State of the Union: Thyroid, Parathyroid, and Adrenal Care Today

An interview with James Lee, MD, Chief of Endocrine Surgery.

Read our previous conversation with Dr. Lee, State of the Union: Thyroid, Parathyroid, and Endocrine Surgery in 2024.

Interventional Endocrinology and the New Guidelines

Last year, we talked about the expansion of interventional endocrinology and active surveillance. Since then, what stands out to you as the most important shift in endocrine care?

The story continues to be about interventional endocrine. Dr. Jenn Kuo is pioneering a new form of percutaneous ablation called pulse field ablation—an even safer, less invasive way of treating thyroid nodules.

The other big development is that the American Thyroid Association (ATA) just released an update to the 2015 guidelines. These are the gold standard for thyroid care not just in the U.S., but around the world. The most important takeaways are: continuing to move toward less invasive care, performing smaller and less extensive operations for low-risk thyroid cancers, and using less adjuvant therapy like radioactive iodine.

The ATA also endorsed interventional endocrine—specifically radiofrequency ablation—as an approved methodology for small thyroid cancers.

Access, Adoption, and Patient Selection

Where are we now with radiofrequency ablation and other interventional options, especially regarding access and insurance coverage?

That’s a great question, because the other major update is that there’s now a CPT code for two different types of percutaneous ablation. That’s huge. Now that we have a CPT code, insurers are covering the procedure, so patients can receive it without paying out of pocket.

How do you determine when to observe versus intervene with small thyroid cancers?

For small thyroid cancers—less than a centimeter or a centimeter and a half—the traditional options are active surveillance, with repeat ultrasound every six to twelve months, or removing half the thyroid. The big change in the new guidelines is adding radiofrequency ablation as another option for treating small thyroid cancers.

Has patient selection evolved at all?

Not really. It’s still very individualized. It’s about having a detailed goals-of-care discussion with the patient. For example, a 70-year-old who wants to avoid surgery and understands their small cancer is unlikely to cause harm in their lifetime may choose observation. But a younger patient, say, a 30-year-old woman with a family history of thyroid cancer, might prefer an operation. It’s all about patient preference and context.

AI and Early Diagnosis

Last year, you mentioned AI and neural networks on the horizon for diagnosis. Have there been any advances?

Nothing major yet. A few institutions have used AI to scan electronic medical records and identify patients with conditions like hypothyroidism or adrenal incidentalomas, flagging them for follow-up. So, there’s interesting work being done at the institutional level, but nothing broad or sweeping across the field yet.

It sounds like many of the barriers are logistical and ethical, rather than scientific.

Parathyroid Trends

You noted last time that more patients with mild hyperparathyroidism were being referred for surgery. Has that trend continued?

Yes. We’re getting better and better at diagnosing parathyroid disease and recognizing that patients with a biochemical diagnosis should be referred for surgical evaluation. There haven’t been major guideline changes, but awareness is definitely increasing.

Is there more recognition of parathyroid disease across the medical community?

For sure. Historically, both patients and physicians might watch mildly elevated calcium levels for years before ordering a parathyroid hormone test. That’s changing. We’re getting better at closing that gap and identifying patients earlier.

Anything new in managing secondary hyperparathyroidism, especially for patients awaiting or recovering from kidney transplant?

It’s about the same, but again, the awareness is improving. We’re recognizing that earlier intervention leads to better long-term health outcomes, so more patients are being referred for evaluation sooner.

Any new techniques or technologies in parathyroid surgery worth noting?

There’s some emerging work with autofluorescence imaging to help identify parathyroid glands during surgery, but it’s probably not a major game-changer yet.

Adrenal Surgery and Robotics

We talked previously about retroperitoneal laparoscopic adrenalectomy. What have you learned about outcomes compared to the traditional transabdominal approach?

The data remain consistent with what we’ve seen since the early days: operative times are shorter, recovery is faster, patients experience less pain, and use fewer narcotics. There hasn’t been a major shift there, but retroperitoneal adrenalectomy continues to show small but meaningful advantages over the transabdominal route.

When would you still recommend the traditional approach?

In cases with very large adrenal nodules over eight centimeters, suspected adrenal cancer, or patients with very high BMIs. For those patients, a transabdominal or robotic transabdominal adrenalectomy is often safer and more practical.

Are there new developments in robotic adrenalectomy, especially for patients with higher BMIs or complex cases?

No major new data, but our experience supports that the robotic transabdominal approach can be particularly beneficial for high-BMI patients. Sometimes, with patients who have a very high BMI, it’s physically difficult to position them safely for the retroperitoneal approach, so robotic transabdominal surgery becomes the better option.

Looking Ahead

If you think about the next five to ten years, what do you expect will be the biggest breakthroughs in thyroid, parathyroid, and adrenal care?

First, interventional endocrine will continue to grow. It’s going to be a bigger and bigger part of what we do. I suspect there’ll be a pendulum swing. At first, perhaps too many procedures as new centers adopt the technology, but eventually we’ll find equilibrium. Ultimately, I think about 30 percent of what we used to do as open operations will be treated with interventional approaches.

And second, molecular profiling and targeted therapies just keep getting better. For patients with metastatic or malignant thyroid and adrenal disease, we’ll soon have new therapies that prolong life and improve quality of life.

How do you see your programs at Columbia evolving to stay at the forefront of these changes?

One of our greatest strengths is that we’re inherently multidisciplinary. Our thyroid, parathyroid, and adrenal programs bring together all the specialists—surgeons, endocrinologists, oncologists, and more. For example, Tito Fojo, one of the leading endocrine oncologists in the world, is part of our team and leading many of the new therapeutic trials. Having all of those perspectives in one place ensures that every patient gets the best, most individualized care, not a one-size-fits-all approach.