Should Primary care have direct access to Thyroid Ultrasound

1
Should Primary care have direct access to Thyroid
Ultrasound?

• Dr Vassiliki Bravis1, Dr Ravi Lingam2 Dr
  Devasenan Devendra1
• Department of Endocrinology1 and Radiology2
• Central Middlesex Hospital

2
Introduction

• Thyroid USS (TUS) is a useful tool in a spectrum
  of thyroid conditions
• High sensitivity, non-invasive, safe
• In some hospitals, primary care has direct access
  to requesting TUS, rather than via a speciality

3
Background

• Referrals for
• Evaluation of neck/thyroid swelling
• Evaluation of other neck mass
• Typical indications (clinical guidance)
• Diffuse thyroid enlargement O/E
• Palpable mass
• Abnormal thyroid function tests

4
Background

• NICE (2005)
• Primary care not recommended as may delay
  referral if cancer suspected
• No specific recommendations for the use of TUS
  in the initial evaluation of most common thyroid
  problems
• British Thyroid Association
• TUS can be used as extension to the clinical
  examination

5
Investigation of thyroid disease

• Blood tests (TSH, Free T4, Free T3 , TPO Ab)
• TUS
• Differentiate solid from cystic nodules
• Show solid components in a cystic nodule
• Identify multinodularity
• Identify associated LN
• CANNOT reliably distinguish benign from malignant
  lesions
• FNA cytology
• Istotope Scan
• CT/MRI/CXR

6
AIM of the audit

• In some hospitals, primary care has direct access
  to requesting TUS, rather than via a speciality
• We were keen to assess the outcomes of TUS
  referred by primary care

7
Method

• All primary care referrals for TUS
• First six months of 2006
• Retrospectively
• Analysed them according to the following 3
  reasons for referral
• 1) suspicion of goitre/thyroid swelling
• 2) abnormal thyroid function
• 3) dysphagia

8
Results

• 77 primary care referrals (first 6/12 of 2006)
• 1) suspicion of goitre/thyroid swelling (45)
• 2) abnormal thyroid function (15)
• 3) dysphagia (17)
• Male (19), female (58)
• Mean age 42.9 (SD 15.96)

9
Results
10
FNA
11
Insufficient FNA

• Of the 4 insufficient samples
• Re-FNA insufficient in 2 with no F/U in our
  records so far
• No F/U with re-FNA in our records in 1
• Insufficient sample to differentiate between
  follicular adenoma or cancer in 1 ? re-FNA failed
  again ? surgery revealed adenoca

12
Conclusion

• Primary care clinicians obtain TUS studies in
  patients without recommended indications prior to
  referral to an endocrinologist
• Primary care access to TUS has not proven of
  value in detecting sinister thyroid pathology
• Efficiency in investigating thyroid pathology as
  well as rationalisation of resources may be
  achieved by involving secondary specialist care
• We recommend a more robust clinical management
  pathway for thyroid nodules that also provides
  appropriate clinical governance

13
Overuse of TUS

• Inexpensive, accessible, non-invasive
• Accurate in describing thyroid morphology, and in
  view of the relative inaccuracy of thyroid
  palpation
• Rarely diagnostic
• Incidentalomas
• Those with normal findings may be less likely to
  be referred to the endocrinologist

14
Discussion-Thyroid dysfunction

• TUS is not indicated for suspected thyroid
  dysfunction
• HxEx, TSH, T4/T3, and thyroid uptake in patients
  with thyrotoxicosis are the appropriate
  diagnostic procedure
• Neither ultrasound nor thyroid scan/uptake is
  useful in the differential diagnosis of
  hypothyroidism

15
Discussion-Dysphagia

• Dyspnoea and dysphagia may be related to a large
  goitre
• TUS adds little to the physical Ex of large
  cervical goitres
• Substernal goitres could be missed by TUS
• Best defined by thyroid scan, CT or MRI
• Neck pain can result from thyroiditis and is
  rarely a symptom of thyroid cancer

16
Discussion-malignancy

• TUS often detects unsuspected small thyroid
  nodules
• The use of TUS should be advocated as a means for
  screening for early thyroid cancer
• Similar rate of thyroid cancer in non-palpable
  and palpable thyroid nodules
• Cure rates in patients with screening-detected
  thyroid cancer, quality of life, survival unclear

17
(No Transcript)
18
References

• Hegedus L. Thyroid ultrasound. Endocrinol Metab
  Clin N Am. 20013033960.
• Holzer S, Reiners C, Mann K, et al. Patterns of
  care for patients with primary differentiated
  carcinoma of the thyroid gland treated in Germany
  during 1996. U.S. and German thyroid cancer
  group. Cancer. 200089192201.
• Deandrea M, Mormile A, Veglio M, et al. Fine
  needle aspiration biopsy of the thyroid
  comparison between thyroid palpation and
  ultrasonography. Endocr Pract. 200282826.
• Nam-Goong IS, Kim HY, Gong G, et al.
  Ultrasonography-guided fine-needle aspiration of
  thyroid incidentaloma correlation with
  pathological findings. Clin Endocrinol (Oxford).
  200460218.
• Bonnema SJ, Bennedbaek FN, Ladenson PW, Hegedus
  L. Management of the nontoxic multinodular
  goiter a North American survey. J Clin
  Endocrinol Metab. 2002871127.
• Clark KJ, Cronan JJ, Scola FH. Color Doppler
  sonography anatomic and physiologic assessment
  of the thyroid. J Clin Ultrasound.
  19952321523.