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Should Primary care have direct access to Thyroid Ultrasound? Dr Vassiliki Bravis 1 , Dr Ravi Lingam 2  & Dr Devasenan Dev...
Introduction <ul><li>Thyroid USS (TUS) is a useful tool in a spectrum of thyroid conditions </li></ul><ul><li>High sensiti...
Background <ul><li>Referrals for: </li></ul><ul><ul><li>Evaluation of neck/thyroid swelling </li></ul></ul><ul><ul><li>Eva...
Background <ul><li>NICE  (2005) </li></ul><ul><ul><li>Primary care not recommended as may delay referral if cancer suspect...
Investigation of thyroid disease <ul><li>Blood tests (TSH, Free T4, Free T3 , TPO Ab) </li></ul><ul><li>TUS </li></ul><ul>...
AIM of the audit   <ul><li>In some hospitals, primary care has direct access to requesting TUS, rather than via a speciali...
Method  <ul><li>All primary care referrals for TUS  </li></ul><ul><li>First six months of 2006  </li></ul><ul><li>Retrospe...
Results <ul><li>77 primary care referrals (first 6/12 of 2006) </li></ul><ul><ul><li>1) suspicion of goitre/thyroid swelli...
Results 1 2 32 12 18 Total 0 1 0 1 3 Dysphagia (17) 1 0 8 0 6 Abnormal TFTs (15) 0 1 24 11 9 ? Goitre (45) Hypo gland Thyr...
FNA  4 1 8 Total 4 0 7 Solitary/dominant nodule (11) 0 1 1 MNG (2) Insufficient Thyroiditis Benign
Insufficient FNA <ul><li>Of the 4 insufficient samples: </li></ul><ul><ul><li>Re-FNA insufficient in 2 with no F/U in our ...
Conclusion <ul><li>Primary care clinicians obtain TUS studies in patients without recommended indications prior to referra...
Overuse of TUS <ul><li>Inexpensive, accessible, non-invasive </li></ul><ul><li>Accurate in describing thyroid morphology, ...
Discussion-Thyroid dysfunction <ul><li>TUS is not indicated for suspected thyroid dysfunction  </li></ul><ul><li>Hx&Ex, TS...
Discussion-Dysphagia <ul><li>Dyspnoea and dysphagia may be related to a large goitre </li></ul><ul><li>TUS adds little to ...
Discussion-malignancy <ul><li>TUS often detects unsuspected small thyroid nodules </li></ul><ul><li>The use of TUS should ...
 
References <ul><li>Hegedus L. Thyroid ultrasound.  Endocrinol Metab Clin N Am.  2001;30:339–60. </li></ul><ul><li>Holzer S...
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GP referrals for Thyroid ultrasound 2006 audit

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GP referrals for Thyroid ultrasound 2006 audit

  1. 1. Should Primary care have direct access to Thyroid Ultrasound? Dr Vassiliki Bravis 1 , Dr Ravi Lingam 2 & Dr Devasenan Devendra 1 Department of Endocrinology 1 and Radiology 2 Central Middlesex Hospital
  2. 2. Introduction <ul><li>Thyroid USS (TUS) is a useful tool in a spectrum of thyroid conditions </li></ul><ul><li>High sensitivity, non-invasive, safe </li></ul><ul><li>In some hospitals, primary care has direct access to requesting TUS, rather than via a speciality </li></ul>
  3. 3. Background <ul><li>Referrals for: </li></ul><ul><ul><li>Evaluation of neck/thyroid swelling </li></ul></ul><ul><ul><li>Evaluation of other neck mass </li></ul></ul><ul><li>Typical indications (clinical guidance): </li></ul><ul><ul><li>Diffuse thyroid enlargement O/E </li></ul></ul><ul><ul><li>Palpable mass </li></ul></ul><ul><ul><li>Abnormal thyroid function tests </li></ul></ul>
  4. 4. Background <ul><li>NICE (2005) </li></ul><ul><ul><li>Primary care not recommended as may delay referral if cancer suspected </li></ul></ul><ul><ul><li>No specific recommendations for the use of TUS in the initial evaluation of most common thyroid problems </li></ul></ul><ul><li>British Thyroid Association </li></ul><ul><ul><li>– TUS can be used as extension to the clinical examination </li></ul></ul>
  5. 5. Investigation of thyroid disease <ul><li>Blood tests (TSH, Free T4, Free T3 , TPO Ab) </li></ul><ul><li>TUS </li></ul><ul><ul><ul><li>Differentiate solid from cystic nodules </li></ul></ul></ul><ul><ul><ul><li>Show solid components in a cystic nodule </li></ul></ul></ul><ul><ul><ul><li>Identify multinodularity </li></ul></ul></ul><ul><ul><ul><li>Identify associated LN </li></ul></ul></ul><ul><ul><ul><li>CANNOT reliably distinguish benign from malignant lesions </li></ul></ul></ul><ul><li>FNA cytology </li></ul><ul><li>Istotope Scan </li></ul><ul><li>CT/MRI/CXR </li></ul>
  6. 6. AIM of the audit <ul><li>In some hospitals, primary care has direct access to requesting TUS, rather than via a speciality </li></ul><ul><li>We were keen to assess the outcomes of TUS referred by primary care </li></ul>
  7. 7. Method <ul><li>All primary care referrals for TUS </li></ul><ul><li>First six months of 2006 </li></ul><ul><li>Retrospectively </li></ul><ul><li>Analysed them according to the following 3 reasons for referral: </li></ul><ul><ul><li> 1) suspicion of goitre/thyroid swelling </li></ul></ul><ul><ul><li>2) abnormal thyroid function </li></ul></ul><ul><ul><li>3) dysphagia </li></ul></ul>
  8. 8. Results <ul><li>77 primary care referrals (first 6/12 of 2006) </li></ul><ul><ul><li>1) suspicion of goitre/thyroid swelling (45) </li></ul></ul><ul><ul><li>2) abnormal thyroid function (15) </li></ul></ul><ul><ul><li>3) dysphagia (17) </li></ul></ul><ul><li>Male (19), female (58) </li></ul><ul><li>Mean age 42.9 (SD 15.96) </li></ul>
  9. 9. Results 1 2 32 12 18 Total 0 1 0 1 3 Dysphagia (17) 1 0 8 0 6 Abnormal TFTs (15) 0 1 24 11 9 ? Goitre (45) Hypo gland Thyroiditis Normal Solitary/ Dominant nodule MNG
  10. 10. FNA 4 1 8 Total 4 0 7 Solitary/dominant nodule (11) 0 1 1 MNG (2) Insufficient Thyroiditis Benign
  11. 11. Insufficient FNA <ul><li>Of the 4 insufficient samples: </li></ul><ul><ul><li>Re-FNA insufficient in 2 with no F/U in our records so far </li></ul></ul><ul><ul><li>No F/U with re-FNA in our records in 1 </li></ul></ul><ul><ul><li>Insufficient sample to differentiate between follicular adenoma or cancer in 1  re-FNA failed again  surgery revealed adenoca </li></ul></ul>
  12. 12. Conclusion <ul><li>Primary care clinicians obtain TUS studies in patients without recommended indications prior to referral to an endocrinologist </li></ul><ul><li>P rimary care access to T US has not proven of value in detecting sinister thyroid pathology </li></ul><ul><li>Efficiency in investigating thyroid pathology as well as rationalisation of resources may be achieved by involving secondary specialist care </li></ul><ul><li>We recommend a more robust clinical management pathway for thyroid nodules that also provides appropriate clinical governance </li></ul>
  13. 13. Overuse of TUS <ul><li>Inexpensive, accessible, non-invasive </li></ul><ul><li>Accurate in describing thyroid morphology, and in view of the relative inaccuracy of thyroid palpation </li></ul><ul><li>Rarely diagnostic </li></ul><ul><li>Incidentalomas </li></ul><ul><li>Those with normal findings may be less likely to be referred to the endocrinologist </li></ul>
  14. 14. Discussion-Thyroid dysfunction <ul><li>TUS is not indicated for suspected thyroid dysfunction </li></ul><ul><li>Hx&Ex, TSH, T4/T3, and thyroid uptake in patients with thyrotoxicosis are the appropriate diagnostic procedure </li></ul><ul><li>Neither ultrasound nor thyroid scan/uptake is useful in the differential diagnosis of hypothyroidism </li></ul>
  15. 15. Discussion-Dysphagia <ul><li>Dyspnoea and dysphagia may be related to a large goitre </li></ul><ul><li>TUS adds little to the physical Ex of large cervical goitres </li></ul><ul><li>Substernal goitres could be missed by TUS </li></ul><ul><li>Best defined by thyroid scan, CT or MRI </li></ul><ul><li>Neck pain can result from thyroiditis and is rarely a symptom of thyroid cancer </li></ul>
  16. 16. Discussion-malignancy <ul><li>TUS often detects unsuspected small thyroid nodules </li></ul><ul><li>The use of TUS should be advocated as a means for screening for early thyroid cancer </li></ul><ul><li>Similar rate of thyroid cancer in non-palpable and palpable thyroid nodules </li></ul><ul><li>Cure rates in patients with screening-detected thyroid cancer, quality of life, survival unclear </li></ul>
  17. 18. References <ul><li>Hegedus L. Thyroid ultrasound. Endocrinol Metab Clin N Am. 2001;30:339–60. </li></ul><ul><li>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. 2000;89:192–201. </li></ul><ul><li>Deandrea M, Mormile A, Veglio M, et al. Fine needle aspiration biopsy of the thyroid: comparison between thyroid palpation and ultrasonography. Endocr Pract. 2002;8:282–6. </li></ul><ul><li>Nam-Goong IS, Kim HY, Gong G, et al. Ultrasonography-guided fine-needle aspiration of thyroid incidentaloma: correlation with pathological findings. Clin Endocrinol (Oxford). 2004;60:21–8. </li></ul><ul><li>Bonnema SJ, Bennedbaek FN, Ladenson PW, Hegedus L. Management of the nontoxic multinodular goiter: a North American survey. J Clin Endocrinol Metab. 2002;87:112–7. </li></ul><ul><li>Clark KJ, Cronan JJ, Scola FH. Color Doppler sonography: anatomic and physiologic assessment of the thyroid. J Clin Ultrasound. 1995;23:215–23. </li></ul>

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