Thyroid Cancer. Endocr Rev 2017; 38. [PMID: 28633444 PMCID: PMC5546880 DOI: 10.1210/er.2017-00067] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Controversy exists over optimal management of low-risk differentiated thyroid cancer. This controversy occurs in all aspects of management, including surgery, use of radioactive iodine for remnant ablation, thyroid hormone supplementation, and long-term surveillance. Limited and conflicting data, treatment paradigm shifts, and differences in physician perceptions contribute to the controversy. This lack of physician consensus results in wide variation in patient care, with some patients at risk for over- or undertreatment. To reduce patient harm and unnecessary worry, there is a need to design and implement studies to address current knowledge gaps.
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Affiliation(s)
- Megan R Haymart
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan 48109
| | - Nazanene H Esfandiari
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan 48109
| | - Michael T Stang
- Division of Endocrine Surgery, Department of Surgery, Duke University, Durham, North Carolina 27710
| | - Julia Ann Sosa
- Division of Endocrine Surgery, Department of Surgery, Duke University, Durham, North Carolina 27710
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