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ENDOCRINOLOGY UPDATE Volume 1 Number 3 2006 ENDOCRINOLOGY NEWS from MAYO CLINIC MC5810-0906.qxd 9/6/06 8:15 AM Page 1 ENDOCRINOLOGY UPDATE volume 1 number 3 2006 ENDOCRINOLOGY NEWS FROM MAYO CLINIC Ts, Zs, and LSCs—Understanding Bone Mineral Density Reports In the absence of established skeletal fragility, assessment of bone mineral density (BMD) by dual-energy x-ray absorptiometry (DXA) is the basis for the diagnosis of osteoporosis. The very low radiation exposure associated with DXA, coupled with extensive epidemiologic data and validation in clinical trials, has made it the Inside This Issue standard clinical tool for the assessment of BMD. However, proper interpretation of the results Thyroid Nodules: A from DXA requires a good understanding of the Systematic and Cost- limitations of this technology. effective Approach . 3 Caveats When Using DXA Intensive Diabetes Self- for the Diagnosis of Osteoporosis management Programs at Modern DXA systems compare the results in a Kurt A. Kennel, MD, and Michael K. O’Connor, PhD Mayo Clinic . 5 patient with a number of normal databases. Kurt monitoring the response to therapy and in the Hypoglycemia—A Role for A. Kennel, MD, of the Division of Endocrinology, Arterial Stimulation Diabetes, Metabolism, and Nutrition at Mayo detection of secondary causes of osteoporosis. Venous Sampling . 6 Clinic in Rochester, notes: “The T-score compares Hence, an understanding of the validity and the patient’s BMD with that of a young adult interpretation of serial measurement data is population, while the Z-score compares it with an essential to avoid making unsupported clinical age-matched population. In both cases, the score decisions. reflects how much the patient’s BMD differs from Michael K. O’Connor, PhD, of the Depart- the mean value for that database (in units of ment of Nuclear Medicine at Mayo Clinic in standard deviations). For the diagnosis of Rochester, says: “One of the most important osteoporosis and assessment of fracture risk, the numbers in a BMD report is the least significant T-score should be used only in postmenopausal change (LSC). This is defined as the smallest women (World Health Organization recom- change that can occur in BMD that we are 95% mendation, found on the WHO Web site listed in sure is due to changes in the patient’s BMD and the Table) and men older than 50 years. The not to machine or patient factors. The LSC varies diagnosis of osteoporosis in healthy premeno- with the type of machine, operator experience, pausal women or healthy men younger than 50 the patient’s position, the region of the body, years should not be made on the basis of the BMD and the patient’s BMD. Because software result alone. These patients should be compared upgrades by manufacturers may incorporate with age- and sex-matched databases to derive Z- different reference populations to generate T- scores. Osteoporosis may be diagnosed if there is and Z-scores, only the LSC in absolute BMD low BMD in the appropriate clinical setting (for (reported as grams per square centimeter) example, glucocorticoid therapy, hypogonadism, should be used for serial comparisons. fragility fracture, hyperparathyroidism).” “At Mayo Clinic in Rochester, the average of 2 scans is determined during each assessment to Technical Issues Important reduce the LSC. Furthermore, an average LSC to Clinical Interpretation for all technicians and densitometers is used in Serial BMD measurements can be helpful in the DXA laboratory to eliminate the need for MC5810-0906.qxd 9/6/06 8:15 AM Page 2 MAYO CLINIC ENDOCRINOLOGY UPDATE 2 patients to be scanned on the same (T-score ≤ǁ2.5) using BMD by DXA in DXA: Online Resources for machine by the same technician when postmenopausal women was chosen to identify Clinicians and Patients serial assessments are performed. The women with a high risk for hip fracture. Dr Patient education LSC at each site and range of BMD is Kennel cautions: “Just as the risk of a cardio- material regarding BMD reported. Absolute changes in BMD vascular event is not determined by serum by DXA: http://www greater than the LSC at the site of cholesterol alone, fracture risk assessment should .mayoclinic.com/health interest likely represent a real change in be based on several clinical risk factors in /bone-density-tests BMD at that site. Values less than the addition to BMD. Notable examples include age, /WO00024 LSC should not be considered as small prior fragility fracture, parental history of hip changes or ‘trends.’ ” WHO Technical Report fracture, history of smoking, chronic glucocort- on Prevention and Clinicians should ask themselves the icoid use, history of falls, and low body weight (see Manage-ment of following questions: serial comparison BMD report below).” While Osteoporosis 2003: • What is the precision error (LSC) of clinicians can look forward to a World Health http://whqlibdoc the local DXA laboratory? Organization absolute fracture risk assessment .who.int/trs/WHO_TRS • Is the precision error (LSC) clearly method that may clarify this approach, it is _921.pdf stated in the DXA report where essential to consider current DXA BMD measure- serial changes in BMD are being ments in the context of other risk factors when US Surgeon General’s reported? assessing the benefits and risks of interventions Report on Bone Health Degenerative changes resulting in to reduce the possibility of fracture. and Osteoporosis 2004: periarticular osteosclerosis or exo- http://www.surgeon phytic bone and undetected compres- general.gov/library/bone health/ sion in the lumbar spine may spur- Serial Comparisons iously elevate the BMD measurement. Lumbar spine L2-L4 results: Official positions on the However, a low T-score at 2 or more use of DXA for the vertebrae, despite the presence of some 11/26/2001 BMD: 0.775 g/cm2, T-score: ǁ3.0 diagnosis and manage- degenerative joint disease, may still be 11/18/2004 BMD: 0.709 g/cm2, T-score: ǁ3.5 ment of osteoporosis at of use to the clinician who can the International Society conclude the lumbar spine BMD is the 04/07/2006 BMD: 0.813 g/cm2, T-score: ǁ2.7 for Clinical Densitometry same or worse than the measured value. Change – baseline: 4.9%/previous: 14.7%. Web site, www.iscd.org However, LSC values are usually quoted for the entire spine, and the fewer The LSC in BMD for the spine is 0.041 g/cm2. vertebrae used in the analysis, the The absolute BMD change from previous, poorer the accuracy of serial measurements. If 0.104 g/cm2, is greater than the LSC. only 1 evaluable vertebra remains after excluding The absolute BMD change from baseline, other vertebrae, diagnosis should be based on a 0.038g/cm2, is less than the LSC. different valid skeletal site (International Society for Clinical Densitometry 2005 recommen- dations, reached via the Web site listed in the Example of a Mayo Clinic BMD report clearly stating Table). least significant change (LSC). This patient had osteomalacia (low T-scores do not always indicate DXA Does Not Stand Alone osteoporosis) due to vitamin D deficiency, which was in Assessing Fracture Risk diagnosed and treated in 2005. The diagnostic threshold for osteoporosis 2006 Graduating Clinical Endocrinology Fellows Left to right (and their upcoming appointments): Neena Natt, MD (program director); Lisa S. Chow, MD (University of Minnesota, Minneapolis); Helen Karakelides, MD (Mayo Clinic Rochester); Julie E. Hallanger-Johnson, MD (MeritCare, Fargo, North Dakota). Endocrinology Consultation 800-313-5077 www.mayoclinic.org MC5810-0906.qxd 9/6/06 8:15 AM Page 3 MAYO CLINIC ENDOCRINOLOGY UPDATE 3 Thyroid Nodules: A Systematic and Cost-effective Approach Thyroid nodules are commonly encountered in clinical practice. In the United States, approximately 300,000 new nodules are diag- nosed each year. Their prevalence ranges from 4% by palpation to more than 60% by ultra- sonography (US). Thyroid “incidentalomas,” found in up to 40% of patients undergoing US evaluation for suspected parathyroid and carotid artery disease, add another level of complexity for the clinician. M. Regina Castro, MD, of the Division of Endocrinology, Diabetes, Metabolism, and Nutrition at Mayo Clinic in Rochester, notes: “Although most thyroid nodules are benign, approximately 5% of all nodules may be malig- nant. Thus, a systematic evaluation is crucial Thomas J. Sebo, MD, M. Regina Castro, MD, and Hossein Gharib, MD both to reassure the majority of patients with benign disease who do not require surgery and and 0.7%, respectively, at Mayo Clinic in to refer for surgical treatment the small minority Rochester). Nondiagnostic specimen rates in the of patients with malignant, suspicious, or large literature average about 15% and may be greatly symptomatic nodules who will benefit from reduced by performing the FNA biopsy under surgical excision.” US guidance. Dr Castro notes: “US guidance is Fine-needle aspiration (FNA) biopsy is a cost- valuable for small nodules (<1.5 cm) and effective and safe outpatient procedure with a essential for all nonpalpable nodules, helping to diagnostic accuracy that approaches 95%. ensure proper needle placement for precise “Thyroid FNA has resulted in up to 75% sampling and avoiding cystic areas in complex reduction in the number of patients requiring nodules which often yield inadequate specimens surgery, while at least doubling the rate of (Figure 1). In patients with multinodular goiters, malignancy found at the time of thyroidectomy,” US guidance is also helpful to select for biopsy says Hossein Gharib, MD, of the Division of those nodules more likely to be malignant Endocrinology, Diabetes, Metabolism, and (hypoechoic nodules with microcalcifications, Nutrition at Mayo Clinic in Rochester. However, irregular borders, increased vascular flow, the yield and accuracy of thyroid FNA depend greater height than width, or rapid growth). on several factors, including whether the nodule Nodule size, in the absence of other worrisome sampled is, for example, a features, is not a good predictor of malignancy.” papillary carcinoma or a Nodules classified on FNA as nondiagnostic follicular neoplasm, the should be reaspirated, preferably under US experience of the individual guidance.
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