AAES 38th Annual Meeting 

April 2 - 4, 2017
Rosen Center Hotel
Orlando, FL

Local Arrangements Chair: Mira Milas, MD

Program Chair: Scott Wilhelm, MD 

Spring 2016
Peter Angelos, MD, PhD, FACS
It is a true honor for me to take over from Steve Libutti as the president of the AAES.  It does not seem so long ago when I first attended the AAES Meeting as a Surgical Resident in 1994.  I was in awe of the expertise of the leaders of the AAES at that time.  What struck me immediately was how engaged all of the attendees at the meeting were.  They seemed to love their work, and they certainly were friendly with a resident such as myself.
It has been more years than I would like to count since that first meeting.  I must admit, the AAES is the one meeting that I never miss.  It has been a constant source of knowledge, challenge, and comradery since that first meeting.  In the few weeks since I have become president, I have heard from many of you, your expressed desire to become more involved in the organization.  In an era when it is increasingly difficult for surgeons to take time away from their practices to attend a national meeting, the AAES continues to grow its attendance. and members continue to volunteer to take on additional work on behalf of the association.  I am grateful for the willingness to pitch in and the continued enthusiasm for making the AAES even stronger in the years to come.
This past year has been an eventful one with the challenge of finding a new management company.  I need to acknowledge the tremendous amount of work that Steve Libutti and Becky Sippel did in identifying and contracting with the new company. I also want to thank the other officers and members of the Council who put in extra time reading applications and participating in the management company interviews.  I am confident that all of the hard work will pay off as we have begun to transition to AMR Management Services, our new management company, in the past few weeks.  Over the summer and early fall, I look forward to working with the officers and Council to developing a strategic plan for the organization that I hope will serve it well in the years to come.  As part of this move forward, we will be updating the AAES Website.  As members, we will all have the opportunity to have input into many of these changes by filling out the membership survey that we will all be receiving.  I hope that you will take the opportunity to provide honest feedback very seriously as the future of the organization depends on this continued engagement by the members.

The annual meeting in Baltimore was a tremendous success, and I would be remiss if I did not thank the Local Arrangements Chair, John A. Olson, Jr., and the Program Chair, James Lee, for their tremendous efforts.  We have already begun working hard on the 2017 meeting that will be held on April 2-4, 2017 at the Rosen Center Hotel in Orlando, Florida in conjunction with the Endocrine Society.  Mira Milas and Scott Wilhelm, (our Local Arrangements Chair and Program Chair respectively for the upcoming meeting) along with Becky Sippel and I are already making plans for what we hope will be another successful meeting.  You will notice some differences with the schedule of the 2017 meeting as we plan for opportunities to interact with our colleagues in the Endocrine Society.  I hope that you will mark your calendars and start working on your abstracts for next year!
I take the responsibility of being President of this wonderful organization very seriously.  I am committed to doing all that I can to help the AAES continue to succeed and grow as an organization devoted to furthering the art and science of endocrine surgery.  In the upcoming months, I hope that you will share with me your ideas about how the AAES can continue to grow and improve in the years to come.

Peter Angelos, MD, PhD, FACS

AAES President 

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Rebecca S. Sippel, MD
There is a great deal of change happening within the AAES and the next year is going to be full of excitement.  For the past 3 years, BSC Management has worked hard to support the needs of the AAES, but our contract with them will be coming to an end in June. We have done a comprehensive search and are excited to announce that we have signed a contract with AMR Management Services, based in Lexington, KY to start in July 2016.  AMR will be working closely with BSC Management to ensure a seamless transition of our services.   Thank you to Stacy Kent our Executive Director for her assistance over the past few years.  You will be missed!  

As part of our contract with our new management company we will be developing a formal strategic plan for the AAES.  In order to get the input of our membership to guide this process we will be doing a membership needs assessment this summer.  When you get the email from us - please take the time to tell us what you like and don't like and how the AAES can better serve your needs going forward!  The input of our membership is going to be critical to developing a successful strategic plan.  

With our management transition, we will also be developing a new website.  We know that our current website doesn't serve our needs well, and we are excited to design a new website that will have the functionality that we need as an organization and will hopefully also be a great resource to our membership.  Please let the IT Committee know what you would like the website to do.

At our recent Business Meeting, we voted on several important bylaws changes which will help to streamline some of our operations.  The greatest change was the creation of a separate treasurer position.  Financially the AAES is in a good position. Last year's meeting generated a significant surplus and early indicators are that this recent meeting in Baltimore will also be a financial success for our organization.  It is great to come into this management transition in a solid financial position, and we look forward to Dr. Sareh Parengi taking over as treasurer of our organization.    Another exciting change is the conversation of the Community Based Surgeons Committee from an "ad hoc" to a "standing" committee.  Community based surgeons are a growing portion of our membership and their committee has been very active over the past few years. We are excited to have them become a standing committee of our organization. The remainder of the bylaws changes will help to simplify the membership process and hopefully allow us to continue to attract new members to our organization.

There is a lot to look forward to over the course of the next year! I look forward to working with you all to help move the AAES into the future!

Rebecca Sippel, MD

AAES Secretary

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Cord Sturgeon, MD
I hope everyone enjoyed the January 2016 issue of SURGERY. We are grateful that the journal has remained enthusiastic and supportive of a dedicated full issue to serve as the proceedings of our annual meeting. My sincere thanks goes to the 71 ad-hoc reviewers who heeded the call to review manuscripts for me this year.
We had an outstanding program at the AAES Annual Meeting in Baltimore. All accepted podium manuscripts will be e-published as soon as they are accepted, and will appear in print accompanied by the full transcription of the discussion at the meeting.  
There is no manuscript submission requirement for poster presenters, and they may submit their work to any journal.  However, poster manuscripts have been favorably received by ANNALS OF SURGICAL ONCOLOGY in the past.  If poster presenters wish to submit full manuscripts of their work to ANNALS OF SURGICAL ONCOLOGY they may do so at the following link: Please select "AAES manuscript" from the drop-down menu.  As an incentive to submit early, the first 10 submitted papers will not have to pay the manuscript submission fee.

I am always looking for members of AAES and endocrine surgery fellows to review manuscripts for SURGERY.  Please email me at if you would like to be an ad hoc reviewer. 

Thanks for your support!

Cord Sturgeon, MD

AAES Recorder

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William B. Inabnet, III, MD, FACS 
The CESQIP continues to grow at a rapid pace. It is anticipated that 2016 will be a banner year for this important quality initiative.  At the time of this writing, 42 institutions are participating with the CESQIP representing a diverse demographic of academic and community hospitals; several additional institutions are in the process of enrolling. Operative data from more than 150 participating surgeons are being entered in the CESQIP registry with total case volume now exceeding 12,000 unique case entries.

In 2016, the first semi-annual push reports were circulated to CESQIP institutions, providing them with the first comprehensive glimpse of their performance compared to that of all participating sites. A fellow's module has been introduced which will permit endocrine surgery fellows to monitor their own performance in real time throughout the course of their training.  The AAES CESQIP Committee will soon start accepting proposals to mine the CESQIP aggregate data; submissions will be open to any investigator, but proposals arising from participating CESQIP sites will receive priority.  The CESQIP is also laying the foundation to develop additional Best Practice Modules, an initiative that will permit interested participating sites to collaborate by collecting additional, more granular data on a quality topic of interest. 

Finally, a new foundation - the Endocrine Surgery Quality (ESQ) Foundation - has been created to house the CESQIP. The ESQ Foundation will oversee the finances of the CESQIP and provide global strategy recommendations. The AAES CESQIP Committee will oversee the aggregate data mining as well as the development of the Best Practice Modules.  Please consider enrolling in the CESQIP; the more active the participation, the more robust the quality improvement for our specialty.

William B Inabnet III, MD, FACS

CESQIP Committee Chair

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EdEducation & Research Committee
Kepal Patel, MD
The Education & Research Committee (ERC) would like to congratulate all the Paul LoGerfo Award Applicants. The competition was fierce and the winners of the 2016-2017 awards were announced at the annual banquet.  Dr. Dhaval Patel from the NIH- Endocrine Oncology Branch, won the Basic Science Research Award for his study, "Comprehensive Metabolomic Analysis of Adrenocortical Carcinoma: Toward Improved Diagnosis, Prognosis and Therapeutic Targets."  Dr. Susan Pitt, from the University of Wisconsin, won the Clinical Research Award for her study, "Decision-Making about Papillary Thyroid Microcarcinoma Treatment."  We look forward to their research presentations at the 2017 AAES Meeting in Orlando, FL.  Each award was in the amount of $10,000.  
Endocrine Surgery Reviews (ESR) is a periodic review of provocative or enlightening contemporary publications in the field of endocrine surgery.  ESR is published twice a year with the newsletter.  If you think a particular article deserves review in ESR, please contact the Editor-in-Chief, Kelly McCoy, at  Please read the most recent reviews in the ESR section of this newsletter.

Kepal Patel, MD

Education and Research Committee Chair

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AccFellowship Accreditation Committee
Sonia L. Sugg, MD 
Congratulations to the 8 fellowship programs that have successfully undergone re-accreditation this year! Many thanks to all the program directors for submitting their reports on time. The committee reviewed current case requirements for fellows and agreed that no changes were needed at this time.  Annual reports and re-accreditation reports will be due on January 23, 2017.  The next deadline for new fellowship application submission will be September 2, 2016. Please request an application form and direct any questions regarding the process to Sonia Sugg at

Sonia Sugg, MD

AAES Fellowship Accreditation Committee Chair

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FellowFellowship Committee
Tracy S. Wang, MD, MPH
August 1, 2016 marks the beginning of a new academic year and 25 new Endocrine Surgery Fellows. Congratulations to the incoming Class of 2017!
There are 24 AAES-accredited fellowship programs across the United States, Mexico, and Canada. The AAES is currently sponsoring the 2016 match for 25 clinical fellowship positions for the 2017 - 2018 academic year.
Important Dates
  • Monday, January 25, 2016: Online application site opens at 9:00 AM PDT.
  • Friday, June 17, 2016: Online application site closes at 11:59 PDT. Applicants interested in applying for a fellowship in Endocrine Surgery must have completed their applications by this time, including all letters of recommendation.
  • Thursday, September 1, 2016: Online ranking site opens at 9:00 AM PDT.
  • Thursday, September 15, 2016: Applicant and Program rank lists due by 11:59 PM PDT.
  • Monday, September 19, 2016: If there are unmatched programs, unmatched programs and candidates will be notified. Programs and candidates will be allowed to contact each other to fill any available fellowship position. Unmatched applicants will be notified only if there are spots available in the match.
  • Monday, September 26, 2016: Due date for secondary rank of any unmatched programs and unmatched applicants.
  • Wednesday, September 28, 2016: Match results announced.
For additional information, please go to or contact the AAES Headquarters Office (, or Dr. Tracy Wang at

Tracy S. Wang, MD, MPH

AAES Fellowship Committee Chair

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MemberMembership Committee
Sanziana A. Roman, MD; Sonia Sugg, MD; Linwah Yip, MD; and Julie Miller, MD
The membership committee approved 49 new members in 2015-2016, which is on par with numbers from the last 3 years. Our overall membership has grown to more than 600 members.

The membership committee worked on clarifying membership requirements for active membership, specifically ensuring transparency for non-academic endocrine surgeons. In order to facilitate transitions of membership categories, and avoid loss of our junior members, the committee has enabled automatic resident/fellow membership to all AAES approved fellows, as well as automatic transition to candidate member status for the graduating trainees.

I believe that our overall membership is strong, and continues to embrace excellence, transparency and facility in navigating our society.

Figure: Membership growth over the last eight years. 

Sanziana Roman, MD

Membership Committee Chair

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ProgramMessage from the 2016 Program Chair
James Lee, MD 
On behalf of this year's program committee, I would like to thank everyone for participating in this year's annual meeting, making it one of the most successful scientific meetings to date. The program committee graded over 200 abstracts, leading to an exceptional program with 35 oral presentations and 50 poster presentations. With record attendance, this was the largest meeting to date.
Highlights from the program included:
  1. Presidential Session on Fostering Multidisciplinary Collaborations led by Drs. Amelia Grover and Kaare Weber.
  2. Historical Lecture on "The Diagnosis and Treatment of Thyroid Cancer: A Historical Perspective" by Dr. Samuel Wells.
  3. President's Invited Lecture on "The Curative Potential of T-cell Transfer Immunotherapy for Patients with Metastatic Cancer" by Dr. Steven Rosenberg
  4. AAESOP Outcomes Lunch Program led by Drs. Tracy Wang, Carrie Lubitz, and Julie Ann Sosa.
  5. Allied Health Professionals session on "The Evaluation and Management of Thyroid Cancer" led by Michelle Mims and Dr. James Broome.
  6. Our annual Interesting Case Session led by our Vice-President, Dr. Doug Fraker.
It has truly been an honor and privilege to serve as Program Committee Chair this year. I would like to personally thank all of the members of the Program Committee, the Executive Committee and the AAES staff for their hard work in making the Annual Meeting Program in Boston a tremendous success.

James Lee, MD 

2016 Program Chair 

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We are excited to announce the 38th Annual Meeting of the American Association of Endocrine Surgeons to be held in conjunction with The Endocrine Society (ENDO 2017) on April 2-4, 2017 in Orlando, Florida at the Rosen Center Hotel and Orlando Convention Center.

This is a historic meeting between our societies which provides a new opportunity for collegiality and joint learning.  It will provide unique experiences that we hope will add value to both the professional education and collegial networks. Like with other joint meetings we have conducted with our sister societies worldwide (AACE, ATA/ITA, IAES), the meeting in Orlando 2017 may require some minor modifications to our traditional meeting format.  Our meeting will still uphold the high level scientific standards for program content that our membership, and that of The Endocrine Society, is accustomed to.  We will still use a standard plenary format for presentation of clinical, basic science, translational, and teaching papers, along with some new avenues of learning for our members and those of the The Endocrine Society.  

A joint "interesting case" session was held in conjunction with members of the AACE - American Association of Clinical Endocrinologists at the 2015 meeting in Nashville, TN.  This highly successful session will again be employed and should make an excellent bridge between our societies.   We are also investigating the option of a poster exchange of some of the top posters from both societies. Finally, the concept of some parallel sessions on key innovative themes, allowing members of both societies to interact outside of the main plenary program, are being considered. Your program chair, Dr. Scott Wilhelm, and your local arrangements chair, Dr. Mira Milas, and the AAES executive council will be working closely with their counterparts at the The Endocrine Society to ensure an outstanding meeting.

The Rosen Centre Hotel will be home base for the AAES with hotel rooms and its own conference center for our plenary sessions.  It also links via Skybridge to the Orlando Convention Center where the Endocrine Society meeting is taking place.  This proximity should make our joint sessions easy for our members to access.  Finally, we hope to arrange wonderful social events that play to the strength of the resort atmosphere in the Orlando area with its many attractions. 

We are looking forward to another great meeting and encourage all AAES members to attend. 

Mira Milas, MD

2017 Program Chair

Scott Wilhelm, MD 

2017 Program Chair

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AdAd Hoc Access and Innovation Committee
Amelia C. Grover, MD
The committee is evaluating and working on new strategies to expand access to and awareness of endocrine surgeons.  These are the main projects we are working on.
The first is a needs assessment of referring providers.  The goal is with a better understanding of their needs we will then create a stronger team member in the multidisciplinary team taking care of endocrine surgery patients. Also for those patients with limited access to specialists, we can evaluate new opportunities to bridge the gap for these patients. 
The second project we are working on is creating a speakers' list. We plan to create a broad group of topics on which many of our members can speak.  For those members who are interested in speaking, we would provide their contact information to interested individuals/organizations.  This would serve as a service to our members and an opportunity to increase awareness of our specialty and expertise. 
Finally, our third project is working with the education committee on educational content for fellows or those early in practice to help them with career development.  These would include practice building and development topics as well as education on challenges and pearls of clinical practice.

Amelia C. Grover, MD

Ad Hoc Access and Innovation Committee Chair

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AMAAAES Applies to the AMA's SSS
Steven A. De Jong, M.D.
The AAES has qualified for representation in the Specialty and Service Society (SSS) of the American Medical Association (AMA). With our Council's approval, we have submitted the necessary application materials, and we will know the outcome in early June of this year. Admittance to the SSS, the largest caucus of the AMA, elevates the stature of the AAES and gives us the opportunity to influence important surgical practice and socioeconomic issues in our rapidly changing world of healthcare.

After joining the SSS, our next goal is to attain delegate status as a member organization of the AMA House of Delegates and join other societies such as the American Association of Clinical Endocrinology, American Academy of Otolaryngology-Head and Neck Surgery, The Endocrine Society, and the American College of Surgeons. It may take a few years to achieve, but success here gives the AAES a real voice in the future of our specialty. Thank you for your past, present, and future support of this important work.

Steven A. De Jong, M.D.

AMA Representative for the AAES 

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PrimaryAAES Guidelines for Definitive Management of Primary Hyperparathyroidism
Sally E. Carty, MD and Scott Wilhelm, MD
The American Association of Endocrine Surgeons (AAES) Guidelines for Definitive Management of Primary Hyperparathyroidism were completed and submitted along with a condensed "Executive Summary" to JAMA Surgery and JAMA in early March 2016.  The guidelines then underwent external review and were extremely well received.  The pHPT guidelines committee will respond to reviewer questions and comments and hopes to have a revised document returned to the publisher by mid-May 2016. 

This has been a productive and collegial enterprise between AAES members and our medical experts in Endocrinology, Pathology, and Radiology.  We as a committee would also gratefully thank Drs. Orlo H. Clark, Clive S. Grant, Herbert Chen, and Beth H. Sutton for their candid and detailed comments in development. Second, we are grateful to the AAES council members and officers, especially Drs. Rebecca S. Sippel and Steven K. Libutti, for their support and aid with this project.  Third, we acknowledge Ms. Carol L. Bykowski and Ms. Stacy Kent for their gracious support and assistance. Finally, we thank the many AAES members who took the time and trouble to offer their insight and critical wisdom to improve these guidelines.

Finally, we would again like to personally thank Dr. Robert Udelsman for his drawing of parathyroid anatomy (normal and ectopic) which is highlighted in the guidelines and was featured in poster form at the 2016 AAES Annual Meeting in Baltimore. Copies of the drawing which were sold at the meeting raised over $2,500 for the Paul LoGerfo Educational Research fund.  
We will keep the membership apprised of the final review and publication process of the guidelines.


Sally E. Carty, MD

AAES Parathyroidectomy Guideline Chair

Scott M. Wilhelm, MD

AAES Parathyroidectomy Guideline Member

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EndoEndocrine Surgery Quarterly

A Novel CYP11B2-Specific Imaging Agent for Detection of 
Unilateral Subtypes of Primary Aldosteronism
Abe T, Naruse M, Young WF, Kobashi N, Doi Y, Izawa A, Akama K, Okumura Y, Ikenaga M, Kimura H, Saji H, Mukai K, and Matsumoto H.  J Clin Endocrinol Metab 2016;101(3):1008-1015.
Reviewer: Kristin L. Long, MD
In Brief
       In this edition of Endocrine Surgery Reviews, we will review "A novel CYP11B2-specific imaging agent for the detection of unilateral subtypes of primary aldosteronism" by Abe et al [1].  This study highlights the development of CDP2230, a fluorine-18-labeled imaging agent designed to more specifically detect unilateral aldosterone-producing adenomas (APAs) when compared to other radiolabeled molecules.  As noted by the authors, adrenal vein sampling currently serves as the gold standard technique for distinguishing between bilateral adrenal hyperplasia and a unilateral APA after the biochemical diagnosis of primary hyperaldosteronism has been confirmed; however, this modality is limited by its invasiveness, operator-dependence, and difficulty in performance and interpretation.  As up to 60% of patients with primary hyperaldosteronism suffer from bilateral hyperplasia, reliably distinguishing the patients with unilateral disease who would benefit from surgical intervention is imperative [2,3].
       The goal of the current study was to develop an imaging agent that would show increased affinity for CYP11B2, the gene encoding aldosterone synthase production, which results in aldosterone production over CYP11B1, which encodes the enzyme 11-beta-hydroxylase, leading to cortisol and corticosterone production.  Abe and colleagues eloquently describe the synthesis of 18F-CDP2230, including the dramatically increased selectivity for CYP11B2 over CYP11B1.  They also highlight their in-vitro experiments with autoradiography demonstrating accumulation of 18F-CDP2230 exclusively in the region of human adrenal tissue pathologically confirmed as aldosterone-producing adenomas.  CDP2230 demonstrated increasing accumulation in the adrenal glands after administration, and showed minimal evidence of degradation throughout the evaluation period.  Additionally, CDP2230 was shown (via PET and PET/MRI models in rats) to accurately image adrenal glands with minimal background uptake.  The in-vivo rat studies confirmed the in-vitro biodistribution models, with adrenal uptake 10-20 minutes after administration. 
       Throughout the study, CDP2230 is compared to 11C-metomidate (MTO), another PET-imaging agent, as well as the analog 123-I-iodometomidate (IMTO), both of which have been reported to successfully distinguish bilateral hyperplasia from unilateral APAs but demonstrate similar affinity for both CYP11B1 and CYP11B2.  While MTO and IMTO both have much higher inhibitory activity for CYP11B1 and CYP11B2 than CDP2230, the selectivity of either compound is significantly weaker than that of CDP2230.
       The authors of this fascinating study are to be commended for their efforts and detailed description of a novel new agent designed to improve the imaging and localization for patients with primary hyperaldosteronism (PA).  PA remains a clinical challenge, and misdiagnosis can lead to unnecessary surgical intervention without subsequent cure of the disease. At present, 18F-CDP2230 has demonstrated usefulness in identifying aldosterone-producing adrenal tissue.  When compared to the currently available compounds, 18F-CDP2230 certainly appears to offer promise as a more selective agent in identifying aldosterone-specific tumors in adrenal tissue. Unfortunately, the major limitation of the study, as acknowledged by the authors, is the lack of direct comparison of 18F-CDP2230 imaging between APAs and hyperplastic adrenal tissue. Given this, the true ability of 18F-CDP2230 to distinguish between a unilateral APA and bilateral adrenal hyperplasia (which is the ultimate goal of the study) remains unknown.  This must be further clarified in order to evaluate the clinical utility of such a compound. 
Future Directions
      As mentioned previously, additional evaluation of the safety and utility of CDP2230 is necessary.  The ability of CDP2230 to delineate between primary aldosteronism caused by a unilateral APA (a surgically treatable condition) and bilateral adrenal hyperplasia (treated medically) must be further tested.  As efforts to find less invasive, easily reproducible, and accurate methods for adrenal imaging continue, we will eagerly anticipate further characterization of the role of CDP2230 as novel new agent in the armamentarium against primary hyperaldosteronism. 
1) Abe T, Naruse M, Young WF, Kobashi N, Doi Y, Izawa A, Akama K, Okumura Y, Ikenaga M, Kimura H, Saji H, Mukai K, and Matsumoto H.  A Novel CYP11B2-Specific Imaging Agent for Detection of Unilateral Subtypes of Primary Aldosteronism.  J Clin Endocrinol Metab 2016;101(3):1008-1015.
2) Rossi GP, Auchus RJ, Brown M, Lenders JWM, Naruse M, Plouin PF, Satoh F, Young WF.  An Expert Consensus Statement on Use of Adrenal Vein Sampling for the Subtyping of Primary Aldosteronism.  Hypertension 2014;63:151-160.
3) Zeiger MA, Thompson GB, Duh QY, Hamrahian AH, Angelos P, Elaraj D, Fishman E, Kharlip J.  American Association of Clinical Endocrinologists and American Association of Endocrine Surgeons Medical Guidelines for the Management of Adrenal Incidentalomas.  Endocrine Practice 2009;15(1):1-20.
Additional High-Yield Reading:
Patel D, Gara SK, Ellis RJ, et al.  FDG PET/CT scan and functional adrenal tumors: a pilot study for lateralization.  World J Surg. 2016 40:683-89.
Gara SK, Wang Y, Patel D, et al.  Integrated genome-wide analysis of genomic changes and gene regulation in human adrenocortical tissue samples.  Nucleic Acids Res. 2015 43:9327-39.
Pasternak JD, Seib CD, Seiser N, et al.  Differences between bilateral adrenal incidentalomas and unilateral lesions.  JAMA Surg. 2015 150:974-8.
Wachtel H, Zaheer S, Shah PK, et al.  Role of adrenal vein sampling in primary aldosteronism: Impact of imaging, localization and age.  J Surg Oncol. 2015 112:144-8.
Ota H, Seiji K, Kawabata M, et al.  Dynamic multidetector CT and non-contrast-enhanced MR for right adrenal vein imaging: Comparison with catheter venography in adrenal venous sampling.  Eur Radiol. 2016 26:622-30.
An International Multi-Institutional Validation of Age 55 Years as a 
Cutoff for Risk Stratification in the AJCC/UICC Staging 
System for Well-Differentiated Thyroid Cancer
Nixon IJ,  Wang LY,Migliacci JC, Eskander A,Campbell MJ,Aniss A,  Morris L,Vaisman F,Corbo R,Momesso D,Vaisman M,Carvalho A,Learoyd D, Leslie WD, Nason RW,Kuk D, Wreesmann V,Morris L,Palmer FL,Ganly I, Patel GS,Singh B,Tuttle MR, Shaha AR,Gonen M,Pathak KA,Shen WT,Sywak M,Kowalski L,Freeman J,Perrier N,and Shah JP. Thyroid 2106;20:373-380.

Reviewer: Aida Taye, MD
In Brief

Despite a rise in the incidence of well-differentiated thyroid cancer (WDTC), the disease specific mortality remains low. The current AJCC/UICC staging for WDTC, which was revised in 1983, classifies all patients under the age of 45 without distant metastasis as stage I (1).  Last year, Nixon et al. from Memorial Sloan Kettering Cancer Center (MSKCC) published their 5-year data from WDTC patients (2).  This study argued that the age cutoff for stage I disease should be increased from 45 to 55 in an effort to improve the prognostic accuracy of the previously established staging system and to prevent overtreatment of low risk patients.  To further prove this point, Nixon et al. organized a collaboration between 10 institutions worldwide in order to retrospectively restage WDTC patients between the ages of 45 and 55 and observe their disease-specific survival (DSS).  In this Endocrine Surgery Review, we analyze their efforts; "An International Multi-Institutional Validation of Age 55 Years as a Cutoff for Risk Stratification in the AJCC/UICC Staging System for Well-Differentiated Thyroid Cancer" (3).
This study is a retrospective analysis of 9484 WDTC patients from MSKCC, University of Manitoba, University of San Francisco, University of Sydney, Mount Sinai Hospital in Toronto, Instituto Nacional do Cancer/Universidade Federal do Rio de Janiero, Barretos Cancer Hospital, and MD Anderson. A study period of 1986 to 2005 was selected intentionally in order to exclude the cohort used in the initial paper, which was performed from 2005 to 2010. The cohorts were stratified by AJCC/UICC staging system using age 45 years and age 55 years as cutoffs. They analyzed their data using the Kaplan-Meier method and Concordance probability estimates. Using age 45 years as a cutoff, 10-year DSS rates for stage I-IV were 99.7%, 97.3%, 96.6%, and 76.3%, respectively. Using age 55 years as a cutoff, 10-year DSS rates for stage I-IV were 99.5%, 94.7%, 94.1%, and 67.6%, respectively. The use of age 55 as a cut off moved almost 10% of their patients (1165) from advanced disease stage category to mostly stage I (98%) and stage II (2%). Most importantly, the down-staging of this group moved 9% of the cohort from "advanced" stage III or IV disease to stage I or II disease. The 10-year DSS of this down-staged group was a remarkable 97.6%.  In their conclusion, they made a plea for a revision of WDTC staging to prevent over staging low-risk patients.


The strength of this paper lies in the efforts put forth by the authors to include patient populations from all around the world, thereby creating a large and heterogeneous cohort. They should be commended for excluding their prior cohort of patients diagnosed from 2005 to 2010 and still producing comparable results in outcomes for designated cohorts.  Similarly, the Manitoba patients were analyzed both separately and with the final cohort, as their data have also previously been used in a publication addressing age cutoff for thyroid cancer staging. We also applaud the authors' strong argument for sparing low-risk patients, aggressive surgical and postoperative radioactive iodine treatment. This concern mirrors the American Thyroid Association's 2015 guidelines.
Aside from being a retrospective study and not a randomized control trial, the weakness of the paper is threefold:

1.)    The retrospectively down-staged patients had already received therapy.  Therefore, additional therapy confounds any claims that patients between the ages of 45 and 55 who had received treatment should be viewed in a similar light as patients under the age of 45 who had not received treatment.
2.)    Treatment regimens for the studied cohorts were not standardized between the institutions. 
3.)    Disease-specific outcomes are important before drawing conclusions about the management of WDTC, especially since the disease is not biologically aggressive. The authors themselves acknowledge the lack of accurate data to prove that the patients' outcome was caused by WDTC.

Future Directives
There is no question that that this paper intelligently addresses the need for further investigation into revising the current AJCC/UICC guideline age cutoff of 45 years and older.  A randomized controlled trial, comparing an age 45 cutoff with an age 55 cutoff for stage I cancer, will be beneficial in deciding the optimal age cutoff. Lastly, it will also be worthwhile to simultaneously evaluate the effect of gender on the staging classification.
  1.  American Joint Committee on Cancer Staging and End Results Reporting, American Cancer Society 1977 Manual for Staging of Cancer, 1977. American Joint Committee for Cancer Staging and End-Results Reporting, Chicago, IL.
  2. Nixon IJ, Kuk D, Wreesmann V, Morris L, Palmer FL, Ganly I, Patel SG, Singh B, Tuttle RM, Shaha AR, Gonen M, Shah JP 2016 Defining a valid age cutoff in staging of well-differentiated thyroid cancer. Ann Surg Oncol 23:410-415.
  3. Nixon IJ,  Wang LY,Migliacci JC, Eskander A,Campbell MJ,Aniss A,  Morris L,Vaisman F,Corbo R,Momesso D,Vaisman M,Carvalho A,Learoyd D, Leslie WD, Nason RW,Kuk D, Wreesmann V,Morris L,Palmer FL,Ganly I, Patel GS,Singh B,Tuttle MR, Shaha AR,Gonen M,Pathak KA,Shen WT,Sywak M,Kowalski L,Freeman J,Perrier N,and Shah JP. An International Multi-Institutional Validationof Age 55 Years as a Cutoff for Risk Stratification in the AJCC/UICC Staging Systemfor Well-Differentiated Thyroid Cancer. Thyroid 2106;20:373-380.
Additional High Yield Reading:
Landa I, Ibrahimpasic T, Boucai L, et al.  Genomic and transcriptomic hallmarks of poorly differentiated and anaplastic thyroid cancers.  J Clin Invest. 2016 126:1052-66.
Shi X, Liu R, Basolo F, et al.  Differential clinicopathological risk and prognosis of major papillary thyroid cancer variants.  J Clin Endocrinol Metab.  2016 101:264-74.
Nixon IJ, Wang LY, Ganly I, et al.  Outcomes for patients with papillary thyroid cancer who do not undergo prophylactic central neck dissection.  Br J Surg. 2016 103:218-25.
Samir AE, Dhyani M, Anvari A, et al.  Shear wave elastography for the preoperative risk stratification of follicular patterned lesions of the thyroid: diagnostic accuracy and optimal measurement plane.  Radiology. 2015 277:565-73.
Ferreira LB, Eloy C, Pestana A, et al.  Osteopontin expression is correlated with differentiation and good prognosis in medullary thyroid carcinoma.  Eur J Endocrinol. 2016 174:551-61.
Jeon MJ, Chun SM, Kim D, et al.  Genomic alterations of anaplastic thyroid carcinoma detected by targeted massive panel sequencing in a BRAF(V600E) mutation-prevalent area.  Thyroid. 2016 26:683-90.

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