Author: Rodrigo Arrangoiz MS, MD, FACS, FSSO

• American Thyroid Association (ATA) Low-Risk of Recurrence Overview:
  • Patients considered low-risk (pre- or post-operative):
    • Intrathyroidal papillary thyroid cancer ≤ 4 cm:
      • T1 to T2
    • No clinical nodal involvement:
      • N0 or minimal N1a
    • No distant metastasis (M0)
    • No aggressive histologic variants
    • No gross extrathyroidal extension
• Core Randomized Trials:
  • ESTIMABL1 (2012, France):
    • Design:
      • 2 × 2 factorial randomized control trial (RCT):
        • Comparing low-dose (1.1 GBq) vs high-dose (3.7 GBq) radioactive iodine (RAI), and rhTSH stimulation vs thyroid hormone withdrawal for remnant ablation
    • Primary Outcome:
      • Remnant ablation success at 6 to 10 months:
        • ~92% to 95%
      • 5‑Year Follow-Up (2018):
        • 98% no evidence of disease
        • No differences between RAI dose or preparation method 
    • Clinical Meaning:
      • Low-dose RAI + rhTSH is as effective as high-dose with withdrawal
      • Lower toxicity, better patient convenience:
        • Incorporated in ATA 2015 guidelines (New Guidelines Coming Out Fall 2025)
  • HiLo (UK, Mallick et al., 2012):
    • Design:
      • Similar to ESTIMABL1:
        • Compared low- vs high-dose plus rhTSH vs withdrawal
    • Outcome:
      • Comparable ablation success and low recurrence rates 
  • ESTIMABL2 (France, 2022):
    • Design:
      • RCT of low-dose RAI (1.1 GBq) vs no RAI, post-total thyroidectomy in low-risk DTC
    • 3-Year Results:
      • Recurrence:
        • 2.7% (no RAI) vs 1.9% (RAI); non-inferior 
    • Commentary:
      • Non-inferiority holds even at lowest end of risk spectrum:
        • Upholds omission in select patients
  • IoN (“Iodine or Not”) Trial (UK, Lancet June 2025):
    • Design:
      • Phase II / III RCT randomizing 504 low-risk DTC patients to RAI vs no RAI
    • 5-Year Data:
      • 98% disease-free without RAI vs 96% with RAI
      • Omitting RAI improved quality of life and reduced isolation burden 
    • Significance:
      • Largest definitive trial confirming RAI omission is safe in ATA low-risk patients
  • Additional Evidence and Observational Data:
    • Long-term observational studies (> 8 years):
      • Show high remission and low recurrence with low-dose RAI 
    • Meta-analyses and reviews echo findings:
      • Low-dose or no RAI yields excellent oncologic outcomes in strictly low-risk DTC
• Clinical Take‑Home Points for Surgeons:
  • Low-dose (1.1 GBq) RAI is sufficient for remnant ablation when RAI is used
  • rhTSH is preferred for patient comfort
  • RAI omission is safe in ATA low-risk cases:
    • Per ESTIMABL2 and IoN with:
      • ~ 98% disease-free survival at 5 years
    • QoL benefit and reduced isolation burden when RAI is not used:
      • Especially relevant for younger, family-centered patients
  • ATA 2015 guidelines:
    • Support selective RAI omission, reinforced by current trials
  • Surgical completeness matters:
    • Trials include total thyroidectomy with low /absent nodal burden
    • Partial thyroidectomy or residual disease was excluded
  • Follow-up protocol:
    • Stringent ultrasound and thyroglobulin monitoring essential when omitting RAI
• Practical ATA-Based Approach:
  • Very Low / Low Risk ATA:
    • Intrathyroidal ≤ 4 cm
    • N0 to N1a
    • No vascular invasion:
      • Omit RAI:
        • Active surveillance with US + Tg (with / without rhTSH)
    • If ablation desired (e.g., Tg monitoring ease):
      • Use 1.1 GBq + rhTSH
  • Intermediate Risk:
    • Minimal extrathyroidal extension
    • > 5 involved nodes:
      • Consider selective RAI at low dose:
        • Decision individualized based on risk tolerance
• Summary:
  • In ATA-defined low-risk DTC:
    • Low-dose RAI + rhTSH is as effective as high-dose or withdrawal methods
  • Importantly, omission of RAI does not compromise outcomes and offers QoL and cost benefits
  • Surveillance replaces ablation, with triggers reserved for structural or biochemical recurrence

👉Did you know that the only cure for primary hyperparathyroidism is surgery?

👉Dr. Rodrigo Arrangoiz is Pioneer in Mexico in radio-guided minimally invasive parathyroidectomy.

https://m.youtube.com/watch feature=youtu.be&v=AgvQmtz1gnA

👉Find more info at http://www.hiperparatiroidismo.info

#Arrangoiz

#ParathyroidExpert #ParathyroidSurgeon #Hiperparatiroidismo #Hipercalcemia #CheckYourCalcium #HeadandNeckSurgeon #EndocrineSurgeon

#Hyperparathyrodism

#CirujanodeParatiroides

#ExpertoenParatiroides

#SociedadQuirurgica

👉4D-CT scans are more sensitive than sestamibi scans or ultrasound for tumor localization in recurrent parathyroid disease.

👉CheckYourCalcium (realízate un calcio total ensangre).

#CheckYourCalcium #Arrangoiz #ParathyroidExpert #ParathyroidSurgeon #Hiperparatiroidism #Hipercalcemia #CheckYourCalcium #HeadandNeckSurgeon #MountSinaiMedicalCenter #MSMC #Miami #Mexico #Hyperparathyroidism

👉Find more info at http://www.hiperparatiroidismo.info and https://www.ncbi.nlm.nih.gov/pubmed/29484563

👉The overproduction of parathyroid hormone (PTH), termed hyperparathyroidism (HPT), can be categorized as primary, secondary, or tertiary.

👉Primary hyperparathyroidism (PHPT) arises from an unregulated overproduction of PTH from an abnormal parathyroid gland.

👉Increased PTH levels may also occur as a compensatory response to hypocalcemic states resulting from chronic renal failure or gastrointestinal (GI) malabsorption of calcium. This secondary HPT can be reversed by correction of the underlying problem (e.g., kidney transplantation for chronic renal failure).

👉However, chronically stimulated parathyroid glands may occasionally become autonomous, resulting in persistence or recurrence of the hypercalcemia after successful renal transplantation, resulting in tertiary HPT. This review paper will focus on PHTP

#Arrangoiz #ParathyroidSurgeon #ParathyroidExpert #Hyperparathyroidism #EndocrineSurgery #Hypercalcemia #MountSinaiMedicalCenter #MSMC #Miami #Mexico

👉The changes in calcium and phosphate that result from renal hyperparathyroidism may increase calcification of the arteries leading to heart attacks and strokes.

👉Learn more at https://www.atherosclerosis-journal.com/article/S0021-9150(18)31349-2/fulltext

👉CheckYourCalcium (realízate un calcio total en sangre).

👉Para más información: http://www.hiperparatiroidismo.info

#CheckYourCalcium #Arrangoiz #ParathyroidExpert #ParathyroidSurgeon #Hiperparatiroidism #Hipercalcemia #CheckYourCalcium #HeadandNeckSurgeon #MountSinaiMedicalCenter #MSMC #Miami #Mexico #Hyperparathyroidism

• Focused parathyroidectomy:
  • Is the preferred approach in patients who have a solitary lesion:
    • That is imaged conclusively by:
      • Ultrasound, sestamibi, or other appropriate imaging modalities
• If the surgeon is not attempting to visualize all four glands:
  • The use of IOPTH:
    • To determine whether all hyperfunctioning tissue has been removed and to document an appropriate drop in PTH levels after the removal of the suspected gland:
      • Is the standard of care
• The most common criterion used:
  • Is a 50% or greater reduction in the PTH level from the baseline 10 minute after parathyroidectomy
• The best clinical marker of single-gland disease:
  • Is concordant preoperative imaging:
    • In combination with an appropriate correction of IOPTH levels
• Previous neck surgery or lack of concordant imaging on two types of studies:
  • Is not a contraindication to attempting focused parathyroidectomy
• Patients suspected of having multigland disease are managed by four-gland exploration via a smaller incision

#Arrangoiz #ParathyroidSurgeon #ParathyroidExpert #Hypercalcemia #PHPT #Hyperparathyroidism #PrimaryHyperparathyroidism #EndocrineSurgery #HeadandNeckSurgeon #CancerSurgeon #Surgeon #Teacher #Miami #Mexico #MountSinaiMedicalCenter #MSMC

👉Per American Association of Endocrine Surgeons (AAES) Guidelines, parathyroidectomy is recommended for all patients under 50 with a diagnosis of primary hyperparathyroidism, regardless of the presence of symptoms or physical findings – Dr. Rodrigo Arrangoiz

👉https://jamanetwork.com/journals/jamasurgery/fullarticle/2542667

👉For more information: http://www.hiperparatiroidismo.info

#Arrangoiz #ParathyroidExpert #ParathyroidSurgeon #Hyperparathyroidism #Hipercalcemia #HeadandNeckSurgeon #MountSInaiMedicalCenter #MSMC #Miami #Mexico #Hiperparatiroidismo #ExpertoenParatiroides #CirujanodeParatiroides

• Exposure of the Prevertebral Fascia:
  • The first step in identifying the superior gland:
    • Is to locate the inferior thyroid artery (ITA)
  • The ITA is a crucial reference point for the location of the superior parathyroid gland:
    • The superior parathyroid gland is usually found in an area 1 cm cranial to the ITA
  • Once the ITA has been identified, blunt dissection cranial to the artery and directly posterior is performed down to the shiny prevertebral fascia
  • The prevertebral fascia defines the posterior extent of the dissection, and the most posterior location possible for a superior parathyroid gland
• Visual:
  • Although it is tempting to dive straight in and attempt to dissect the first piece of tissue that resembles parathyroid tissue, considerable time and effort can be saved by slowly and deliberately confirming the key landmarks and looking for some of the morphological features described in section “Pearls for Identification of Parathyroid Glands” (published in a previous Blog)
  • The identification of a parathyroid gland begins withcareful visual inspection:
    • Start by looking for a gland or fat pad in a 1 to 2-cm area cranial to the ITA on the posterior surface of the thyroid lobe (Figure 1)
• Digital
  • The superior glands can be found in a number of positions in association with structures from the fourth branchial arch, including:
    • Retropharyngeal
    • Retroesophageal
    • Para-esophageal
    • Adjacent the hyoid bone
  • Further, when a superior gland enlarges:
    • It tends to do so in a posterior and caudal direction and can pass behind the ITA to lie below the inferior gland
  • After careful visual inspection in the area 1 cm cranial tothe ITA, these potential positions are digitally palpatedfor using five maneuvers (Fig. 1.4):
    • The index finger is introduced into the space previously created above the ITA and directly down to the prevertebral fascia / retroesophageal space and then swept along the esophagus to feel in the retroesophageal / retropharyngeal positions
    • The finger is then swung caudally until the finger lies vertically with the tip below the ITA
    • The tissue over the tip of the finger is gently balloted, feeling for an enlarged superior gland to contact the tip of the posterior index finger
    • The finger is then swung back to a horizontal position
    • The finger is withdrawn slowly while the tip remain in contact with the esophagus and trachea, deliberately feeling for the trachea-esophageal groove

#Arrangoiz #ParathyroidSurgeon #ParathyroidExpert #Hyperparathyroidism #Hypercalcemia #HeadandNeckSurgeon #MSMC #MountSinaiMedicalCenter #Miami #Mexico #Surgeon #Teacher

👉Normocalcemic hyperparathyroidism (HPT) is characterized by normal calcium, high PTH levels, and may be a distinct entity that behaves differently than classical HPT.

👉Rodrigo Arrangoiz MS, MD, FACS cirujano de tumores de cabeza y cuello / cirugia endocrina es experto en el manejo del hiperparatiroidismo primario.

👉Introdujo a su país (Mexico) la técnica de exploración bilateral de cuello con valoración de la funcionalidad de las glándulas paratiroides con paratiroidectomia radioguiada:

https://m.youtube.com/watch?v=AgvQmtz1gnA&time_continue=127

👉Su entrenamiento fue el siguiente:

• Cirugia general y gastrointestinal:
• Michigan State University:
• 2004 al 2010• Cirugia oncológica / tumores de cabeza y cuello / cirugia endocrina:
• Fox Chase Cancer Center (Filadelfia):
• 2010 al 2012• Maestria en ciencias (Clinical research for healthprofessionals):
• Drexel University (Filadelfia):
• 2010 al 2012• Cirugia de tumores de cabeza y cuello / cirugiaendocrina
• IFHNOS / Memorial Sloan Kettering Cancer Center:
• 2014 al 2016

#Arrangoiz

#CirugiadeTumoresdeCabezayCuello

#CirugiaEndocrina

#CirugiaOncologica

#HeadandNeckSurgery

#EndocrineSurgery

#SurgicalOncology

#Hyperparathyroidism

#Hiperparatiroidism

#MountSinaiMedicalCenter

#MSMC

#Miami

#Mexico