Schmitz, John J.

Abstract Disclosure: J.R. Hewlett: None. J.G. Sfeir: None. R.A. Wermers: None. J.J. Schmitz: None. Percutaneous ethanol ablation (PEA) is a non-surgical technique used in the management of hyperparathyroidism (HPT) since the 1980s. Previously published cohorts are small and/or focused on patients with primary hyperparathyroidism (PHPT) in the setting of multiple endocrine neoplasia type 1 (MEN1). New randomized controlled trial data suggests similar response rates between parathyroidectomy and PEA (98.5% vs 91.1%) for uniglandular disease, and a previously published cohort of PEA in patients with MEN1 and recurrent multiglandular PHPT at our institution reported post-PEA normocalcemia in 74.5% of patients. This retrospective cohort study examined the treatment response to PEA in those with PHPT (including MEN1) and tertiary HPT (THPT) at a single institution between 1997-2023. Those with secondary hyperparathyroidism or eucalcemic PHPT were excluded. The primary outcome was a serum calcium ≤10.1 mg/dL at 3-6 months and secondary outcomes included number and volume of ethanol injections, time to recurrence of HPT, and complications of PEA. A total of 83 patients were included. Most were women (62.7%) and the median age at diagnosis of HPT was 40 years. The majority had PHPT (90.4%), and many (86.7%) had previously undergone surgery. The most common indications for PEA were risk for hypoparathyroidism with additional surgery (72.3%) poor surgical candidacy (16.9%), and patient preference (8.4%). The mean calcium was 10.7 mg/dL (95% CI 10.56-10.85) and the mean PTH was 164 pg/mL (95% CI 120.6-208.3) prior to PEA. The mean number of ethanol injections was 3.0 (95% CI 2.6 – 3.4) and the cumulative volume of ethanol was 1.2 mL (95% CI 1.0-1.4). At 3-6 months, 68.3% of treated patients had calcium ≤10.1 mg/dL with a mean value of 9.4 mg/dL (95% CI 9.1-9.6). Of those, 42% did not have recurrence at most recent follow-up. Of those with recurrence, a post-PEA calcium ≤10.1 mg/dL at 3-6 months was associated with a longer time to recurrence than those without (36.9 months versus 3.75 months; P=0.0009). There was no significant difference between the number of times (P=0.56) or the volume (P=0.41) of ethanol injected between those with calcium of ≤10.1 mg/dL at 3-6 months and those without. Hypocalcemia was observed in 8 (9.6%; transient in 75%), hypoparathyroidism in 3 (3.6%; transient in 66.7%), laryngeal nerve injury in 2 (2.4%; transient in 50%), and hoarseness in 9 (10.8%; transient in 100%) patients. This is the largest North American cohort of patients who received PEA for HPT and represents a broader review of HPT than previously published. Our rate of post-PEA eucalcemia is lower than previously reported, however this cohort was complex with a high proportion of multiglandular disease (80.7%), MEN1 (39.8%) and prior surgeries (mean 1.7 per person; 95% CI 1.5-1.9). PEA remains a safe and effective treatment for patients with recurrent HPT, especially those at high risk of post-surgical hypoparathyroidism. Presentation: Monday, July 14, 2025

This cohort study examines trends in patient access of radiology imaging results after implementation of the 21st Century Cures Act in different clinical settings.

Abstract The use of radiofrequency ablation (RFA) of benign, symptomatic thyroid nodules is growing in clinical practice. Objective outcomes of symptom relief are needed to support the use of this treatment. Thus, a previously established thyroid nodule symptom scoring system was prospectively administered to patients prior to RFA of symptomatic thyroid nodules and then at 1, 3, 6, and 12 months following ablation. A total of 38 patients of mean age 57 years were treated with RFA between August 2022 and January 2024 and completed at least 1 follow-up survey. Five of these patients underwent simultaneous ablation of 2 thyroid nodules; the remainder had a single nodule treated. Mean modified symptom score prior to RFA was 3.5 (SD 1.6) with higher scores correlating with increasing baseline nodule volume (R = 0.46, P = 0.0038). Patient symptom scores decreased at the first 1-month survey (mean 1.2; SD 1.3) and 3-month survey (mean 0.9; SD 1.3) with durable response in those patients with more extended follow-up. In those patients with imaging follow-up, decreasing nodule size was shown to correlate with decreasing symptoms. The early results of this study show that RFA of benign, symptomatic thyroid nodules results in quantifiable symptom relief within 3 months of treatment. Such objective measures of symptom relief may be used to measure long-term durability of treatment.

Abstract Background Percutaneous ablation of parathyroid adenomas provides a minimally invasive treatment option for primary hyperparathyroidism. However, the overall performance of this technique remains underexplored. This meta-analysis evaluates the effectiveness and safety of various ablation techniques for parathyroid adenomas. Methods Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, multiple databases, including Ovid MEDLINE and Cochrane, were systematically searched. Studies that provided separate data for radiofrequency (RF), microwave ablation (MWA), and ethanol ablation technique were included. Outcomes of interest were changes in serum calcium, PTH, and phosphorus levels, along with normocalcemia rates at 6 to 12 months after ablation. Safety outcomes included transient hoarseness, permanent hoarseness, severe hemorrhage, major complications, and severe hypocalcemia. Data were pooled using a random-effects model, with pooled prevalence and 95% CIs calculated. Also, the publication bias was assessed with Egger's test for each outcome measure. Results Twenty studies (815 patients) were included. The posttreatment normocalcemia rate at 6 to 12 months was 85.6% (95% CI, 80.48-90.72). Serum PTH and calcium levels significantly decreased, with mean differences of 101.49 pg/mL (95% CI, 73.50-129.48) and 0.39 mmol/L (95% CI, 0.34-.45), respectively. Permanent hoarseness and major complications were rare, with incidences of 0.28% (95% CI, 0.00-1.05) and 0.31% (95% CI, 0.00-1.09). The safety and efficacy outcomes of RF, MWA, and ethanol ablation were comparable. Conclusion Our findings indicate that percutaneous ablation of parathyroid adenomas is safe and effective within the first year of the treatment. Additionally, they suggest that RF, MWA, and ethanol ablation techniques can each be employed depending on patients' needs without particular limitations.

Abstract Imaging-guided percutaneous core needle biopsy is currently the most common technique for the investigation of potentially malignant bone lesions. It allows precise needle placement and better visual guidance, leading to improved diagnostic accuracy. Needle tract seeding (NTS) is a rare complication of biopsies in general, and its true incidence remains unknown. This study aimed to assess the risk of NTS in patients with thyroid cancer who underwent bone biopsy. For our cohort, we extracted data from the electronic medical record at the Mayo Clinic in Rochester (Minnesota, USA). Inclusion criteria included patients with a history of thyroid cancer who underwent biopsy for bone metastasis between 1/1/2014 and 10/1/2023. We identified a cohort of 20 patients that fit our inclusion criteria. Of these 20 patients, 2 patients developed NTS after CT-guided bone biopsy. Cases of seeding had a larger tumor size, a more aggressive histopathological presentation, a significantly shorter duration between cancer diagnosis and bone metastasis, and underwent more tumor manipulation procedures, such as biopsy and radiofrequency ablation, in contrast to those without seeding. In conclusion, our study identified NTS to have an incidence of 10% after biopsies of bone metastasis related to thyroid carcinoma. These are likely the result of an interplay of risk factors, including tumor biology, penetrated tissues and procedural technical details. Further studies with larger sample sizes are needed to confirm our findings and identify strategies to mitigate NTS.

Abstract Incidental findings in diagnostic imaging are common, but follow-up recommendations often lack consistency. The Society of Radiologists in Ultrasound (SRU) issued guidelines in 2021 for managing incidentally detected gallbladder polyps, aiming to balance follow-up with avoiding overtreatment. There is variable adherence to these guidelines in radiology reports, however, which makes it difficult for the clinician to pursue appropriate follow-up for the patient. The purpose of this project is to test the feasibility of a Large Language Model (LLM)–based tool to incorporate SRU guidelines into radiology reports. Additionally, we propose a framework for closely integrating societal follow-up recommendations into radiology reports, using this tool as an example. Following institutional review board approval, we retrospectively reviewed gallbladder ultrasound examinations performed on adult ED patients in 2022. Data on patient demographics and radiology report content were collected. Using the 2021 SRU guidelines, we developed an interactive tool employing a retriever-augmented generator (RAG) and prompt engineering. A board-certified radiologist tested the accuracy, whereas a board-certified emergency medicine physician assessed the clarity and consistency of the recommendations. The interactive tool, GB-PRL, outperformed leading closed-source and open-source LLMs, achieving 100% accuracy in risk categorization and follow-up recommendations on hypothetical user queries (P < 0.001). The tool also showed superior accuracy compared to radiology reports on retrospective data (P = 0.04). Although GB-PRL demonstrated greater clarity and consistency, the improvement from the radiology reports was not statistically significant (P = 0.22). Further work is needed for prospective testing of GB-PRL before integrating it into clinical practice.

Abstract Background Autonomously functioning thyroid nodules (AFTNs) constitute 5% to 7% of thyroid nodules and represent the second most common cause of hyperthyroidism following Graves’ disease. Currently, radioactive iodine (RAI) and surgery are the standard treatment options, and both incur a risk of postprocedural hypothyroidism and other surgery and radiation-related complications. Methods This work aimed at assessing the efficacy of radiofrequency ablation (RFA) as an alternative treatment option for resolving hyperthyroidism and the nodule volume rate reduction (VRR) and its associated adverse events. Results A total of 22 patients underwent RFA for a solitary AFTN. Seventy-two percent (n = 16) had subclinical hyperthyroidism, 9% (n = 2) had overt hyperthyroidism, and 18% (n = 4) were biochemically euthyroid on antithyroid medication. Average pretreatment TSH was 0.41 mIU/L (SD = 0.98) and free T4 1.29 ng/dL (SD = 0.33). Following a single RFA session, hyperthyroidism resolved in 90.9% (n = 20) and average VRR (61.13%) was achieved within 3 to 6 months following the ablation. Except for 1 nodule, none of the nodules grew during the follow-up period (16.5 months). Two patients (9%) developed transient tachycardia requiring short-term beta-blocker therapy, and 2 developed mild hypothyroidism requiring levothyroxine therapy. Two patients developed recurrent hyperthyroidism and elected to undergo lobectomy and repeat RFA respectively. No serious adverse effects were noted in this cohort. Conclusion RAI and/or surgery represent the standard of care for toxic adenomas, but RFA shows excellent efficacy and safety profile. Therefore, at centers with RFA expertise, it should be considered an alternative treatment strategy, avoiding radiation and surgery-related complications.