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The statement was drafted by a multidisciplinary, global writing task force led by co-chairs Catherine Sinclair, MD, Icahn School of Medicine at Mount Sinai and Monash University, and Jennifer H. Kuo, MD, Section of Endocrine Surgery, Department of Surgery, Columbia University. The document highlights this continually emerging technology, focusing on principles for safe implementation and application to the thyroid field. The final document integrates feedback from the endocrinology, endocrine surgery, otolaryngology and radiology fields and it underwent formal peer-review in Thyroid. Potential author conflict of interest was managed, and transparency maintained in formulating the consensus statement.

“The field of thyroidology is dynamic, with frequent innovation and discovery informed by an ever-evolving knowledge base. It’s challenging for clinicians to know how to incorporate novel technologies and techniques into their practices,” said Julie Ann Sosa, MD, FACS, ATA President. “This can result in variation in practice, which implies that there can be variation in the quality of care provided. This new American Thyroid Association statement crosses national borders and specialties, establishing best thyroid ablation practices informed by evidence in order to improve patient outcomes.”

Thermal and chemical ablation refers to a group of versatile, non-surgical techniques that are used to treat benign thyroid nodules. In North America, chemical ablation techniques have been utilized for decades however thermal techniques have only recently been introduced. Many international case series and consensus statements have been published in the past decade evaluating and summarizing the indications, contra-indications and outcomes of thermal and chemical ablation techniques for benign thyroid nodules. However, there are no documents to date in the United States focusing primarily on the safe adoption and implementation of ablation techniques, including learning curve considerations and necessary pre-procedural skillsets. The objective of this ATA Statement is to provide a framework for the safe adoption and implementation of thermal and chemical ablative technologies for benign thyroid nodules in the United States by i) defining and discussing safety considerations in pre-procedural, peri-procedural and post-procedural settings; ii) recognizing that although these emerging technologies hold promise, they are not without risk and require development of a unique skillset for optimal, safe performance; and iii) defining the training, prior knowledge and steps that should be considered by any physician who desires to incorporate thyroid nodule ablation into their practice.

The consensus statement is globally recognized and is endorsed by the American Academy of Otolaryngology Head and Neck Surgery, American Association of Endocrine Surgeons, American Head and Neck Society, Society of Interventional Radiology (SIR), Latin-American Thyroid Society (LATS), Asia and Oceania Thyroid Association (AOTA), and the Asia Pacific Society of Thyroid Surgery (APTS).

The consensus statement is expected to be a useful reference tool for the global surgical and endocrine communities. The consensus statement does not establish a standard of care and specific outcomes are not guaranteed. Treatment decisions must be made based on the independent judgment of health care providers and each patient’s individual circumstances. A consensus statement is not intended to take the place of physician judgment in diagnosing and treatment of particular patients.

About the American Thyroid Association
The American Thyroid Association (ATA) is dedicated to transforming thyroid care through clinical excellence, education, scientific discovery and advocacy in a collaborative and diverse community. ATA is an international professional medical society with over 1,700 members from 43 countries around the world. The ATA promotes thyroid awareness and information through Clinical Thyroidology^® for the Public, a resource that summarizes research for patients and families, and extensive, authoritative resources on thyroid disease and thyroid cancer in both English and Spanish. The ATA website  serves as a bonafide clinical resource for patients and the public who look for reliable thyroid-related information.

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Danica M. Vodopivec, MD
The University of Texas MD Anderson Cancer Center
Houston, TX
March 24, 2022

Medullary thyroid cancer (MTC) is a rare thyroid malignancy and considered a neuroendocrine type of tumor. It originates from the parafollicular or C-cells of the thyroid, which are neural crest derivatives and produce a variety of biogenic amines, including calcitonin and carcinoembryonic antigen (CEA) ─ used as tumor markers. MTC represents up to 4% of thyroid cancer cases, and accounts for about 14% of all thyroid cancer related deaths(1,2).

MTC can be sporadic (or acquired via somatic mutation) in 75% of the cases and hereditary (or familial via germline mutation) in the remaining 25%, with the latter comprising the polyglandular cancer syndrome known as multiple endocrine neoplasia 2 (MEN2) types A and B. The RET oncogene is the most common genetic alteration in MTC, being present in 100% of MEN2 syndromes and in about 45% of sporadic MTC. Mutually exclusive point mutations of RAS has been reported in sporadic MTC but with less frequency (approximately 15%), and the remainder cases of sporadic MTC do not have identifiable mutations(3).

Many patients are diagnosed incidentally in the absence of symptoms, although some may experience compressive symptoms, diarrhea, and/or flushing. MTC is initially diagnosed by US-guided fine-needle aspiration (FNA) biopsy of a thyroid nodule. There are no distinctive ultrasound features between MTC and a follicular-derived thyroid cancer; hence, cytology findings suggestive of MTC should be further assessed with immunohistochemistry. MTC stains positive for calcitonin, chromogranin, and CEA, and negative for thyroglobulin. The advent of molecular genetic testing for thyroid nodules has significantly improved diagnosis among indeterminate FNA samples(4–7). After a cytological diagnosis of MTC (prior to surgery), the serum calcitonin and CEA levels should be measured followed by a genetic testing for a RET germline mutation. All patients with MTC should undergo genetic testing because up to 7% of apparent sporadic MTC are indeed de-novo hereditary mutations, meaning not inherited from either parent. In addition, up to 75% of patients with MEN2B have a de-novo germline RET mutation. It is important that pediatricians, primary providers, and dentists be able to recognize the characteristic MEN2B body features ─ including a marfanoid body habitus, eye abnormalities (thickened and everted eyelids and inability to produce tears), mucosal neuromas in the eyelids and aerodigestive tract (visible in the lips, tongue, nostrils), and diffuse ganglioneuromas of the gastrointestinal tract leading to chronic constipation, abdominal pain, and possible intestinal obstruction(1).

Total thyroidectomy with cervical lymph node dissection is the standard treatment. Unfortunately, there is only a 10% cure rate when cervical lymph nodes are involved at the time of initial surgery(1). Post-operative levothyroxine should be administered to maintain euthyroidism, and radioactive iodine treatment is not indicated. For persistent locoregional and/or distant metastases, repeat surgery, external beam radiation, or other focal therapies can be implemented. When these therapies are no longer options due to progressive or symptomatic disease, systemic therapy should be considered. There are 4 FDA approved kinase inhibitors for MTC. The non-selective multi-kinase inhibitors, vandetanib and cabozantinib(8,9), were the first drugs approved for MTC. The selective RET-inhibitors, selpercatinib and pralsetinib, were approved in 2020 and may be used as first or subsequent lines of therapy for RET mutated MTC(10,11). New treatments with immunotherapy, tumor vaccines, peptide receptor radionuclide therapy (PRRT) are being studied in clinical trials for MTC.

References:
1. Wells SA, Asa SL, Dralle H, et al. Revised American Thyroid Association guidelines for the management of medullary thyroid carcinoma. Thyroid 2015; 25: 567–610.
2. Roman S, Lin R, Sosa JA. Prognosis of medullary thyroid carcinoma: demographic, clinical, and pathologic predictors of survival in 1252 cases. Cancer 2006; 107: 2134–2142.
3. COSMIC https://cancer.sanger.ac.uk/cosmic.
4. Wirth LJ, Waguespack SG, Busaidy NL, et al. Genomic landscape of FNAs positive for medullary thyroid cancer (MTC) and potential impact on systemic therapy. JCO 2019; 37: 6087–6087.
5. Hu MI, Waguespack SG, Dosiou C, et al. Afirma Genomic Sequencing Classifier and Xpression Atlas Molecular Findings in Consecutive Bethesda III-VI Thyroid Nodules. J Clin Endocrinol Metab 2021; 106: 2198–2207.
6. Ciarletto AM, Narick C, Malchoff CD, et al. Analytical and clinical validation of pairwise microRNA expression analysis to identify medullary thyroid cancer in thyroid fine-needle aspiration samples. Cancer Cytopathol 2021; 129: 239–249.
7. Nikiforov YE, Baloch ZW. Clinical validation of the ThyroSeq v3 genomic classifier in thyroid nodules with indeterminate FNA cytology. Cancer Cytopathology 2019; 127: 225–230.
8. Wells SA, Robinson BG, Gagel RF, et al. Vandetanib in Patients With Locally Advanced or Metastatic Medullary Thyroid Cancer: A Randomized, Double-Blind Phase III Trial. JCO 2012; 30: 134–141.
9. Elisei R, Schlumberger MJ, Müller SP, et al. Cabozantinib in Progressive Medullary Thyroid Cancer. JCO 2013; 31: 3639–3646.
10. Wirth LJ, Sherman E, Robinson B, et al. Efficacy of Selpercatinib in RET -Altered Thyroid Cancers. N Engl J Med 2020; 383: 825–835.
11. Subbiah V, Hu MI, Wirth LJ, et al. Pralsetinib for patients with advanced or metastatic RET-altered thyroid cancer (ARROW): a multi-cohort, open-label, registrational, phase 1/2 study. The Lancet Diabetes & Endocrinology; 0. Epub ahead of print 9 June 2021. DOI: 10.1016/S2213-8587(21)00120-0.

Disclaimer:
The ideas and opinions expressed on the ATA Blogs do not necessarily reflect those of the ATA. None of the information posted is intended as medical, legal, or business advice, or advice about reimbursement for health care services. The mention of any product, service, company, therapy or physician practice does not constitute an endorsement of any kind by ATA. ATA assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of the material contained in, posted on, or linked to this site, or any errors or omissions.

For more information on Thyroid Topics please visit: https://www.thyroid.org/thyroid-information/

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Catherine F. Sinclair, BSc (Biomed), MBBS (Hons), FRACS, FACS
Monash University, Malvern, Australia
Icahn School of Medicine at Mount Sinai, New York, NY
January 20, 2022

The rise of thyroid thermal ablative (TA) techniques in North America over the past 3 years has been rapid. These techniques have emerged as compelling alternatives to surgery for benign nodular disease. Multiple international studies have shown excellent long-term nodule volume reductions, minimal complications, rapid recovery, and efficacy in avoidance of thyroid hormone supplementation. Long-term follow-up data for North American populations is not yet available, however early results mirror those of international series. Future randomized trials comparing long-term outcomes of TA to surgery will better define the value of TA for thyroid nodule management.

Disease indications for TA are gradually evolving from benign nodules to include malignancy, regional metastatic disease, and hyperparathyroidism. The most promising of these new indications is papillary thyroid microcarcinoma (PTMC) where recent case series with 2-5 years follow-up have demonstrated low to non-existent rates of disease progression and metastases. If this data is validated in larger trials with longer follow-up durations, TA may well become the preferred treatment modality for select, localized PTMC although patient selection guidelines and indications for treatment will need to be carefully considered and characterized.

Apart from disease indications, some fundamental aspects of TA are still being refined.

• Is there an optimal patient age range for TA?
• Should TA be utilized prophylactically on smaller nodules that are not yet symptomatic in anticipation of future symptoms?
• What is the optimal energy to be delivered to ensure sustained nodule volume reduction?
• How much does nodule composition determine treatment response?
• What is the optimal follow-up protocol for ablated nodules and optimal timing for repeat ablation procedures?
• Should there be regulation of pre-requisite skills / training for physicians wishing to commence TA programs?

These are just some of the questions that will need to be addressed to ensure our patients are selected appropriately, are adequately counselled about risks and benefits, are assured of optimal procedural safety, and experience consistent treatment outcomes. Answering these questions will require multidisciplinary collaboration and forward planning and will ultimately define TA’s role in treatment algorithms for neck endocrine disease.

Disclaimer:
The ideas and opinions expressed on the ATA Blogs do not necessarily reflect those of the ATA. None of the information posted is intended as medical, legal, or business advice, or advice about reimbursement for health care services. The mention of any product, service, company, therapy or physician practice does not constitute an endorsement of any kind by ATA. ATA assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of the material contained in, posted on, or linked to this site, or any errors or omissions.

For more information on Thyroid Topics please visit: https://www.thyroid.org/thyroid-information/

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Sara Ahmadi, MD, ECNU
Brigham and Women’s Hospital
Boston, MA
November 19, 2021

Thyroid nodules and thyroid cancer are common clinical problems in adults. The yearly incidence of thyroid cancer in the United States has almost tripled from 4.9 per 100,000 in 1975 to 14.3 per 100,000 in 2009. It has been predicted that thyroid cancer will replace colorectal cancer as the fourth leading cancer diagnosis by 2030(1,2).

Surgery is the primary treatment for thyroid cancer. Most patients with differentiated thyroid cancer have an excellent outcome with a 98% long-term disease-specific survival.

Traditional therapy with total thyroidectomy and radioactive iodine(RAI) has not shown added benefit in patients with low-risk differentiated thyroid cancer and might result in more harm. Thyroid lobectomy, selective use of radioactive iodine, and active surveillance have gained attention in recent years. They have been recommended as potential management options for low-risk thyroid cancer and micropapillary thyroid cancer in the current American Thyroid Association guidelines(2). This has led to significant changes in clinical practice. A study of 35,291 patients using National Surgery Quality Improvement Program Data showed that there has been a 10-fold increase in the rate of thyroid lobectomy rather than total thyroidectomy after the publication of 2015 ATA guidelines(3).

However, many patients with differentiated thyroid cancer may overestimate the mortality implications, which may drive their willingness to undergo more aggressive treatment(4).

The Discrete Choice Survey Study of a cohort of 150 patients with newly diagnosed differentiated thyroid cancer or thyroid nodule requiring surgery showed that risk of thyroid cancer recurrence impacted patient’s preference around surgical treatment options the most, followed by risk of requiring completion thyroidectomy and recurrent laryngeal nerve injury. The risk of hypocalcemia and hypothyroidism had the least impact on patients’ preferences around treatment options. This study also showed that the average patient would prefer total thyroidectomy unless the risk of requiring completion thyroidectomy can be reduced to 30% or less(5).

Patients’ concern and worry can also limit their acceptability of less aggressive treatment options. A survey of 243 patients with papillary thyroid cancer enrolled in an active surveillance program showed cancer worry is common among these patients. However, the patient’s level of concern improves over time(6).

Patient-physician communication also plays an essential role in providing the patient with a good understanding of the risks and benefits of different treatment options and an informed decision-making process. Computerized patient decision aids in addition to usual care can be associated with a significant increase in patients’ medical knowledge around treatment options and a reduction in decisional conflict at the time of decision making(7). In a recent study, 1319 patients with thyroid cancer in whom selective use of radioactive iodine was recommended were surveyed to assess patient perspectives regarding RAI decision making. More than half of the patients perceived they did not have a choice regarding RAI. These patients were also more likely to receive RAI and to have lower decision satisfaction(8).

There has been a significant change in clinical practice since the publication of the 2015 ATA guidelines. It is of vital importance that we improve our understanding of patients’ preferences, ensure excellent patient-physician communication, and use educational decision aids in conjunction with physician counseling to facilitate shared-decision making.

References:
1. Rahib L, Smith BD, Aizenberg R, Rosenzweig AB, Fleshman JM, Matrisian LM. Projecting cancer incidence and deaths to 2030: the unexpected burden of thyroid, liver, and pancreas cancers in the United States. Cancer research. 2014;74(11):2913-2921.
2. Haugen BR, Alexander EK, Bible KC, et al. 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid : official journal of the American Thyroid Association. 2016;26(1):1-133.
3. Ullmann TM, Gray KD, Stefanova D, et al. The 2015 American Thyroid Association guidelines are associated with an increasing rate of hemithyroidectomy for thyroid cancer. Surgery. 2019.
4. Dixon PR, Tomlinson G, Pasternak JD, et al. The Role of Disease Label in Patient Perceptions and Treatment Decisions in the Setting of Low-Risk Malignant Neoplasms. JAMA Oncol. 2019.
5. Ahmadi S, Gonzalez JM, Talbott M, et al. Patient Preferences Around Extent of Surgery in Low-Risk Thyroid Cancer: A Discrete Choice Experiment. Thyroid : official journal of the American Thyroid Association. 2020;30(7):1044-1052.
6. Davies L, Roman BR, Fukushima M, Ito Y, Miyauchi A. Patient Experience of Thyroid Cancer Active Surveillance in Japan. JAMA Otolaryngol Head Neck Surg. 2019;145(4):363-370.
7. Sawka AM, Straus S, Rodin G, et al. Thyroid cancer patient perceptions of radioactive iodine treatment choice: Follow-up from a decision-aid randomized trial. Cancer. 2015;121(20):3717-3726.
8. Wallner LP, Reyes-Gastelum D, Hamilton AS, Ward KC, Hawley ST, Haymart MR. Patient-Perceived Lack of Choice in Receipt of Radioactive Iodine for Treatment of Differentiated Thyroid Cancer. J Clin Oncol. 2019;37(24):2152-2161.

Disclaimer:
The ideas and opinions expressed on the ATA Blogs do not necessarily reflect those of the ATA. None of the information posted is intended as medical, legal, or business advice, or advice about reimbursement for health care services. The mention of any product, service, company, therapy or physician practice does not constitute an endorsement of any kind by ATA. ATA assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of the material contained in, posted on, or linked to this site, or any errors or omissions.

For more information on Thyroid Topics please visit: https://www.thyroid.org/thyroid-information/

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Special Collection: Virtual Review of Novel Ablation Techniques for Benign and Malignant Thyroid Nodules

This Special Collection of recent publications from the American Thyroid Association® journals highlights current understanding and new advances regarding novel thyroid nodule ablation techniques. The highlighted studies, reviews, commentaries, and videos focus on the use of thermal ablation technologies such as laser ablation, radiofrequency ablation, microwave ablation, and high-intensity focused ultrasound that have emerged as potential management options for benign and malignant thyroid nodules over the past decade.

Read these articles, commentaries, and videos, selected by the Editors-in-Chief of Thyroid®, ClinicalThyroidology®, and VideoEndocrinology,™ free through April 30, 2021.

VIEW THE SPECIAL COLLECTION

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1. 1. Dr. Trevor Angell of the Division of Endocrinology, Diabetes, and Hypertension at Brigham and Women’s Hospital and Harvard Medical School, in Boston, Massachusetts, will present a study called “Xpression Atlas Findings in the Genomic Sequencing Classifier (GSC) Clinical Validation Cohort.”

      The GSC used in this study classifies cytologically indeterminate thyroid nodules as either benign (B) or suspicious (S). The ability to detect genomic variants and fusions was recently expanded by the Xpression Atlas (XA), which identifies 761 nucleotide variants and 130 fusion gene pairs in 511 genes. In this study, researchers used XA to analyze the mutational spectrum of 190 nodules classified with standard histologic diagnoses (using microscopic studies of the tissues) as belonging to categories III and IV in the Bethesda System for Reporting Thyroid Cytopathology (BSRTC). The conclusion was that GSC is better than XA for ruling out cancers, while the two used together may provide additional insights into pathway activation and potential cancer treatment targets.

1. 1. Another study involving XA will be presented by Dr. Allan C. Golding of the Memorial Center for Integrative Endocrine Surgery in Hollywood, Florida. Titled “Xpression Atlas Variants and Fusions Found Among 4,742 Thyroid Nodules,” the study involved reanalyzing all clinical samples with complete XA profiles from July 2017 to April 3, 2018.

      Overall, fusions were detected less frequently than variants across all BSRTC categories. This analysis supported excluding XA reporting among GSC-benign nodules. However, markedly different genomic insights were found between cohorts at increased risk of cancer, specifically, those in categories III through VI of the BSRTC. Together, the GSC and XA contribute substantial genomic content to advance preoperative risk stratification.

1. 1. In a presentation by Dr. Christine Cherella of Boston Children’s Hospital (BCH), attendees will learn how “Malignancy Rates of Thyroid Nodules Differ Between Children and Adults Within Indeterminate Cytopathological Categories.” Thyroid nodules are more common in older individuals but are more likely to be malignant in younger ones. Although the BSRTC is widely used to interpret fine-needle aspiration (FNA) cytology, it is unclear whether BSRTC diagnostic categories suggest the same risk of malignancy in younger versus older patients.

      Researchers evaluated all consecutive patients who underwent FNA of a thyroid nodule ≥1 cm in diameter, at the BCH and the Brigham and Women’s Hospital between 1998 and 2016. They found that, in children and adults with clinically relevant thyroid nodules, malignancy rates differ within indeterminate BSRTC categories defined by similar morphologic features. This finding likely reflects true differences in nodule biology rather than variations in cytological classification.

1. 1. Dr. Yu-kun Luo of the Ultrasound Department, General Hospital of Chinese PLA, Beijing, China, will present a study titled “Artificial Intelligence-Assisted Ultrasound Diagnosis for Thyroid Nodules.” Due to uneven development of medical resources, diagnostic accuracy for thyroid nodules varies greatly. The aim of this study was to explore a novel AI-assisted ultrasound diagnostic system to improve the efficiency and accuracy of thyroid nodule diagnosis.

      To test the accuracy of the new system, 500 pathologically confirmed thyroid nodules were selected, including 208 benign and 292 malignant ones. The images of all nodules, acquired from 10 different types of ultrasound equipment, were dynamically stored in the form of consecutively longitudinal and transverse sections. The AI-assisted diagnostic system recognized and analyzed the features of the images and offered recommendations for diagnosis. The diagnostic accuracy of the system was then compared with that of junior and senior physicians. Results showed the diagnostic accuracy of the AI system alone was higher than that of junior physicians (77.6% vs. 70.5%); however, accuracy could reach 92.4% when junior physicians were assisted by the new AI system—higher than the accuracy of senior physicians (85.6%) unassisted by the system. For nodules of different sizes, testing showed no significant difference in diagnostic accuracy among the three groups.

1. 1. Another presentation will be given by Dr. Mingbo Zhang of the same department in Beijing’s General Hospital. Dr. Mingbo will describe a “Randomized controlled clinical trial of ethanol-sensitized radiofrequency ablation (RFA) for benign solid thyroid nodules” that took place between June 2016 and February 2018. While solid thyroid nodules are good candidates for RFA surgery, they often require high power and energy, which increase the incidence of complications. This study used ethanol as a sensitizer before RFA to explore whether that could achieve a safer, faster, and more effective result.

      Seventy-two patients with 84 nodules among them were enrolled in the study group and in a conventional RFA group, respectively, each with 42 nodules. The researchers concluded that ethanol can significantly improve the efficiency of RFA, reduce the time and energy of the ablation, and reduce the occurrence of complications.

1. In a presentation titled “Efficacy and Safety of Thermal Ablation of 200 Benign Thyroid Nodules: Comparison of Three Techniques (Radiofrequency, Laser, High Intensity Focused Ultrasound),” Dr. Adrien Ben Hamou of the Endocrinology Department at the University Hospital in Lille, France, will describe a bicentric retrospective study conducted between October 2013 and January 2018.

   The aim was to compare the three ablation methods for treating benign thyroid nodules. Two hundred nodules were treated in 176 patients with benign histology or cytology, all of whom refused surgery. Clinical, biological, and ultrasound evaluation was performed before treatment. Researchers compared variations in volume and symptoms as well as side effects at 6 weeks and 12 months after treatment. Volume reduction between radiofrequency (RFA) and laser (LA) ablation was significantly different at 6 weeks but not at 12 months. After adjustments, no significant difference was observed at either 6 weeks or 12 months between RFA and high-intensity focused ultrasound (HIFU) or between LA and HIFU. Clinical symptoms were reduced in all three groups. Very few transient but potentially serious side effects were reported, the causes of which should be analyzed.

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 The American Thyroid Association (ATA) is the leading worldwide organization dedicated to the advancement, understanding, prevention, diagnosis, and treatment of thyroid disorders and thyroid cancer. ATA is an international membership medical society with over 1,700 members from 43 countries around the world. Celebrating its 95^th anniversary, the ATA continues to deliver its mission of being devoted to thyroid biology and to the prevention and treatment of thyroid disease through excellence in research, clinical care, education, and public health.  These efforts are carried out via several key endeavors:

• The publication of the highly regarded professional journals Thyroid, Clinical Thyroidology, and VideoEndocrinology
• Annual scientific meetings
  
• Biennial clinical and research symposia
  
• Research grant programs for young investigators
  
• Support of online professional, public, and patient educational programs
  
• Development of guidelines for clinical management of thyroid disease and thyroid cancer

 The ATA promotes thyroid awareness and information online through Clinical Thyroidology for the Public and extensive, authoritative explanations of thyroid disease and thyroid cancer in both English and Spanish. The ATA website serves as the clinical resource for patients and the public who look for reliable information on the Internet. Every fifth year, the American Thyroid Association joins with the Latin American Thyroid Society, the European Thyroid Association, and the Asia and Oceania Thyroid Association to cosponsor the International Thyroid Congress (ITC).

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Información Importante Sobre los Nódulos Tiroideos con la Dra Regina Castro de la Clínica Mayo
Interviewed and produced by Philip James | May 4, 2017 | Endocrine, Pathology, Podcast

You Have a Thyroid Nodule, What Happens Next? with Dr. Regina Castro from The Mayo Clinic
Interviewed and produced by Philip James | Apr 2, 2017 | Pathology, Podcast, Surgery

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