AAES 38th Annual Meeting 
April 2-4, 2017

Early Bird Registration Deadline: 
February 1, 2017

March 31 - April 1, 2017
Orlando, FL
Local Arrangements Chair: Mira Milas, MD
Program Chair: Scott Wilhelm, MD
Dates: April 2-4, 2017

Durham, NC
Local Arrangements Chair: Julie Ann Sosa, MD
Dates: May 6-8, 2018

Los Angeles, CA
Local Arrangements Chair: Michael Yeh, MD
Dates: TBD

April 1 - 4
Orlando, FL

May 3-7
Austin, TX

October 18-22
Victoria, BC, Canada

Fall 2016
It is a true honor for me to serve as President of the American Association of Endocrine Surgeons this year. For almost 25 years, I have felt that the AAES has been my professional home. I have thoroughly enjoyed the friendships and collaborative relationships that I have had the good fortune to cultivate through the AAES over many years. For this reason, it has been very humbling to serve a President this year.
As I am sure most of you know, this summer we shifted to a new management company, AMR. I want to thank the entire AMR team for all of their efforts at making a very smooth transition. In conjunction with the move to the new management team, the leadership of the AAES thought it would be an opportune time to undertake a formal strategic planning process. This process began in the fall and will continue into the new year as we clarify what is the appropriate mission for the AAES in the years to come. You will be hearing more details of this process in the upcoming months as we define our short and long term objectives so that we can continue to grow and serve our members and ultimately benefit our patients.
Ever since I first learned in residency that there was such a thing as an endocrine surgeon, I have felt that it is the greatest practice that a surgeon could possibly have. The anatomy and physiology of endocrine glands is fascinating and the operations demand technical mastery. I have felt fortunate to be able to practice endocrine surgery. JAMA-Surgery recently published an article that provides an objective assessment that quantifies what I have felt for these many years. In an article entitled, "Quality of Life and Burnout Rates Across Surgical Specialties: A Systematic Review," Marisa Pulcrano (a medical student at Georgetown University) and Drs. Stephen R. T. Evans and Michael Sosin completed a systematic review of quality of life and burnout among various surgical specialties. It is no surprise to me that these authors found that of the 16 specialties assessed, endocrine surgeons demonstrated the highest career satisfaction at 96% (tied with pediatric surgery). For those of us who work in academic medical centers where we interact regularly with medical students and surgical residents, we should remember this data and not hesitate to communicate the wonderful aspects of a career in endocrine surgery to those we teach.
The upcoming spring meeting in Orlando is coming together wonderfully. The meeting this year will be a special one in that we will be co-located with the Endocrine Society. Dr. Mira Milas, our Local Arrangements Chair, and Dr. Scott Wilhelm, our Program Chair, have been working hard to put together a great meeting that will maintain much of our traditional format while allowing some integrated programming with our colleagues in the Endocrine Society. The Program Committee has had to choose from many excellent abstracts to put together another outstanding scientific program that I am confident we will all learn from.
I hope that you will take the time to read through this Newsletter to see the many ways that the AAES Officers and Committee Chairs are serving you through the organization. I cannot thank all of them enough for their dedication and hard work.
I wish you all joyous and healthy holidays and I can't wait to see you in Orlando in the spring!

Rebecca S. Sippel, MD
Greetings from the Secretary office of the AAES! This has been an exciting year for the AAES and lots of changes are happening!  In July we made the transition to a new management company, AMR, located in Lexington, KY. We have been busy the last 6 months getting AMR acclimated to our organization and to our specialty and they are working closely with us to help us improve and streamline our operations. We both have a lot to learn in the process, but the transition is going well.  You may have already noticed some changes, like a new membership directory, a new on-line mechanism to pay dues, and a new abstract submission platform.   We are also working on a website redesign.  We are collating changes that are needed and functionality that needs to be added and we are hoping to launch the new and improved site by late spring of 2017.

Since our last newsletter, we, under the leadership of Dr. Barry Inabnet have successfully transitioned CESQIP to its own stand-alone organization, the Endocrine Surgery Quality Foundation (ESQ).  CESQIP still remains an important initiative started within the AAES, but now it is managed as a separate entity, which enhances both its fiscal and legal management. We will continue to have a committee within the AAES, the CESQIP Committee, to help with the oversight of this program, but the operations of this are no longer housed within our organization.
Planning for our upcoming meeting in Orlando, under the direction of Drs. Scott Wilhelm and Mira Milas, is well underway and it looks to be a fabulous scientific and social program. This will be an exciting meeting as it is going to be not only a co-located meeting, but an integrated meeting with the Endocrine Society. We are altering the format of our meeting in order to clear Monday afternoon to allow us the opportunity to run integrated sessions with our endocrine colleagues.  I think this is going to be an outstanding meeting and I hope that you are all looking forward to joining us in Orlando this April!

As part of our new contract with AMR, they have helped our leadership go through its first strategic planning session this fall. The weekend retreat in Lexington, KY was a great opportunity for the council to review the data from our membership survey this summer and to help us determine what our goals and priorities need to be over the next few years. Our strategic plan in robust and there are a lot of items that we want to start working on, but it is clear that this will be a long-term process.  As we finalize the details of the plan we look forward to sharing more details to our membership. 
Our organization is vibrant and our membership is full of exciting ideas. Our recently developed strategic plan has highlighted many important issues that we want to focus on over the next year and I look forward to working with all of you to help make the AAES an even better organization! 

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Cord Sturgeon, MD
I hope you will enjoy the January 2017 issue of SURGERY.  The issue has been organized by topic, and includes editorials on controversial papers, and transcriptions of all the discussions of the podium presentations. I am sincerely grateful to all the ad-hoc reviewers who accepted my invitations to review AAES manuscripts. I am looking forward to the April 2-4, 2017 meeting in Orlando, and preparing another issue of the journal to serve as the proceedings of the AAES.  
2017 Manuscript Deadlines
  • February 1: Manuscript deadline
  • May 1: First revisions due back to Recorder
  • July 1: All papers submitted to SURGERY
2017 Manuscript Submission
All AAES Podium Papers must be submitted online by February 1 at . After you register or log in, click on "submit a new paper", enter the title, and then choose the category "AAES Society Paper" from the drop down menu.

There is no manuscript submission requirement for poster presenters, however poster manuscripts have been favorably received by both SURGERY and ANNALS OF SURGICAL ONCOLOGY in the past. To submit full manuscripts to ANNALS OF SURGICAL ONCOLOGY, use the following link:  Please select "AAES manuscript" from the dropdown menu. 

The journal SURGERY offers a free service called AudioSlides. These are brief, webcast-style presentations that are shown next to published articles on ScienceDirect and can be viewed for free. Authors can modify their AAES PowerPoint presentation to create AudioSlides. This format gives you the opportunity to explain your research in your own words and promote your work by embedding it on your own website and sharing in social media. I strongly encourage creating an AudioSlides presentation to accompany your manuscript. 

Manuscript Reviewers Needed

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

Thanks for your support!

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Sareh Parangi, MD
It is my honor to be the first to serve in the role of Treasurer to the AAES which was developed by the AAES Council due to the growing demands for fiscal management of our society. We are growing and it shows! We have now transitioned to a new management company, AMR and set a budget for the new fiscal year.
Last year our total revenue was $513K and our total expenses were $446K; we did well when compared to the 2015-2016 budgetary goals that had been set. Our annual meeting was successful from a financial standpoint due to strong support from exhibitors, sponsors and educational grants.
This year our total budget (2016-2017) includes an operating budget of $164K for running our organization and an annual meeting budget of $307K for a total budget of 671K. Our management company costs are our largest single total expenditure at $132K when considering our non annual meeting costs..
As Treasurer my goals for the next three years are aligned with our strategic plan:
  1. Significantly increase fundraising efforts to be able to support the research and educational missions of the AAES by identifying and implementing creative fundraising tactics.
  2. Further strengthen our relation with the AAES Foundation by coordinating our fundraising efforts.
  3. Establish a fiscally strategy for our future educational products for members and the surgical community.
  4. Help the AAES implement our new website/social media platforms in a fiscally sound manner
  5. Make sure our dues match the needs of our society
  6. Look for creative ways to decrease our budget where possible while maintaining the best services for our members
  7. Suggest safe investments for our reserves
I hope that each and every one of you will reach out to me ( with important ideas related to our fiscal goals. We depend on you for helping us fundraise and to maintain contact with our old sponsors and to generate new leads for sponsorships.  Together we will continue to make the AAES a fiscally strong organization for the next generation of endocrine surgeons.

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Barbra Miller, MD
Since the AAES' transition to our new management company, AMR, the IT Committee has been hard at work for its members. As part of the transition, a much needed re-build of the AAES website has commenced. Suggestions received from past membership surveys along with input from AAES committees and the Executive Council are being carefully considered. Thank you for your responses to these surveys! Stay tuned for the launch of the new website which is expected to be near the time of the 2017 AAES Annual meeting.

Also as a result of responses to membership surveys and some hard work done by your fellow AAES members, we have heard the desire for continued member engagement throughout the year rather than having most organizational activity occur at the Annual meeting. As part of this effort, various technology will be utilized to drive increased member activity. An AAES Facebook page is being created. We'll let you know when you can 'Friend' the AAES.

AAES is now on Twitter! We now have a full-time active Twitter account. In the past, we have simply used Twitter during our annual meetings. Follow @TheAAES on Twitter. An email was recently sent to the membership with documents detailing how to join Twitter if you are not already tweeting as well as how to join a Twitter hashtag chat. The first AAES Twitter journal club will start soon. Watch for more information to come in the near future.

The IT committee looks forward to continuing to serve our fellow AAES members. Please contact any of the IT committee members with suggestions or concerns.
Best wishes to all for a happy holiday season!
Barbra S. Miller, MD
Information Technology Committee Chair

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Linwah Yip, MD
We are pleased to report that the AAES membership is robust and growing.  Overall, we have 497 members and are accepting new applications in all membership categories until January 31, 2017.  We are looking forward to presenting the new members to be voted upon at our annual meeting in Orlando.  Thank you to James Lee, James Howe, and Julie Miller for their significant contributions to the committee thus far.

We have been working with our new management company to simplify the online application forms and these changes have already been implemented.  In response to our increasingly diverse endocrine surgery practice patterns, we have outlined options for applicants applying for Active Membership to demonstrate special interest in endocrine surgery and these can be found on the Become a Member page of our website. We hope these changes will help streamline the new membership process.

We encourage you to continue to spread the word about the AAES and benefits of membership to your interested colleagues.  We greatly appreciate your efforts and your support of our new members.  

Requirements for membership can be found online at, and any questions can be addressed to

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Tracy S. Wang, MD, MPH
There are currently 25 AAES-accredited fellowship programs  across the United States, Mexico, and Canada. In September 2016, the AAES Fellowship Match successfully placed 24 outstanding candidates for the 2017-2018 academic year, to start August 1, 2017. 

Congratulations to the incoming Class of 2018!

Brigham and Women's Hospital Lindsay Kuo, MD
Columbia University Denise Lee, MD
Johns Hopkins University School of Medicine Eyas Alkhalili, MD
Massachusetts General Hospital Heather Wachtel, MD
Mayo Clinic College of Medicine Veljko Strajina, MD
Medical College of Wisconsin  Ioanna Mazotas, MD
University of Miami Leonard M. Miller School of Medicine Melissa Mao, MD
Icahn School of Medicine at Mount Sinai Anna Aronova, MD
NorthShore University HealthSystem, John H. Stroger Jr. Hospital of Cook County Huan Yan, MD
Baylor Scott & White Clinic/Texas A&M HSC Rebekah Campbell, MD
University of Calgary Jane Mills, MD
University of California, San Francisco  Yufei Chen, MD
Iheoma Nwaogu, MD
University of Michigan Jason Glenn, MD
University of Pittsburgh Janeil Belle, MD
University of Wisconsin- Madison Alexandria McDow, MD
Yale University School of Medicine Neeta Erinjeri, MD
Cleveland Clinic Iuliana Bobanga, MD
Cassandre Benav, MD 
University of Chicago Salman Alsafran, MD
University of Texas MD Anderson Cancer Center Jonathan Zagzag, MD
Duke University Medical Center Hadiza Kazaure, MD
University of California, Los Angeles Yasmine Assadipur, MD
Weill Cornell Medical College Brendan Finnerty, MD
University of Texas Southwestern Medical Center James Davis, MD
The AAES will be sponsoring the 2017 Match for clinical fellowship positions for the 2018 - 2019  academic year in the spring/summer of 2017.
Important Dates (Tentative)
  • Wednesday, February 15, 2017: Online application site opens at 9:00 AM CST.
  • Friday, June 2, 2017: Online application site closes at 11:59 CDT. Applicants interested in applying for a fellowship in Endocrine Surgery must have completed their applications by this time, including all letters of recommendation.
  • Monday, August 14, 2017: Online ranking site opens at 9:00 AM CDT.
  • Wednesday, September 6, 2017: Applicant and Program rank lists due by 11:59 PM PDT.
  • Monday, September 11, 2017: 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 18, 2017: Due date for secondary rank of any unmatched programs and unmatched applicants.
  • Wednesday, September 20, 2017: Match results announced.
For additional information, please go to or contact the AAES Headquarters Office , or Dr. Tracy Wang ( ).

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Kepal Patel, MD
The Education and Research Committee (ERC) continues to promote the AAES goals of supporting new research and education and is actively involved in disseminating educational information to patients, health care providers, and AAES members.  We are in the process of initiating several novel and exciting projects utilizing social media and other resources to reach a wider audience.
One of the major duties of the ERC is to select the recipients of the Paul LoGerfo Award. The purpose of the Paul LoGerfo Award is to enrich the discipline of endocrine surgery and to advance the careers of junior investigators who are interested in a career in academic endocrine surgery.  We will continue to fund two awards, $10,000 each.  The 2017 deadline for the Paul LoGerfo Award is February 15th. Please look for the announcement soon. We welcome proposals in a wide spectrum of research topics including surgical ethics, education, epidemiology, biostatistics, outcomes, health care delivery, as well as clinical or basic science research pertaining to the field of endocrine surgery.
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 Editors-in-Chief, Carrie Lubitz ( ) and Insoo Suh ( ).  Please read the most recent reviews in the ESR section of this newsletter.

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Sally Carty, MD
Over the past year, AAES has really moved along in its development and presentation of evidence-based guidelines for the management of endocrine surgery disease processes.  
First, we are delighted to announce that the AAES Guidelines for Definitive Management of Primary Hyperparathyroidism were electronically published in JAMA Surgery on August 10, 2016.  The AAES Parathyroidectomy Guidelines were structured as a brief Executive Summary accompanied by a more lengthy online Supplement containing additional details, pearls, references, discussions of controversy, and expert advice.  Last month, the AAES Parathyroidectomy Guidelines then came out in print (Wilhelm et al, October 2016;15(10):959-968) and were showcased with a thought-provoking Editorial from Dr. Julie Ann Sosa (JAMA Surg October 2016;151(10):969.) The 16 task force authors worked very hard to complete the project from soup to nuts in 2.5 years, and are grateful to all the AAES members and fellow travelers who helped in the writing process.  We sincerely hope that members have a chance to read these comprehensive evidence-based practice guidelines, which are the first of their kind for surgeons.

Next, to cohere and exposit best practices after decades of change in the field, AAES will prepare and publish Clinical Practice Guidelines for Thyroidectomy.  Drs. Chris McHenry and Sally Carty are co-chairing the new task force, which is composed of 19 multidisciplinary authors including experts from pathology, endocrinology, and otolaryngology.  Working with first author Dr. Kepal Patel, the authors are making timely progress so far, and anticipate presenting their work to AAES members for suggestions and comments in about a years' time.

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Sonia L. Sugg, MD 
Annual reports and re-accreditation reports will be due on January 23, 2017.  Forms will be emailed in December 2016. The next deadline for a letter of intent to apply for a new fellowship is August 1, 2017, and the application submission deadline will be September 5, 2017. 

Please request an application form and direct any questions regarding the process to Sonia Sugg at 

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William B. Inabnet, III, MD
It is a privilege to serve as Chair of the CESQIP Committee and to have the opportunity to update the AAES membership.
Growth : More than 170 surgeons from 48 institutions have joined the collaborative. Recent enrollees include Massachusetts General Hospital, Penn State, Johns Hopkins and the Brigham and Women's Hospital. Close to 17,000 unique case entries have now been entered into the CESQIP modules. Under the leadership of Miguel Herrera and in conjunction with a 3rd party sponsor, a consortium of 30 Central and South American sites are poised to join CESQIP, positioning our quality initiative to be the "go to" outcomes entity for endocrine surgery in the Americas.
Knowledge : In early 2017, the CESQIP Committee will be rolling out the procedures and policies for investigators to query the CESQIP aggregate data set.  The Committee is working diligently to assure that the process is fair, consistent and transparent.  In order to understand the process from beginning to end and to troubleshoot any obstacles, the CESQIP Committee is performing the very first aggregate data analysis on a thyroid surgery outcomes topic.  It is anticipated that the CESQIP Committee will start accepting proposals on March 1, 2017. At present, only investigators at participating CESQIP sites are eligible to query the aggregate data set.
Value : In 2015, Congress passed the Medicare Access and CHIP Reauthorization Act (MACRA), a complex piece of legislation that established the Quality Payment Program (QPP). A key component of the QPP - the Merit-Based Incentive Payment System (MIPS) - signifies a shift from fee-for-service reimbursement to a reimbursement structure based on the value (or quality) of care. MIPS data will be used to calculate performance pay: incentive payment for good outcomes and penalties for poor outcomes.  Data collected in 2017 will be used to calculate quality payments in 2019, whereby 8% of dollars will be a risk (4% positive and 4% negative).  By 2022, 18% of dollars will be at risk.  CESQIP is applying to the Center for Medicare and Medicaid Services to become a Qualified Clinical Data Registry (QCDR), which would allow CESQIP participants to participate in MIPS.  Surgeons who do not participate in a MIPS or an Alternative Payment Model in 2017 will be assessed an automatic 4% penalty in 2019.  The CESQIP Committee and the Endocrine Surgery Quality Foundation recommends that all AAES members consider joining CESQIP to actively participate in this process. For more information, please visit the CESQIP website at or email us at

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Michael Starks, MD 
It has been an exciting time at the AAES and the community based endocrine surgeons committee is representative of the change that is occurring within our organization.  Our committee became a standing committee of the AAES at the last annual meeting in April 2016, charged with representing the needs of surgeons who are practicing in community settings, where much of endocrine surgery happens, especially thyroid and parathyroid surgery. 
As a committee, we have been working on several projects.  The most visible will be a panel session at the next AAES meeting in Orlando.  This will be focusing on medical liability and mitigating malpractice risk in your practice.  We have a great group of speakers and some interesting facets of this topic to discuss. 
We also have begun to create an online resource helpful to surgeons in community practice, whether they are a newly graduated endocrine fellow or a general surgeon who becomes the de facto endocrine surgeon in their area.  This will be an electronic handbook that can be accessed to provide help and advice about many areas that are important in developing and maintaining an endocrine surgical practice.
Less visibly, but further reaching, we have been active in helping to educate surgeons with an interest in endocrine surgery nationally and internationally through the ACS endocrine surgery discussion board, of which I am the editor.  Currently there are over 3000 members and the site has been accessed by over 600 surgeons in the last month.  AAES member contributions have been valuable, providing direction for the discussion.  The board has been a good place to ask a clinical question, i.e. how to manage a particular patient. We have been working with the AAES Education and Fellowship Committees to broaden the experience available on this site with journal club articles and complex cases.  Recently, we offered the discussion board members access to an interesting case panel discussion organized by MD Anderson and presented by several of the endocrine surgical fellows.  This was well organized, well presented and informative.  We hope to have similar opportunities in the future.   The site can be accessed at acs or by downloading the ACS Communities app.  Please log on and join in the conversation.  Your questions and responses will help raise the bar of how endocrine surgery is delivered.
Finally, our committee would like to accurately represent each of the community based surgeons and their needs, as well as provide them with representation through the AAES.  The recent strategic planning meeting last fall put greater emphasis on the community based surgeon and your role in this organization.  We will be identifying community surgeons, both current members and non-member, assessing their needs and improving their ability to care for patients.  I would love to hear from you if you have specific suggestions about how this committee could be of help to you in your practice.  Please email me at

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Geoffrey B. Thompson, MD
The AAES Foundation continues to flourish.  We have reached the halfway mark to our $1,000,000 goal.  An ongoing development plan with AMR is in the works. 

We are pleased to note that going forward, the invited guest lecture, chosen by the sitting President, will be named the Orlo and Carol Clark Distinguished Lecturer in Endocrine Surgery.  We would like to raise $60,000 for this distinguished lecture.  Due to the kind and generous donation of $20,000 from a grateful patient, we are one-third of the way toward achieving this goal.  The first lecture will occur in 2017 at the annual AAES meeting.  We encourage all of our members to donate specifically to this fund; especially all of Dr. Clark's prior fellows.  This will be a wonderful honor for our beloved teacher and friend, as well as for Carol who has been very active in the AAES over the years. 

We will continue to provide two $15,000 research grants annually, with awardees being selected by our Education and Research Committee headed up by Dr. Kepal Patel.  We are also planning to provide Endocrine Surgery University with an annual contribution of $5,000 to help offset their expenses for this wonderful weekend conference for our graduating endocrine surgery fellows.  This is held each year just prior to the annual AAES meeting. 

Please continue to support the AAES Foundation directly.  You may specify your donation to go to the Paul LoGerfo Fund, the Normal Thompson Fellowship, or the Orlo and Carol Clark Distinguished Lecture in Endocrine Surgery.  Unspecified funds will go directly into the AAES Foundation account. 

We wish you all a wonderful holiday season.  The Foundation Board looks forward to seeing all of you at the annual meeting this spring.

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Scott Wilhelm, MD 
Dear Colleagues,

As the Holidays approach, I first want to wish each of you in my AAES family a peaceful and joyous holiday season.  As you know, the deadline has come and gone for abstract submission for the 2017- AAES 38th Annual Scientific meeting which this year will be held concurrently with the Endocrine Society in Orlando, FL from April 2-4, 2017. As expected, we had an outstanding group of abstracts submitted that your program committee is currently reviewing and preparing into this year's scientific sessions. 

This year's meeting has held new challenges and new opportunities in partnering with the Endocrine Society.  As always, we will remain true to the core nature of our AAES scientific sessions and poster session with high quality presentations and cutting edge research.  Our Historical Lecture will be given by Dr. David Narhwold, Professor Emeritus at Northwestern University in Chicago, IL who has had a strong personal connection and guiding hand to our President, Dr. Peter Angelos. The Presidential invited lecturer will be Dr. Jack Gilbert who will discuss "Cancer and the Microbiome."

We will again feature a Community Endocrine Surgeon program which will be led by Dr Michael Starks. I think we have all seen the power of the Endocrine Surgery Digest from the American College of Surgeons that Michael has championed. He is working hard to assemble what should be an outstanding panel to review, "The Medicolegal Aspects of Endocrine Surgery." We will also once again host an Allied Health Care Symposium led by those who interact with our patients and staff to facilitate the care required to manage our complex patient needs. We highly encourage you to extend the invitation to attend this year's meeting for your Department's Allied Health care team.

Our partnership with the Endocrine Society has been nothing short of phenomenal.  Our senior leadership, program committee, and AMR management team have been working closely with their senior leadership for the last 6 months to craft what should be a very meaningful and successful scientific and collegial partnership. We are planning to hold an afternoon of joint programming featuring a joint Interesting Case Session (similar to Nashville-2015). It will be a panel style format with experts from both societies, moderated by our own Dr. Samuel Snyder. It will be followed by two parallel sessions including a Surgical Video session with "How I do it" videos chaired by Dr. James Lee and some Pro/Con Symposium talks featuring staff from both societies on some controversial topics in Endocrine Surgery.

This should be a meeting to explore new ideas, revisit traditional values, see old friends and make some new ones. I am honored to be your Program Chair and can't wait to see you in Orlando for what should be a meeting to remember!

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Oncologic Progress for the Treatment of Parathyroid Carcinoma Is Needed

Christakis I, Silva AM, Kwatampora LJ, Warneke CL, Clarke CN, Williams MD, Grubbs EG, Lee JE, Perrier ND. J Surg Oncol. 2016; 114(6):708-713

Reviewer: Reese W. Randle MD, University of Wisconsin

In Brief
Parathyroid cancer is rare, implicated in only about 1% of cases of primary hyperparathyroidism. As a whole, earlier recognition of hyperparathyroidism has resulted in a shift in the clinical presentation of patients with benign disease, but it is unclear if a similar shift has occurred in patients with parathyroid cancer. This uncertainty prompted Christakis and colleagues to investigate the presentation, management, and outcomes of parathyroid cancer over time (1). To this end, they performed a retrospective review of MD Anderson's experience managing parathyroid cancer over the past 35 years. They compared the presentation, treatment, and survival of 26 patients with parathyroid cancer undergoing surgery between 1980 and 2001 to 31 patients undergoing surgery between 2002 and 2015. 

Gender distribution and age at initial surgery changed during the study period with a higher proportion of female patients and a higher mean age in the more recent time period, but for the most part, the presentation of patients changed little. Patients in both groups presented with calcium levels averaging between 13 and 14 mg/dl and parathyroid hormone levels greater than 10 times the upper limit of normal. Presenting symptoms and the type of operations performed between the two groups were not significantly different although only about three quarters of the patients in the earliest time period had operative data available for analysis. Adjuvant therapy included chemotherapy or external beam radiation in only a small and seemingly decreasing proportion of patients. Lastly, overall and disease free survival did not improve in the more recent time period, and when compared to historical data from 1968 to 1982, progress in improving outcomes has plateaued (2). 

Christakis and colleagues concluded that MD Anderson's experience from 1980 to 2015 demonstrate a concerning lack of progress in the management of parathyroid cancer. They highlight the pressing need for better diagnostic tools, refined surgical therapy, and novel systemic treatment. 

As a single institution, the group at MD Anderson is able to provide data at the individual level such as laboratory values, disease presentation, and time to recurrence that are important variables for investigations of parathyroid cancer and are unfortunately absent in larger, national datasets. An additional strength lies in how they have reported their data consistently since 1968 allowing clinicians to see how clinical management has impacted (or not impacted) outcomes over time. Although many may criticize the use of overall survival instead of disease-specific survival as the primary outcome, overall survival is likely to capture the sequela of hypercalcemia more comprehensively than diseases-specific survival (3). In other words, cardiovascular or renal causes of death from parathyroid cancer driven hypercalcemia are unlikely to be classified as cancer related even at the institutional level. 
The unavoidable rarity of parathyroid cancer is certainly the greatest limitation in this study. The small numbers available subject findings to substantial risk of type II errors. For example, some of the presenting symptoms, laboratory values, and surgical approaches are reportedly 2-3 fold different between groups, yet these differences are not statistically different. 
Future Directions
The development of a consensus staging system for parathyroid cancer is paramount to facilitate additional study of this rare malignancy. As Christakis and colleagues suggest, multi-institutional collaborative efforts are essential to help combine the detail of institution level studies with the statistical power of population based datasets. Additional efforts should focus on earlier detection of disease, refining the extent of surgical resection, and development of effective systemic therapies. 
  1. Christakis I, Silva AM, Kwatampora LJ, Warneke CL, Clarke CN, Williams MD, Grubbs EG, Lee JE, Perrier ND. Oncologic Progress for the Treatment of Parathyroid Carcinoma Is Needed. J Surg Oncol. 2016; 114(6):708-713.
  2. Anderson BJ, Samaan NA, Vassilopoulou-Sellin R, Ordonez NG, Hickey RC. Parathyroid Carcinoma: features and difficulties in diagnosis and management. Surgery. 1983; 94(6):906-15.
  3. Schneider DF. Parathyroid Carcinoma: Is it time for a change? Ann Surg Oncol. 2015; 22:3772-3773.

Additional High Yield Reading:
  1. Intraoperative near-infrared autofluorescence imaging of parathyroid glands. Ladurner R, Sommerey S, Arabi NA, et al. Surg Endosc. 2016 Nov epub ahead of print.
  2. Central venous parathyroid hormone monitoring using a novel, specific anatomic method accurately predicts cure during minimally invasive parathyroidectomy. Edwards CM, Folek J, Dayawansa S, et al. Am J Surg Sept epub ahead of print.
  3. Use of calcium and parathyroid hormone nomogram to distinguish between atypical primary hyperparathyroidism and normal patients. World J Surg Oct epub ahead of print.
  4. Intraoperative ex vivo parathyroid aspiration: A point of care test to confirm parathyroid tissue. Surgery. 2016;160(4):850-7.

Reoperative Surgery in Patients with Multiple Endocrine
Neoplasia Type 1 Associated Primary Hyperparathyroidism

Xavier M. Keutgen, MD, Naris Nilubol, MD, FACS, Sunita Agarwal, PhD, James Welch, MCG, Craig Cochran, RN, Steve J. Marx, MD, Lee S. Weinstein, MD, William F. Simmonds, MD, and Electron Kebebew, MD, FACS. Annals of Surgical Oncology 2016; Epub July 27, 2016.

Reviewer: Henry Reinhart, MD, Baylor Scott & White Clinic/ Texas A&M HSC

In Brief
This study deals with recurrent or persistent primary hyperparathyroidism (pHPT) in multiple endocrine neoplasia type 1 (MEN1) patients. The authors sought to evaluate the usefulness of different preoperative localizing studies and the value of intraoperative PTH (IOPTH). Since pHPT is the most common presentation of MEN1 it often precedes the diagnosis of MEN1. For this reason surgeons may perform a single gland excision leading to persistent or recurrent hyperparathyroidism (1-4). Since the risks of recurrent laryngeal nerve injury or hypothyroidism are greater in the re-operative neck, the authors sought to assess the various localizing studies and IOPTH to better plan the surgery and to assess the outcomes (5,6). 
Thirty patients were identified with MEN1 that needed reoperation for persistent or recurrent pHPT. Previous operative notes and pathology reports were obtained to aid in planning. The diagnosis of MEN1 was based on genetic analysis (73%) or family history associated with two or more endocrinopathies (27 %). Hyperparathyroidism was diagnosed via elevated serum calcium or ionized calcium and an elevated parathyroid hormone (PTH). In addition to working up associated endocrine tumors, non-invasive imaging for pHPT included ultrasound (US), Tc99m-sestamibi scan (MIBI), MRI of the neck, and CT scan of the neck. Invasive modalities included selective venous sampling, arteriography, hypocalcemic infusion with venous sampling, and PTH measurement. Twenty-nine of thirty patients had at least two forms of localization and IOPTH performed.

The authors found a remission rate of 87% at their institution with a recurrence rate of only 13%. This was lower compared to a previous institutional study (33%) possibly due to a shorter follow up (33 months vs. 58). They attribute the use of localization studies as another possible reason for the improved remission rates. The use of US along with MIBI had a sensitivity of 100 and 85% (respectively) when used to locate a single enlarged gland. The sensitivity dropped to 88 and 72% for detection of all enlarged glands. Patients that had conflicting US and MIBI results required a CT or MRI which identified an offending gland 50% of the time making them useful adjuncts. The small number of patients undergoing invasive studies did not allow for any conclusions.

 IOPTH was very valuable when localizing studies only found one enlarged gland yet multiple abnormal glands were present. IOPTH did not drop in 5 patients prompting additional exploration, which identified additional glands. This enabled a minimally invasive surgery to lower risks, which could then be expanded if needed.

There was no genotype found in this study that was linked with higher recurrence of pHPT. Patients without pancreatic manifestations of MEN1 did not have recurrent of pHPT at follow up. The study also recommended the use of cryopreservation because of the need for delayed auto transplantation. Lastly, bone mineral density (BMD) scores were not improved at last follow up although nephrocalcinosis was improved.

The authors of this study should be applauded for trying to add clarity to the difficult topic of MEN1 associated pHPT in a previously operated field. Some weaknesses of this study were addressed by the authors including the small size, short follow up, and retrospective nature. The study also spans many treatment eras. One final critique is the large variability in the specific combination of the preoperative imaging tests obtained.

Some questions raised by this paper include whether the authors performed the measurement of PTH gradients in the antecubital veins for patients with autografts. This would clarify whether the persistent/recurrent HPT is graft dependent or due to a missed gland. Also, while the paper states a low final IOPTH was not associated with hypoparathyroidism, it does not indicate what final IOPTH was considered acceptable.

While the risks of a complete exploration should be weighed against a minimally invasive surgery, it has been shown a subtotal (3 or 3 ½ gland) resection or total parathyroidectomy with transplantation has a lower risk of recurrence (7, 8). This may be the best means of avoiding a third or fourth operation in these patients. If performed by an experienced endocrine surgeon the risks associated by re-exploration may be mitigated. Also, it should be noted that a subtotal parathyroidectomy may have some benefits when compared to total parathyroidectomy with transplantation as there is no obligate postsurgical hypoparathyroidism and there is only one incision (9).

One of the essential points of this review was the importance of IOPTH in the intraoperative decision making process. In essence, IOPTH was critical to success irrespective of imaging.

Future Directions
The future of many aspects of surgery is rooted in the genotype and phenotype of diseases. With the discovery of specific genotypes associated with different rates of recurrence in MEN1, surgeries could potentially be tailored to the patient's genotype (10). A large prospective study of the specific genotypes found in recurrence of pHPT could greatly add to this area of study.

  1. Goudet P, Murat A, Binquet C, Cardot-Bauters C, Costa A, Ruszniewski P, et al. Risk factors and causes of death in MEN1 disease. A GTE (Groupe d'Etude des Tumeurs Endocrines) cohort study among 758 patients. World J Surg. 2010;34(2):249-55.
  2. Lourenco DM, Jr., Toledo RA, Coutinho FL, Margarido LC, Siqueira SA, dos Santos MA, et al. The impact of clinical and genetic screenings on the management of the multiple endocrine neoplasia type 1. Clinics. 2007;62(4):465-76.
  3. Pieterman CR, Schreinemakers JM, Koppeschaar HP, Vriens MR, Rinkes IH, Zonnenberg BA, et al. Multiple endocrine neoplasia type 1 (MEN1): its manifestations and effect of genetic screening on clinical outcome. Clin Endocrinol. 2009;70(4):575-81
  4. Waldmann J, Fendrich V, Habbe N, Bartsch DK, Slater EP, Kann PH, et al. Screening of patients with multiple endocrine neoplasia type 1 (MEN-1): a critical analysis of its value. World J Sur. 2009;33(6):1208-18
  5. Carling T, Udelsman R. Parathyroid surgery in familial hyperparathyroid disorders. J Intern Med. 2005;257(1):27-37.
  6. Hubbard JG, Sebag F, Maweja S, Henry JF. Primary hyperparathyroidism in MEN 1: how radical should surgery be? Langenbeck's Arch Surg. 2002;386(8):553-7.
  7. Ellen FyrstenOlov NorlénOla HessmanPeter StålbergPer Hellman. Long-Term Surveillance of Treated Hyperparathyroidism for Multiple Endocrine Neoplasia Type 1: Recurrence or Hypoparathyroidism? World J Surg (2016) 40: 615.
  8. Nilubol, N., Weinstein, L.S., Simonds, W.F., Jensen R.T. Marx S.F., Kebebew E. Limited Parathyroidectomy in Multiple Endocrine Neoplasia Type 1-Associated Primary Hyperparathyroidism: A Setup for Failure. Ann Surg Oncol (2016) 23: 416.
  9. Lairmore, T., Govednik, C., Quinn, C., Sigmond, B., Lee, C., Jupiter, D. A randomized, prospective trial of operative treatments for hyperparathyroidism in patients with multiple endocrine neoplasia type 1. Surgery (2014) 156: 1326-35.
  10. Langer, P., Wild, A., Schilling, T., Nies c., Rothmund M., Bartsch D. K. Multiple Endocrine Neoplasie Typ 1. Der Chirug (2004) 75: 900.

Additional High Yield Reading:
  1. Medullary thyroid cancer associated with germline RETK666N mutation. Xu JY, Grubbs EG, Waguespack SG, et al. Thyroid. 2016 Oct epub ahead of print.
  2. Survival and causes of death in patients with von-Hippel-Lindau disease. Binderup ML, Jensen AM, Budtz-Jorgensen E, et al. J Med Genet. 2016 Aug epub ahead of print.
  3. Long term outcomes in patients with Multiple Endocrine Neoplasia type 1 and pancreaticoduodenal neuroendocrine tumors. Clin Endocrinol. 2016 Oct epub ahead of print.
  4. Utility of chromogranin A, pancreatic polypeptide, glucagon and gastrin in the diagnosis and follow-up of pancreatic neuroendocrine tumors in Multiple Endocrine Neoplasia type 1 patients. Qiu W, Christakis I, Silva A, et al. Clin Endocrinol. 2016;85(3):400-7.

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