Compliance of British Thyroid Ultrasound "U" Guidelines Are we all speaking the "Unified" Thyroid language?

Transcription

1 Compliance of British Thyroid Ultrasound "U" Guidelines Are we all speaking the "Unified" Thyroid language? Poster No.: C-1158 Congress: ECR 2016 Type: Scientific Exhibit Authors: P. Gopalan, S. Singh, S. Vaidyanathan, S. Karthik; Leeds/UK Keywords: Endocrine disorders, Audit and standards, Ultrasound, Thyroid / Parathyroids DOI: /ecr2016/C-1158 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 39

2 Aims and objectives To evaluate the degree of compliance to the guidelines issued by British Thyroid Association (BTA) regarding the formal reporting of thyroid nodules detected on ultrasound assessment of thyroid gland and also incidental thyroid nodules detected on neck ultrasound in our institution. It is expected that reporting guidelines would improve patient management in terms of streamlining the reporting outcome and hence providing a standardized care and also cost effectiveness by reducing unnecessary fine needle aspiration of thyroid nodules (1) Page 2 of 39.

3 Methods and materials Incidence of thyroid nodules is common. According to Framingham study palpable (2) nodules are present in 6.4% of women and 1.5% of men aged in unselected subjects using ultrasound assessment the incidence of ultrasound detected nodules can be very varied. As per Ezzat S et al % women would have at least 1 thyroid nodule on ultrasound assessment (3, 4). The estimated risk of malignancy in thyroid nodules is (5) about 5%. The data indicate that although each nodule is potentially malignant, a considerable process of selection must ensue before a decision can be made as to which nodules require surgical intervention. Inappropriate use and reporting of imaging will result in an epidemic of thyroid nodules, the majority of which will be benign (6). BTA issued guidelines in July 2014 regarding (7). radiological reporting of ultrasound detected thyroid nodules to address this issue As per BTA, this allows Radiologists to use an US (U) classification (U1-U5) system for the prediction of malignancy and helps to determine whether a FNAC should be performed (8-12). According to BTA guidelines all thyroid nodules are categorized into one of five the following categories. U1 - Normal Thyroid gland. Page 3 of 39

4 Fig. 1: Normal Thyroid gland References: Radiology, NHS, Leeds and Bradford teaching hospitals - Leeds/UK U2 - Benign (a) halo, iso-echoic / mildly hyper-echoic (b) cystic change +/- ring down sign (colloid) (c) micro- cystic / spongiform (d & e) peripheral egg shell calcification (f) peripheral vascularity. Page 4 of 39

5 Fig. 2: U2 - Cystic nodule with peripheral vascularity References: Radiology, NHS, Leeds and Bradford teaching hospitals - Leeds/UK Page 5 of 39

6 Fig. 3: U2 - Spongiform Nodule References: Radiology, NHS, Leeds and Bradford teaching hospitals - Leeds/UK U3- Indeterminate/Equivocal (a) homogenous, hyper-echoic (markedly), solid, halo (follicular lesion). (b)? hypo-echoic, equivocal echogenic foci, cystic change (c) mixed/central vascularity Page 6 of 39

7 Fig. 5: U3 - Mixed echogenicity, cystic cggange References: Radiology, NHS, Leeds and Bradford teaching hospitals - Leeds/UK Page 7 of 39

8 Fig. 6: U3 - Mixed central vascularity. References: Radiology, NHS, Leeds and Bradford teaching hospitals - Leeds/UK Page 8 of 39

9 Fig. 7: U3 - Solid hyperechoic References: Radiology, NHS, Leeds and Bradford teaching hospitals - Leeds/UK Page 9 of 39

10 Fig. 8: U3 - Solid mixed vascularity. References: Radiology, NHS, Leeds and Bradford teaching hospitals - Leeds/UK U4. Suspicious of Malignancy (a) solid, hypo-echoic (cf thyroid) (b) solid, very hypo-echoic (cf strap muscle) (c) disrupted peripheral calcification, hypo-echoic (d) lobulated outline Page 10 of 39

11 Fig. 9: U4 - Solid hypoechoic nodule References: Radiology, NHS, Leeds and Bradford teaching hospitals - Leeds/UK Page 11 of 39

12 Fig. 10: U4 - Solid hypoechoic and hypervascular References: Radiology, NHS, Leeds and Bradford teaching hospitals - Leeds/UK U5. Malignant (a) solid, hypo-echoic, lobulated / irregular outline, micro-calcification. (? Papillary carcinoma) (b) solid, hypo-echoic, lobulated/irregular outline, globular calcification (? Medullary carcinoma) (c) intra-nodular vascularity (d) shape (taller >wide) (AP>TR) Page 12 of 39

13 (e) characteristic associated lymphadenopathy Fig. 11: U5 - Taller than wide and micro calcification References: Radiology, NHS, Leeds and Bradford teaching hospitals - Leeds/UK Page 13 of 39

14 Fig. 12: U5 - Irregular outline References: Radiology, NHS, Leeds and Bradford teaching hospitals - Leeds/UK Page 14 of 39

15 Fig. 13: U5 - mixed vascularity pattern References: Radiology, NHS, Leeds and Bradford teaching hospitals - Leeds/UK In our department, - we formally introduced use of BTA guidelines for reporting of thyroid nodules from January In an attempt to form a systematic approach, it was agreed that the new guidelines should be used in all index presentations of thyroid nodules and a plan was formulated to include the follow up cases of thyroid nodules at a later stage. Page 15 of 39

16 Materials: - 4 months period from September - December 2014 was used as a training and educational period before the guideline introduction into clinical practice. - All the sonographers involved in neck and thyroid imaging were informed about the BTA guidelines with imaging correlates and a proper consultant radiologist review back up was set up for the sonographers who often scanned independently across multiple sites - The teaching was arranged in small group discussions by consultant radiologists with interest in head and neck imaging and a consultant sonographer. - In addition, various handouts and charts were printed to be displayed in sonographer reporting areas where imaging was performed for ready reference available at time of issuing formal ultrasound report - The formal introduction of BTA guidelines was commenced on 1st January Methods: - A retrospective audit was performed for a period of 5 months from January May A data base search was performed using CRIS (Computerized Radiology Information System). - All ultrasound reports of neck and thyroid were reviewed retrospectively by two radiologists in training. - Both index presentations and follow up scans were included initially however for the purpose of this audit, only the index scans were included. Page 16 of 39

17 Images for this section: Fig. 1: Normal Thyroid gland Radiology, NHS, Leeds and Bradford teaching hospitals - Leeds/UK Page 17 of 39

18 Fig. 2: U2 - Cystic nodule with peripheral vascularity Radiology, NHS, Leeds and Bradford teaching hospitals - Leeds/UK Page 18 of 39

19 Fig. 3: U2 - Spongiform Nodule Radiology, NHS, Leeds and Bradford teaching hospitals - Leeds/UK Page 19 of 39

20 Fig. 4: U2 - Mildly hyperechoic and halo. Radiology, NHS, Leeds and Bradford teaching hospitals - Leeds/UK Page 20 of 39

21 Fig. 5: U3 - Mixed echogenicity, cystic cggange Radiology, NHS, Leeds and Bradford teaching hospitals - Leeds/UK Page 21 of 39

22 Fig. 6: U3 - Mixed central vascularity. Radiology, NHS, Leeds and Bradford teaching hospitals - Leeds/UK Page 22 of 39

23 Fig. 7: U3 - Solid hyperechoic Radiology, NHS, Leeds and Bradford teaching hospitals - Leeds/UK Page 23 of 39

24 Fig. 8: U3 - Solid mixed vascularity. Radiology, NHS, Leeds and Bradford teaching hospitals - Leeds/UK Page 24 of 39

25 Fig. 9: U4 - Solid hypoechoic nodule Radiology, NHS, Leeds and Bradford teaching hospitals - Leeds/UK Page 25 of 39

26 Fig. 10: U4 - Solid hypoechoic and hypervascular Radiology, NHS, Leeds and Bradford teaching hospitals - Leeds/UK Page 26 of 39

27 Fig. 11: U5 - Taller than wide and micro calcification Radiology, NHS, Leeds and Bradford teaching hospitals - Leeds/UK Page 27 of 39

28 Fig. 12: U5 - Irregular outline Radiology, NHS, Leeds and Bradford teaching hospitals - Leeds/UK Page 28 of 39

29 Fig. 13: U5 - mixed vascularity pattern Radiology, NHS, Leeds and Bradford teaching hospitals - Leeds/UK Page 29 of 39

30 Results Total of 1220 ultrasound reports were reviewed. Out of these the 860 reports were related to thyroid imaging either thyroid being imaged as a primary area of interest or as a part of comprehensive assessment of neck. Fig. 14: Results Graph 1 References: Radiology, NHS, Leeds and Bradford teaching hospitals - Leeds/UK Page 30 of 39

31 Fig. 15: Results - Graph 2 References: Radiology, NHS, Leeds and Bradford teaching hospitals - Leeds/UK Page 31 of 39

32 Fig. 16: Results - Graph 3 References: Radiology, NHS, Leeds and Bradford teaching hospitals - Leeds/UK Fig. 17: Results - Graph 4 References: Radiology, NHS, Leeds and Bradford teaching hospitals - Leeds/UK Page 32 of 39

33 Images for this section: Fig. 14: Results Graph 1 Radiology, NHS, Leeds and Bradford teaching hospitals - Leeds/UK Page 33 of 39

34 Fig. 15: Results - Graph 2 Radiology, NHS, Leeds and Bradford teaching hospitals - Leeds/UK Fig. 16: Results - Graph 3 Page 34 of 39

35 Radiology, NHS, Leeds and Bradford teaching hospitals - Leeds/UK Fig. 17: Results - Graph 4 Radiology, NHS, Leeds and Bradford teaching hospitals - Leeds/UK Page 35 of 39

36 Conclusion The process of introduction and implementation of BTA guideline into the reporting practice for Thyroid US at a large centre with a big group of sonographers performing thyroid US across multiple sites has been reasonably successful. There has been a gradual and steady increase in adaptation of use of BTA guideline in reporting thyroid nodules. The uptake was slow to start with but as the time has progressed, the compliance has gradually increased. Our aim is to expand the use of the BTA guidelines to 90% compliance and subsequently to a 100% over the course of the next 12 to 18 months. We will be presenting this audit data to both the Radiologist body and the sonographers followed by a further review of the BTA guidelines and another round of educational presentations to the sonographers culminating in a half day thyroid study day for Radiologists and sonographers in the latter part of Page 36 of 39

37 Personal information Dr. S. Singh Radiology Registrar Leeds Teaching Hospital NHS Trust Leeds (UK) Dr. P. Gopalan Radiology Registrar Bradford Teaching Hospitals NHS Foundation Trust Bradford (UK) Dr. S. Vaidyanathan Consultant Radiologist Leeds Teaching Hospital NHS Trust Leeds (UK) Dr. S Karthik Consultant Radiologist Leeds Teaching Hospital NHS Trust Leeds (UK) Page 37 of 39

38 References 1. Horvath E et al. An ultrasonogram reporting system for thyroid nodules stratifying cancer risk for clinical management. J Clin Endocrinol Metab 2009; 94: Vander, J.B., Gaston, E.A., and Dawber, T.R. The significance of nontoxic thyroid nodules: final report of a 15-year study of the incidence of thyroid malignancy. Ann Intern Med 1968; 69: Ezzat S, Sarti DA, Cain DR, Braunstein GD. Thyroid incidentalomas. Prevalence by palpation and ultrasonography. Arch Intern Med (Aug) 22;154(16): Brander A, Viikinkoski P, Nickels J, Kivisaari L.Thyroid gland: US screening in a random adult population. Radiology.1991(Dec); 181(3): Iannuccilli JD, Cronan JJ, Monchik JM. Risk for malignancy of thyroid nodules as assessed by sonographic criteria: the need for biopsy. J Ultround Med Nov; 23(11): Juan P Brito, John C Morris, Victor M Montori. Thyroid cancer: zealous imaging has increased detection and treatment of low risk tumours BMJ 2013; British Thyroid Association Guidelines for the Management of Thyroid Cancer. Clinical Endocrinology (2014), 81 (Suppl. 1), Cesur, M., Corapcioglu, D., Bulut, S. et al. Comparison of palpation guided fine needle aspiration biopsy to ultrasound guided fine needle aspiration biopsy in the evaluation of thyroid nodules. Thyroid. 2006; 16, Lee, Y.H., Kim, D.W. & In, H.S. Differentiation between benign and malignant thyroid solid thyroid nodules using an ultrasound classification system. Korean Journal of Radiology. 2011; 12, Kim, E.K., Park, C.S., Chung, W.Y. et al. New sonographic criteria for recommending fine-needle aspiration biopsy of nonpalpable solid nodules of the thyroid. American Journal of Roentgenology. 2002; 178, Page 38 of 39

39 11. Moon, W.J., Jung, S.L., Lee, J.H. et al. Benign and malignant thyroid nodules: US differentiation - Multicenter retrospective study. Radiology. 2008; 247, Papini, E., Gugliemi, R., Bianchini, A. et al. Risk of malignancy in non-palpable thyroid nodules: predictive value of ultrasound and color-doppler features. Journal of Clinical Endocrinology and Metabolism. 2002; 87, Page 39 of 39