Page 2 - Kansas Journal of Medicine, Volume 10 Issue 1
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KANSAS JOURNAL of M E D I C I N E                                     INTRODUCTION
                                                                        	 Thyroid nodules are very common with an estimated preva-
   Adherence to Guideline Recommendations in                            lence of 4 - 7% by palpation1-3 and up to 30 - 60% based on autop-
              Patients with Thyroid Nodules                             sy studies.3 Fine-needle aspiration (FNA) biopsy is the standard
                                                                        of care for work-up and exclusion of thyroid cancer. Around 5
     Rudruidee Karnchanasorn, M.D.1, Kristine Grdinovac, M.D.1,         - 15% of thyroid nodules are malignant, but the malignancy risk
                   Nichole Smith, M.D.2, Bhairvi Jani, M.D.3,           increases based on age, sex, history of head and neck radiation,
                        G. John Chen, Ph.D., M.D., MPH4                 and family history.1,4 The incidence of thyroid cancer increased
                                                                        by 2.4 fold from 1973 to 20025, which is likely due to increasing
     1University of Kansas Medical Center, Department of Internal       use of ultrasound (US). Various practice guidelines for manage-
          Medicine, Division of Metabolism, Endocrinology and           ment of thyroid nodules have been published, including the most
                             Genetics, Kansas City, KS                  recent 2015 American Thyroid Association (ATA)6 guideline.
             2Medical University of South Carolina, Division of         Clinical risk factors of malignancy include childhood radiation
                                                                        exposure, rapid growth of a nodule, hoarseness, vocal cord pa-
      Endocrinology, Diabetes & Medical Genetics, Charleston, SC        ralysis, dysphagia, or a family history of thyroid cancer or mul-
        3Saint Louis University, Division of Gastroenterology and       tiple endocrine neoplasia syndromes. Suspicious US features in-
                           Hepatology, Saint Louis, MO                  clude hypoechogenicity, microcalcifications, taller than wide on
                                                                        transverse view, or infiltration of the surrounding tissue. ATA
     4University of Kansas Medical Center, Department of Internal       recommends FNA based on sizes and sonographic patterns,
              Medicine, Division of Health Services Research,           starting at 1 cm with intermediate to high suspicion patterns.
                                    Kansas City, KS                     	 A serum thyroid-stimulating hormone (TSH) level
                                                                        should be obtained in all patients. If TSH is suppressed,
    ABSTRACT                                                            a radionuclide thyroid scan (I-SCAN) should be ob-
    Introduction. Thyroid nodules are common and fine-nee-              tained. FNA generally is not indicated for hyperfunc-
    dle aspiration (FNA) biopsy is the standard of care for work-       tioning nodules due to low likelihood of malignancy.
    up to exclude thyroid cancer. In this study, we examined            	 In this study, we examined the discrepancy between daily
    the discrepancy between daily practice and recommended              practice and recommended diagnostic approach to thyroid nod-
    diagnostic approach for management of thyroid nodules,              ules, based on history taking, laboratory, and imaging studies.
    based on history taking, laboratory, and imaging studies.
    Methods. This was a retrospective chart review of 199 pa-           	 Patients who underwent ultrasound-guided FNA (UGFNA)
    tients who had ultrasound-guided fine needle aspira-                at our institution during January 1, 2010 to December 31, 2011
    tion (UGFNA) performed at a Midwest academic medi-                  were retrospectively reviewed. The date range was chosen to
    cal center from January 2010 to December 2011. The                  begin following the revised ATA guideline published in 2009.
    quality measures were selected based on recommended clini-          We randomly selected 200 subjects and one patient was ex-
    cal practice guidelines, including family history, history of neck  cluded due to duplicate records. Patients with previous his-
    radiation, neck symptoms, TSH test, and thyroid ultrasound.         tory of thyroid cancer or thyroid surgery were excluded. The
                                                                        study protocol was approved by the local institutional review
    Results. The majority of patients were Caucasian females. Fam-      board. Data abstraction from the electronic medical record were
    ily history of thyroid cancer and childhood neck radiation ex-      entered in REDcap7, including demographic information, rel-
    posure were documented in 79 subjects (40%) and 76 subjects         evant clinical history including family history of thyroid can-
    (38%), respectively. Neck symptoms were documented in most          cer, history of childhood neck radiation, neck symptoms, TSH
    subjects, including dysphonia (56.8%), dysphagia (69.9%), and       values, suspicious ultrasound characteristics, and I-SCAN re-
    dyspnea (41.2%). Most subjects had a TSH measured and an ul-        sults. The quality measures were determined based on five
    trasound performed prior to biopsy (75% and 86%, respectively).     categories: (1) documentation of family history of thyroid
                                                                        cancer, (2) documentation of history of childhood neck radia-
    Conclusions. It appears there is a gap between current patient      tion, (3) documentation of neck symptoms including dyspho-
    care and clinical practice guidelines for management of thyroid     nia, dysphagia, and dyspnea, (4) presence of TSH values prior
    nodules. Clinical history and ultrasound features for risk strati-  to UGFNA, and (5) presence of thyroid US prior to UGFNA.
    fication of UGFNA were lacking, which could reflect physicians’     	 The ultrasound results were categorized according to nod-
    unfamiliarity with the guidelines. As thyroid nodules are com-      ules sizes, number of nodules, echogenicity, presence of mi-
    mon, enhancing knowledge of the current guidelines could im-        crocalcification, presence of irregular margins, presence of
    prove appropriate work-up. Further studies are needed to identify   suspicious cervical lymph nodes, and evidence of growth from
    factors associated with the poor compliance with clinical guide-    previous US. All analyses were conducted using SAS statisti-
    lines in management of thyroid nodules. KS J Med 2017;10(1):1-2.    cal software, version 9.4 (SAS Institute, Inc., Cary, NC, USA).

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