Current Opinion in Endocrinology & Diabetes and Obesity最新文献

Purpose of review: The aim of radioactive iodine (RAI) in differentiated thyroid cancer (DTC) is ablation of thyroid remnant and/or treatment of residual disease. This review compares guidelines recommending the use of RAI (or not) in DTC, with a focus on randomized trials in low-risk DTC. Molecular genotyping offers therapeutic options in advanced RAI-refractory DTC.

Recent findings: The ESTIMABL2 and IoN trials suggest that thyroidectomy (with or without central compartment lymph node dissection) followed by surveillance is sufficient in low-risk DTC, despite key differences in inclusion criteria, recurrence-definition, and monitoring protocols. RAI practice is tailored in many aspects: selection of intermediate-risk DTC for RAI and activity based on individual factors, including early dynamic risk assessment; lesional dosimetry in advanced DTC; restrictions following RAI; and choice of systemic therapy in the RAI-refractory setting.

Summary: RAI in DTC is evolving towards a risk-adapted model. Escalating evidence indicates that RAI may be safely withheld in a large proportion of low-risk DTC. Optimal management of intermediate-risk DTC remains controversial, due to heterogeneity in clinical and pathological characteristics and conflicting data over survival advantage. Well designed studies incorporating molecular genotype may be key in identifying those most likely to benefit from RAI and in elucidating mechanisms of RAI-resistance.

Purpose of review: Endogenous Cushing's syndrome is one of the most difficult diagnoses in endocrinology. It is mainly based on biochemical tests that assess qualitative and quantitative alterations in cortisol production. Whether performed on blood, saliva, urine, or hair, the biochemical tests currently available have limited diagnostic specificity and sensitivity. Their performance varies depending on the individual characteristics of the patient, the stage of the disease, and the laboratory techniques used to determine cortisol levels. Knowledge of these factors will help physicians choose the most appropriate diagnostic test for each individual.

Recent findings: Relevant studies and meta-analyses have clarified the actual performance of various biochemical tests in a real-world setting. In addition, the diagnostic arsenal for Cushing's syndrome has been expanded with new tools, such as hair cortisol and cortisone assays, new methods for measuring cortisol in urine or saliva, and new approaches such as steroid metabolomics or multiomics techniques.

Summary: This review is a critical reappraisal of the merits and drawbacks of the various "old" and new biochemical tools. Its purpose is to provide the physician with practical advice on the use of biochemical tests at various stages of Cushing's syndrome in order to improve diagnostic accuracy.

Purpose of review: To summarize the epidemiology and clinical implications of adrenal incidentalomas, as well as the recommended hormonal and radiological evaluation, treatment and follow-up that should be carried out in patients with adrenal incidentalomas.

Recent findings: The prevalence of adrenal incidentalomas has increased in the last decades due to advanced and more sensitive imaging modalities, their increased utilization, and the aging population. The evaluation of patients with adrenal incidentalomas should be focused on addressing two questions: Is the tumor functional, and is the tumor malignant? In relation to functionality, although most adrenal incidentalomas are clinically nonfunctioning, a significant proportion of patients have mild autonomous cortisol secretion and a lower proportion over functional adrenal syndromes. The differentiation between malignant and benign lesions is usually based on the radiological appearance of the lesion in CT and/or MRI. Adrenalectomy is considered the first-line treatment for malignant and functioning tumors. Radiological follow-up is not necessary for lesions classified as benign, but for indeterminate lesions, CT/MRI should be repeated in 6-12 months.

Summary: Adrenal incidentalomas are a common clinical problem, and their assessment should be focused on ruling out hormonal hypersecretion and malignancy. In general, adrenalectomy is considered the treatment of choice for malignant and functioning adrenal tumors.

Purpose of review: This review examines the critical role of the high-density lipoprotein (HDL)/scavenger receptor class B type 1 (SCARB1) pathway in adrenal glucocorticoid production during stress, emphasizing recent mechanistic evidence and its clinical implications.

Recent findings: SCARB1 mediates the selective uptake of HDL-derived cholesteryl esters by adrenocortical cells, providing the cholesterol substrate needed for rapid glucocorticoid synthesis under stress. Experimental models show that loss of SCARB1 function abolishes stress-induced glucocorticoid production even when low-density lipoprotein (LDL) is abundant, confirming that LDL cannot substitute for HDL/SCARB1-mediated cholesterol delivery. ACTH rapidly upregulates SCARB1 expression and function, driving microvillar channel formation and enhancing cholesterol flux to mitochondria. Disruption of this pathway impairs the physiologic stress response and increases vulnerability to inflammatory complications. Human genetic data and clinical observations reinforce these findings and highlight the impact of hypoalphalipoproteinemia and SCARB1 defects on adrenal reserve.

Summary: The HDL/SCARB1 axis is essential for acute glucocorticoid synthesis and integrates lipid metabolism with endocrine and immune resilience. This shifts the focus from HDL-C from a passive biomarker to HDL to an active endocrine cofactor. Preserving HDL functionality and SCARB1 integrity should guide the design of HDL-targeted interventions, especially in patients at risk for sepsis, systemic inflammation, or adrenal insufficiency.

Purpose of review: Adrenal tumors are increasingly detected due to widespread use of cross-sectional imaging, with mild autonomous cortisol secretion (MACS) present in up to 50% of cases. This review summarizes the current evidence linking MACS to cardiometabolic comorbidities and outcomes, and evaluates the impact of adrenalectomy and emerging medical therapies.

Recent findings: MACS is consistently associated with higher prevalence of hypertension, impaired glucose metabolism, dyslipidemia, obesity, and cardiovascular events compared to nonfunctioning adrenal tumors (NFATs). Several observational studies and randomized controlled trials have shown that adrenalectomy can improve blood pressure and glycemic control, although evidence regarding lipid metabolism and obesity is mixed. Despite growing evidence, gaps remain in predicting which patients will benefit most from surgical or medical therapy.

Summary: MACS is clinically relevant entity with substantial cardiometabolic burden. While adrenalectomy may confer benefits in selected patients, individualized risk stratification remains a key challenge. Future research should focus on identifying predictive biomarkers, clarifying therapeutic thresholds and conducting large-scale prospective trials to inform clinical decision-making.

Purpose of review: To review the current medical evidence in the diagnosis and management of thyroid nodules.

Recent findings: The widespread use of imaging modalities in recent years has led to frequent discovery of incidental thyroid nodules. These nodules are mostly benign (over 90%), hence precise insight in evaluating nodules of concern and following up other nodules is important to avoid unnecessary surgeries and its complications.

Summary: Certain nodules, which are symptomatic or suspicious on clinical evaluation, need further evaluation with ultrasonography and cytopathology before embarking on definitive treatment. Indeterminate nodules can further be analysed by newer advances like molecular tests, liquid biopsy to guide further management. Active surveillance is an option for select malignant nodules that fit the defined criteria. Small benign nodules which are symptomatic or of cosmetic concern can also be treated with minimally invasive options of ethanol injection or thermal ablative techniques. Hemithyroidectomy is diagnostic for follicular neoplasm or definitive treatment for solitary, symptomatic or hypersecreting benign nodules or even for small solitary thyroid carcinoma. Total thyroidectomy is option of choice for symptomatic or hypersecreting or malignant multiple nodules.

Purpose of review: Subclinical hyperthyroidism is a clinical condition where thyroid-stimulating hormone (TSH) is below the normal range along with normal levels of circulating thyroid hormones. It is associated with cardiovascular complications such as atrial fibrillation, but the effects on other organ systems is less certain. There are areas of uncertainty in the management of this condition, which this review seeks to address by reviewing relevant literature from the last 18 months.

Recent findings: Data on prevalence from recent meta-analyses are in line with previous studies. Individual TSH reference ranges are influenced by genetic factors, which suggests that current reference ranges may be leading to misdiagnosis. Further research has increased the strength of evidence for the association with atrial fibrillation. A meta-analysis has shown increased risk of osteoporosis and fractures. Data support an association between subclinical hyperthyroidism and dementia. A randomised controlled trial has recently been conducted to investigate the effect of treatment on atrial fibrillation incidence, in which post hoc-analysis showed normalisation of TSH decreased risk of atrial fibrillation.

Summary: Degree of TSH suppression is an important element of clinical assessment. Subclinical hyperthyroidism is associated with atrial fibrillation, osteoporosis and dementia. Further research in this field is warranted.

Purpose of review: Whilst the prognosis of thyroid carcinoma remains excellent, patients with advanced thyroid carcinoma have a considerable burden of disease. Clinicians continue to face and manage challenging scenarios in the setting of thyroid cancer, particularly in those with recurrent disease, metastatic disease or special scenarios such as thyroid cancer in pregnancy. The purpose of this article is to provide an overview of thyroid cancer management and an update in emerging areas of management, particularly in the setting of locally advanced disease.

Recent findings: Systemic treatment of thyroid malignancy, particularly in the setting of locally advanced thyroid cancer, is rapidly evolving. Advances in targeted therapy have allowed for previously unresectable thyroid malignancies to undergo surgery, with significant increases to disease-free survival. Genomic profiling of tumours allows for specific mutations to be targeted with promising results for this cohort of patients.

Summary: This overview of the current management of thyroid carcinoma pays close attention to differentiated thyroid malignancy, with summaries of assessment, work-up and surgical management. Focus is made to the scenarios that continue to challenge clinicians, with up-to-date summaries of recent advances in this field.

Purpose of review: Adrenocortical carcinoma (ACC) is a rare and aggressive malignancy with limited therapeutic options and poor prognosis. This review highlights recent advances in risk stratification, systemic therapies, surgical approaches and personalized treatment strategies to improve outcomes in ACC.

Recent findings: Significant progress has been made in molecular characterization of ACC, enabling more precise risk stratification and prognostication. Novel biomarkers and integrated scoring systems now complement traditional staging methods. Therapeutic advances include refinements in surgical approaches for both localized and metastatic disease, while systemic treatment options are expanding beyond traditional mitotane-based regimens. Immunotherapy and targeted agents show emerging promise, particularly in molecularly selected patients. The role of adjuvant therapy continues to evolve, with recent evidence supporting more selective application based on individual risk assessment. Multimodal strategies combining locoregional and systemic therapies are demonstrating improved outcomes in advanced disease.

Summary: The ACC treatment landscape is undergoing significant transformation, moving toward personalized approaches guided by molecular profiling and risk-adapted strategies. While challenges remain in overcoming treatment resistance and validating new biomarkers, the integration of advanced diagnostics with innovative therapies offers hope for improved patient outcomes. Future progress will depend on collaborative research efforts and the development of robust clinical trials.

Purpose of review: This review outlines the indications for medical management of hypercortisolism and summarizes available and emerging pharmacologic agents.

Recent findings: Endogenous Cushing syndrome is a complex endocrine disorder resulting from chronic cortisol excess. The underlying etiology of Cushing syndrome is due to either adrenocorticotropic hormone (ACTH)-dependent causes, such as pituitary tumors (Cushing disease) or ectopic ACTH syndrome from nonpituitary neuroendocrine tumors, or ACTH-independent causes, such as autonomous cortisol production by adrenal adenomas, hyperplasia, or carcinomas. Cushing syndrome is associated with increased cardiometabolic morbidity and mortality, infections, thromboembolic events, cognitive and psychiatric disorders, and reduced quality of life. Successful treatment significantly reduces mortality and improves associated clinical and metabolic consequences of chronic hypercortisolism. Management of Cushing syndrome varies depending on the underlying etiology. While surgical resection of the causal lesion remains the first-line treatment for all etiologies of Cushing syndrome, second-line treatments, such as medical management, radiation therapy, and bilateral adrenalectomy, may be needed when surgery is not feasible or has failed.

Summary: We discuss the efficacy of medical therapies for hypercortisolism, combination therapy strategies, special considerations in unique populations, and monitoring protocols. Finally, we explore emerging treatments and potential future directions in the management of this complex condition.