GP referrals for Thyroid ultrasound 2006 audit

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Should Primary care Should Primary care have direct access to have direct access to Thyroid Ultrasound? Thyroid Ultrasound? Dr Vassiliki Bravis Dr Vassiliki Bravis 1 , Dr Ravi Lingam , Dr Ravi Lingam 2 & Dr Devasenan & Dr Devasenan Devendra Devendra 1 Department of Endocrinology Department of Endocrinology 1 and Radiology and Radiology 2 Central Middlesex Hospital Central Middlesex Hospital

Transcript of GP referrals for Thyroid ultrasound 2006 audit

Page 1: GP referrals for Thyroid ultrasound 2006 audit

Should Primary care Should Primary care have direct access to have direct access to Thyroid Ultrasound?Thyroid Ultrasound?

Dr Vassiliki BravisDr Vassiliki Bravis11, Dr Ravi Lingam, Dr Ravi Lingam22 & Dr Devasenan & Dr Devasenan DevendraDevendra11

Department of EndocrinologyDepartment of Endocrinology11 and Radiology and Radiology22

Central Middlesex HospitalCentral Middlesex Hospital

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IntroductionIntroduction

• Thyroid USS (TUS) is a useful tool in a Thyroid USS (TUS) is a useful tool in a spectrum of thyroid conditionsspectrum of thyroid conditions

• High sensitivity, non-invasive, safeHigh sensitivity, non-invasive, safe

• In some hospitals, primary care has In some hospitals, primary care has direct access to requesting TUS, direct access to requesting TUS, rather than via a specialityrather than via a speciality

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BackgroundBackground

• Referrals for:Referrals for:– Evaluation of neck/thyroid swellingEvaluation of neck/thyroid swelling– Evaluation of other neck massEvaluation of other neck mass

• Typical indications (clinical guidance):Typical indications (clinical guidance):

– Diffuse thyroid enlargement O/EDiffuse thyroid enlargement O/E– Palpable massPalpable mass– Abnormal thyroid function testsAbnormal thyroid function tests

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BackgroundBackground

• NICE NICE (2005)(2005)

– Primary care not recommended as may Primary care not recommended as may delay referral if cancer suspecteddelay referral if cancer suspected

– No specific recommendations for the No specific recommendations for the use of TUS in the initial evaluation of use of TUS in the initial evaluation of most common thyroid problems most common thyroid problems

• British Thyroid Association British Thyroid Association – – TUS can be used as extension to the TUS can be used as extension to the

clinical examinationclinical examination

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Investigation of thyroid Investigation of thyroid diseasedisease• Blood tests (TSH, Free T4, Free T3 , TPO Blood tests (TSH, Free T4, Free T3 , TPO

Ab)Ab)• TUSTUS

• Differentiate solid from cystic nodulesDifferentiate solid from cystic nodules• Show solid components in a cystic noduleShow solid components in a cystic nodule• Identify multinodularityIdentify multinodularity• Identify associated LNIdentify associated LN• CANNOT reliably distinguish benign from malignant CANNOT reliably distinguish benign from malignant

lesionslesions

• FNA cytologyFNA cytology• Istotope ScanIstotope Scan• CT/MRI/CXRCT/MRI/CXR

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AIM of the auditAIM of the audit

• In some hospitals, primary care has In some hospitals, primary care has direct access to requesting TUS, direct access to requesting TUS, rather than via a specialityrather than via a speciality

• We were keen to assess the We were keen to assess the outcomes of TUS referred by primary outcomes of TUS referred by primary carecare

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Method Method

• All primary care referrals for TUS All primary care referrals for TUS • First six months of 2006 First six months of 2006 • RetrospectivelyRetrospectively• Analysed them according to the Analysed them according to the

following 3 reasons for referral:following 3 reasons for referral: 1) suspicion of goitre/thyroid swelling1) suspicion of goitre/thyroid swelling

2) abnormal thyroid function2) abnormal thyroid function3) dysphagia3) dysphagia

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ResultsResults

• 77 primary care referrals (first 6/12 77 primary care referrals (first 6/12 of 2006)of 2006)– 1) suspicion of goitre/thyroid swelling 1) suspicion of goitre/thyroid swelling

(45)(45)– 2) abnormal thyroid function (15)2) abnormal thyroid function (15)– 3) dysphagia (17)3) dysphagia (17)

• Male (19), female (58)Male (19), female (58)

• Mean age 42.9 (SD 15.96)Mean age 42.9 (SD 15.96)

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ResultsResultsMNGMNG Solitary/ Solitary/

DominanDominant nodule t nodule

NormalNormal ThyroiditiThyroiditiss

Hypo Hypo glandgland

? Goitre ? Goitre (45)(45)

99 1111 2424 11 00

Abnormal Abnormal TFTs (15)TFTs (15)

66 00 88 00 11

DysphagiDysphagiaa

(17)(17)

33 11 00 11 00

TotalTotal 1818 1212 3232 22 11

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FNA FNA BenignBenign ThyroiditisThyroiditis InsufficienInsufficien

tt

MNG (2)MNG (2) 11 11 00

Solitary/Solitary/dominant dominant nodule nodule (11)(11)

77 00 44

TotalTotal 88 11 44

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Insufficient FNAInsufficient FNA

• Of the 4 insufficient samples:Of the 4 insufficient samples:– Re-FNA insufficient in 2 with no F/U in Re-FNA insufficient in 2 with no F/U in

our records so farour records so far– No F/U with re-FNA in our records in 1No F/U with re-FNA in our records in 1– Insufficient sample to differentiate Insufficient sample to differentiate

between follicular adenoma or cancer in between follicular adenoma or cancer in 1 1 re-FNA failed again re-FNA failed again surgery surgery revealed adenoca revealed adenoca

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ConclusionConclusion

• Primary care clinicians obtain TUS studies in Primary care clinicians obtain TUS studies in patients without recommended indications prior patients without recommended indications prior to referral to an endocrinologist to referral to an endocrinologist

• PPrimary care access to rimary care access to TTUS has not proven of US has not proven of value in detecting sinister thyroid pathologyvalue in detecting sinister thyroid pathology

• Efficiency in investigating thyroid pathology as Efficiency in investigating thyroid pathology as well as rationalisation of resources may be well as rationalisation of resources may be achieved by involving secondary specialist careachieved by involving secondary specialist care

• We recommend a more robust clinical We recommend a more robust clinical management pathway for thyroid nodules that management pathway for thyroid nodules that also provides appropriate clinical governancealso provides appropriate clinical governance

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Overuse of TUSOveruse of TUS

• Inexpensive, accessible, non-invasiveInexpensive, accessible, non-invasive• Accurate in describing thyroid Accurate in describing thyroid

morphology, and in view of the relative morphology, and in view of the relative inaccuracy of thyroid palpationinaccuracy of thyroid palpation

• Rarely diagnostic Rarely diagnostic • IncidentalomasIncidentalomas• Those with normal findings may be less Those with normal findings may be less

likely to be referred to the likely to be referred to the endocrinologistendocrinologist

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Discussion-Thyroid Discussion-Thyroid dysfunctiondysfunction

• TUS is not indicated for suspected TUS is not indicated for suspected thyroid dysfunction thyroid dysfunction

• Hx&Ex, TSH, T4/T3, and thyroid Hx&Ex, TSH, T4/T3, and thyroid uptake in patients with thyrotoxicosis uptake in patients with thyrotoxicosis are the appropriate diagnostic are the appropriate diagnostic procedureprocedure

• Neither ultrasound nor thyroid Neither ultrasound nor thyroid scan/uptake is useful in the scan/uptake is useful in the differential diagnosis of differential diagnosis of hypothyroidismhypothyroidism

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Discussion-DysphagiaDiscussion-Dysphagia

• Dyspnoea and dysphagia may be related Dyspnoea and dysphagia may be related to a large goitreto a large goitre

• TUS adds little to the physical Ex of large TUS adds little to the physical Ex of large cervical goitrescervical goitres

• Substernal goitres could be missed by Substernal goitres could be missed by TUSTUS

• Best defined by thyroid scan, CT or MRIBest defined by thyroid scan, CT or MRI• Neck pain can result from thyroiditis and Neck pain can result from thyroiditis and

is rarely a symptom of thyroid canceris rarely a symptom of thyroid cancer

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Discussion-malignancyDiscussion-malignancy

• TUS often detects unsuspected small TUS often detects unsuspected small thyroid nodulesthyroid nodules

• The use of TUS should be advocated as a The use of TUS should be advocated as a means for screening for early thyroid cancermeans for screening for early thyroid cancer

• Similar rate of thyroid cancer in non-Similar rate of thyroid cancer in non-palpable and palpable thyroid nodulespalpable and palpable thyroid nodules

• Cure rates in patients with screening-Cure rates in patients with screening-detected thyroid cancer, quality of life, detected thyroid cancer, quality of life, survival unclearsurvival unclear

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ReferencesReferences

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2.2. Holzer S, Reiners C, Mann K, et al. Patterns of care for patients with primary 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 differentiated carcinoma of the thyroid gland treated in Germany during 1996. U.S. and German thyroid cancer group. 1996. U.S. and German thyroid cancer group. Cancer. Cancer. 2000;89:192–201. 2000;89:192–201.

3.3. Deandrea M, Mormile A, Veglio M, et al. Fine needle aspiration biopsy of the Deandrea M, Mormile A, Veglio M, et al. Fine needle aspiration biopsy of the thyroid: comparison between thyroid palpation and ultrasonography. thyroid: comparison between thyroid palpation and ultrasonography. Endocr Pract. Endocr Pract. 2002;8:282–6. 2002;8:282–6.

4.4. Nam-Goong IS, Kim HY, Gong G, et al. Ultrasonography-guided fine-needle Nam-Goong IS, Kim HY, Gong G, et al. Ultrasonography-guided fine-needle aspiration of thyroid incidentaloma: correlation with pathological findings. aspiration of thyroid incidentaloma: correlation with pathological findings. Clin Endocrinol (Oxford). Clin Endocrinol (Oxford). 2004;60:21–8.2004;60:21–8.

5.5. Bonnema SJ, Bennedbaek FN, Ladenson PW, Hegedus L. Management of Bonnema SJ, Bennedbaek FN, Ladenson PW, Hegedus L. Management of the nontoxic multinodular goiter: a North American survey. the nontoxic multinodular goiter: a North American survey. J Clin Endocrinol J Clin Endocrinol Metab. Metab. 2002;87:112–7. 2002;87:112–7.

6.6. Clark KJ, Cronan JJ, Scola FH. Color Doppler sonography: anatomic and Clark KJ, Cronan JJ, Scola FH. Color Doppler sonography: anatomic and physiologic assessment of the thyroid. physiologic assessment of the thyroid. J Clin Ultrasound. J Clin Ultrasound. 1995;23:215–23. 1995;23:215–23.