Blog

• Title:
  • Outcome after ablation in patients with low‑risk thyroid cancer (ESTIMABL1)
• Design:
  • A multicenter, randomized, open-label, phase III equivalence trial:
    • Across 24 centers in France (2007 to 2010)
• Population:
  • 752 adults with low-risk papillary or follicular differentiated thyroid cancer (DTC) post-total thyroidectomy
• Randomization (1:1:1:1) into four groups:
  • RAI dose:
    • Low (1.1 GBq / ~30 mCi) vs High (3.7 GBq / ~100 mCi)
  • TSH stimulation:
    • rhTSH injections vs thyroid hormone withdrawal
• Primary Endpoint:
  • Successful remnant ablation at 6 to 10 months:
    • Defined as stimulated thyroglobulin ≤ 1 ng/mL and no residual tissue on ultrasound
• Initial and Long-Term Efficacy:
  • 6 to 10 Month Ablation Success:
    • ~ 92% across all groups:
      • With equivalence between:
        • Low and high dose
        • rhTSH vs withdrawal
  • 5.4-Year Median Follow-Up (n = 726):
    • 98% had no evidence of disease (715 / 726)
    • 11 patients had evidence of persistent or recurrent disease (structural or biochemical)
      • Recurrence was evenly distributed across RAI dose and stimulation method:
        • Indicating no impact of strategy on long-term outcomes
• Prognostic Predictors:
  • Stimulated thyroglobulin at ablation:
    • Was predictive of eventual disease status and ablation success:
      • Patients with higher thyroglobulin were more likely to have persistent disease regardless of group
  • No lymph node stratification influence or stimulation method effect was observed
• Clinical Implications:
  • Low-dose RAI (1.1 GBq) with rhTSH is validated as standard of care:
    • Equivalent efficacy with better patient experience
  • ATA 2015 guidelines endorse this strategy for low-risk DTC:
    • Simplified staging and reduced toxicity
  • No impact on long-term disease-free survival:
    • Supports tailored management based on disease biology rather than RAI intensity
• Evidence Synthesis:
  • Meta-analysis of RCTs (> 1,500 patients, 4 to 10 years follow-up):
    • Confirms no difference in long-term recurrence between 1.1 GBq and 3.7 GBq (OR 0.93, 95% CI 0.53–1.63)
  • Similar equivalence was seen between rhTSH vs hormone withdrawal and across centers (France & UK)
  • HiLo trial results align, confirming comparable recurrence rates with low-dose RAI and rhTSH
• Surgical Take-Home Points:
  • Remnant ablation using low-dose RAI + rhTSH is effective and minimizes side effects compared to high-dose or withdrawal strategies
  • Stimulated thyroglobulin at post-op ablation is a stronger predictor of recurrence than RAI dose or preparation method
  • No difference in long-term disease-free survival across dose or stimulation arms supports risk-adapted RAI use
  • Multidisciplinary protocols should adopt low-dose rhTSH-based ablation for ATA low-risk patients, reserving higher dose only for select cases (e.g., unresected tissue, aggressive pathology)
  • Surveillance strategies:
    • Regular ultrasound + Tg on levothyroxine; use stimulated Tg selectively for indeterminate findings

👉Negative preoperative imaging does not exclude patients from surgery for hyperparathyroidism.

👉Experienced parathyroid surgeons have high cure rate (95%) with or without preoperative localization.

👉https://doi.org/10.1210/jc.2002-021095

#CheckYourCalcium #Arrangoiz #ParathyroidSurgeon #PararhyroidExpert MountSinaiMedicalCenter #MSMC #Miami #Mexico #HeadandNeckSurgeon #Hyperparathyroidism

• 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