AACE/ACE Advanced Endocrine Neck Ultrasound Training Course 2016

Transcription

1 AACE/ACE Advanced Endocrine Neck Ultrasound Training Course 2016

2 This 9mm left inferior nodule should remind us all why we re here!

3

4

5

6

7

8

9

10 There is no absolute number of images required for documentation ECNU does not require a set number of images AIUM does require the 13 routine images or a cine loop for review of the entire gland As a minimum it is imperative to have images of both lobes in the transverse and longitudinal views Nodules should be shown in two views. If you could review the images one year from now and create a meaningful report, you probably have a sufficient number of images.

11 Identification data Indication Explanation of the Procedure Thyroid Size (measurements) Thyroid parenchyma description Description of pathology Impression Recommendations

12

13 Annotation on the fly, while you are thinking about it.

14

15 Remember, Doppler Grades DO NOT Apply to Lymph Nodes nor parathyroid glands.

16 3. Correlation with pending thyroid antibodies and I123 uptake is planned.

17

18 Demographics Facility where study performed / Phsician name Patient name and other identifier Date of birth Requesting/Primary Physician Name of examination Thyroid US; USG-FNA; Parathyroid US; Endocrine Neck US (i.e., post-op) Date of Exam

19 Indication for exam Thyroid Nodule Multinodular goiter Goiter Palpable neck mass Hashimoto s thyroiditis Hyperthyroidism Thyroid nodule / cyst seen on other imaging Hyperparathyroidism Thyroid Cancer preoperative lymph node study Detect recurrent disease in cancer patients High risk patients for occult malignancy Localize lesion for FNA biopsy

20 Right papillary thyroid cancer, s/p total thyroidectomy and subsequent I131 therapy. Adding any necessary descriptors such as 1.9 cm Right tall cell variant papillary thyroid cancer, s/p total thyroidectomy and subsequent I131 therapy. T1b, N0, M0 (STAGE 1) Right thyroid nodule found on CT angiogram. History of Papillary thyroid cancer in sister.

21 Using physician performed, real-time ultrasound limited to the thyroid gland and anterior neck, longitudinal and transverse images were obtained of both lobes and isthmus. OR FOR CANCER: Using physician performed, real time ultrasound limited to the thyroid bed and anterior neck, including nodes ( Levels I, II, III, IV, V, and VI), longitudinal and transverse images were obtained. Leave OFF the brand name of the machine and the mhz of the probe This is not relevant to the report.

22 Body of Report Description e.g.: personally performed in realtime with a linear probe in both transverse and longitudinal planes Size of each lobe in three dimensions Length x AP x Transverse (standard, or specify if any other order used) AP measurement of isthmus Echotexture of thyroid parenchyma Size, location, number and characteristics of nodules and cysts Comment on vascularity of gland and abnormalities Abnormalities of adjacent soft tissues

23 Potential limitations of study should be noted Comparison to other studies Impression is very important Precise diagnosis preferred Differential diagnosis when appropriate Recommendations for follow-up ultrasound or for additional studies (I-123 or FNA, etc)

24 Measurements should include: longitudinal/sagittal, a transverse measurement depth (AP-ANTERIOR to POSTERIOR) of each lobe and a depth measurement of the isthmus. LONGITUDINAL X DEPTH(AP) X WIDTH(TRV). ECNU convention Best to specify order at some point All measurements are expressed as: longitudinal x AP x transverse, unless otherwise specified.

25 Archived Images necessary for exam Transverse: Sup, Mid, Inf each lobe Longitudinal: Med, Mid, Lat each lobe Isthmus: Trans view w/ AP measurement **Video clips are acceptable!** Abnormalities: three dimensions Requires at least two images (TRV and SAG) At least one Doppler image for each nodule Annotate images with orientation/location

26 Overall, the thyroid gland is enlarged and asymmetric with a prominent right lobe. The gland has a hypoechoic and heterogeneous echotexture. Overall, the thyroid gland is enlarged and asymmetric with a prominent left lobe. The gland has a homogeneous echotexture with increased vascularity.

27 NOT LESIONS NOT MASSES NOT GROWTHS NOT HYPODENSITIES NOT POLYPS NOT GOITERS NOT AREAS NOT NODULARITIES NOT NODULATIONS

28 THREE MAJOR DESCRIPTORS: SOLID, CYSTIC, or complex HYPOECHOIC, HYPERECHOIC OR ISOECHOIC HOMOGENEOUS OR HETEROGENEOUS These are good ROOTS to expand upon, but other modifiers can also be added. Borders: Smooth, distinct, irregular, infiltrative, vague, ill defined, halo characteristics Calcifications: micro, coarse, peripheral, punctate Taller than wide

29 Note Arabic Numbers, Not Roman Numerals Doppler is always capitalized Grade 1 (Absent) No Doppler flow is seen. Grade 2 (Peripheral) Doppler flow is seen. Grade 3 (Penetrating) Doppler flow is seen. Grade 4 (Intense) Doppler flow is seen.

30 All thyroid / cervical ultrasound studies should comment on nodes. AIUM guidelines now require a brief examination of the lateral neck for the presence of nodes. Describe nodes by: size (3D), shape, echogenicity, hilar line, calcification and cystic degeneration.

31 Impressions: Bullet # 1- GLAND OVERVIEW (Summation statement.) Bullet# 2- Pathology seen. Bullet#3 Comment on nodes. Bullet#4- Comparison to previous if applicable. Recommendations: Timing for followup study FNA needed Lab or other imaging suggested

32 A follow-up ultrasound in 6-12 months is recommended in keeping with the 2015 American Thyroid Association Guidelines.

33

34

35

36

37 Including a mapping image with ultrasound findings is an option that many find useful

38 Thyroid Ultrasound and Biopsy Report Patient: DOB or other identifier: Date of examination: Indication:Thyroid Nodule. Ultrasound guidance for fine needle aspiration biopsy. Referring physician: Real-time imaging was performed in two planes. INSERT DESCRIPTION Following informed consent a procedural pause was held to confirm patient identity and site of biopsy. After sterile preparation, fine needle aspiration biopsy was performed using direct ultrasound guidance to confirm accurate needle placement. Three aspirations were made using 27 gauge needles. Samples were submitted for cytology. The patient tolerated the procedure well without complication. After care instructions were provided. Impression: Summary description. An uncomplicated fine needle aspiration biopsy of the (location) thyroid nodule was performed under ultrasound guidance. Plans: (Note: All measurements are reported as transverse x AP x longitudinal unless otherwise indicated.)

39 Thyroid Ultrasound Report Patient: DOB or other identifier: Date of examination: Indication: History of total thyroidectomy for Stage thyroid cancer (date) Referring physician: Real-time imaging was performed in two planes. Comprehensive evaluation of the medial and lateral neck compartments was carried out. The thyroid is surgically absent. There are no abnormal masses within the thyroid beds. No abnormal lymph nodes are identified in the central or lateral neck compartments. Impression: Negative comprehensive neck ultrasound with no evidence of recurrent thyroid cancer. A repeat ultrasound should be performed in years. (Note: All measurements are reported as transverse x AP x longitudinal unless otherwise indicated.)

40 Thyroid Ultrasound Report Patient: DOB or other 2 nd identifier Date of examination: Indication: History of total thyroidectomy for papillary carcinoma Negative Thyrogen scans 2010 and Essentially negative ultrasound 2013, with single borderline lymph node identified. Referring physician: Dr. C. G. Real-time imaging was performed in two planes. Comprehensive evaluation of the medial and lateral neck compartments was carried out. The thyroid is surgically absent. There are no abnormal masses within the thyroid beds. Once again, a prominent lymph node is identified in the left neck compartment III, deep to the SCM muscle. This measures 1.02 x 0.52 x 1.25 centimeters. (L:S = 1.96) This has enlarged from the prior study performed one year ago at which time it measured 0.6 x 0.3 x 1.1 centimeters. The internal echotexture is heterogeneous, and there is variable posterior enhancement suggestive of cystic necrosis. No other abnormal lymph nodes are identified. There several small nodes with normal morphology identified superior to the index node. Impression: Comprehensive neck ultrasound demonstrating interval enlargement of a left lateral lymph node previously identified. There is an abnormal internal echotexture. Fine needle aspiration biopsy will be performed of the node with samples submitted for cytology and thyroglobulin analysis. (Note: All measurements are reported as transverse x AP x longitudinal unless otherwise indicated.)