Thyroid Sonography: Variability of Reporting Recommendations for Fine-Needle Aspiration

Program: Abstracts - Orals, Featured Poster Presentations, and Posters
Session: MON 471-496-Thyroid Neoplasia & Case Reports
Monday, June 17, 2013: 1:45 PM-3:45 PM
Expo Halls ABC (Moscone Center)

Poster Board MON-480
Caitlin A White*1, Carolynn Joy A Nassar2, Jill E Langer3 and Susan J Mandel4
1Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 2Perelman School of Medicine, University of Pennsylvania, 3Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 4Perelman School of Medicine, University of Pennsylvania, Ardmore, PA
Background: Management of thyroid nodules in euthyoid, adult patients is primarily based on results of thyroid sonography (US). The American Thyroid Association (ATA) and Society of Radiologists in Ultrasound (SRU) have published guidelines to determine when FNA is typically warranted based on nodule size and sonographic appearance. The ATA guidelines also include recommendations based on risk factors for thyroid cancer. Our goal was to assess variability in FNA recommendations between our institution and other imaging centers.

Methods: This retrospective review identified 83 new patients referred to the  Hospital at the University of Pennsylvania (HUP) endocrinology practice from 3/1/12 - 8/13/12 who had US exams ( O_US) performed facilities outside HUP prior to referral and repeat US exams  performed at HUP either in our endocrinology or combined endocrinology-radiology thyroid nodule clinic. O_US and HUP_US reports were evaluated for presence of a specific recommendation (FNA or surveillance) and concordance of the recommendation with ATA and SRU guidelines.

Results: O_US reports provided a specific clinical recommendation regarding FNA in 47/83 (57%) patients: 40 recommended FNA of a specific nodule, 7 recommended no FNA. In the 40 where O_US reports recommended FNA, HUP_US recommendations were concordant in 24 (65%), but in 14 (35%) HUP_US led to change of management either because FNA was considered not indicated (12.5%, 5 pts) or FNA of a different nodule was indicated (22.5% 9 pts), diagnosing 1 cancer. HUP_US reports recommended FNA in 2/7 (29%) pts where O_US did not recommend FNA, diagnosing 1 cancer. No clinical recommendation was provided in 36 (43%) O_US reports. For these pts, HUP_US reports recommended FNA in 21 pts (58%) diagnosing 4 thyroid cancers. In the remaining 15 pts (42%) HUP_US did not detect nodules meeting ATA or SRU criteria for FNA. HUP_US recommended FNA in 52/83 (63%) patients. For all 52 pts, the HUP_US recommendation was consistent with ATA guidelines. In 49/52 (92%) this recommendation was consistent with SRU guidelines. The 3 discrepancies were based upon size cutoffs for 2 nodules and knowledge of a family history of thyroid cancer in 1 pt, leading to FNA of a <1cm calcified nodule. 

Conclusions: Our results indicate many O_US reports fail to provide specific recommendations regarding FNA of thyroid nodules. In O_US reports that did provide a specific recommendation for FNA, when evaluated with repeat imaging and application of ATA and SRU guidelines, clinical management changed in 35% and led to the  diagnosis of thyroid cancer in 6/83 (7%).  This suggests that patients may benefit from having their US exams at centers with expertise in both the performance and interpretation of the thyroid ultrasound.

Nothing to Disclose: CAW, CJAN, JEL, SJM

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