Advanced Thyroid and Parathyroid Ultrasound

Part IUltrasound in Clinical Practice: Philosophy and Logistics

© Springer International Publishing Switzerland 2017

M. Milas et al. (eds.)Advanced Thyroid and Parathyroid Ultrasoundhttps://doi.org/10.1007/978-3-319-44100-9_1

1. Thyroid and Parathyroid Ultrasound: Comprehensive and Problem-Focused Point-of-Care Utilization in Clinical Practice

Marelle Yehuda¹  , Elizabeth O. Westfall²  , Mira Milas³   and Andrew G. Gianoukakis¹  

(1)

Department of Medicine, Division of Endocrinology, Harbor-UCLA Medical Center and the David Geffen School of Medicine at UCLA, 1124 West Carson St. RB-1, Torrance, CA 90502, USA

(2)

Department of Medical Imaging, Banner - University Medical Center Phoenix, 1111 E. McDowell Road, Phoenix, AZ 85006, USA

(3)

Department of Surgery and the Endocrinology & Metabolism Institute, University of Arizona College of Medicine - Phoenix, Banner - University Medical Center Phoenix, 1441 North 12th Street 2nd floor, Phoenix, AZ 85006, USA

Marelle Yehuda

Email: [email protected]

Elizabeth O. Westfall

Email: [email protected]

Mira Milas

Email: [email protected]

Andrew G. Gianoukakis (Corresponding author)

Email: [email protected]

Keywords

Point of careUltrasoundHistoryThyroidParathyroidMultidisciplinary

1.1 Introduction

The modern use of bedside ultrasonography has changed the practice of medical care. Ultrasonography’s relative ease of use, low cost, and bedside availability have made it invaluable in many clinical settings including those in which patients with thyroid and parathyroid disease are evaluated.

This chapter provides an overview of comprehensive and point-of-care applications of ultrasound (US) in the medical and surgical evaluation of patients with thyroid or parathyroid pathology. We also address potential pitfalls in the use of point-of-care neck ultrasound: the interobserver variability, the limited sensitivity of ultrasound to detect various pathologies, and the need to employ other imaging methods when appropriate.

1.1.1 History of Sonography

The modern ultrasound arises from the concept of echolocation and the pulse echo principle. In the late eighteenth century, experimental biologist Lazzaro Spallanzani, demonstrated that bats use sound waves for hunting and navigation [1]. In the ensuing centuries, scientists continued to study the concept of sound and echolocation and eventually began utilizing knowledge of sound waves and principles of physics to measure distance underwater, known as Sound Navigation and Ranging or SONAR. As this technology became more refined during World War II, the medical profession attempted to employ ultrasound as a therapeutic treatment for various ailments, such as arthritis [2]. The first physician credited with producing clinical ultrasound images for diagnostic purposes was Karl Dussik, an Austrian neurologist at the University of Vienna who used ultrasound to image and measure the intracranial ventricles [2]. Around the same time, George Ludwig, a researcher at the Naval Medical Research Institute, began experimenting with A-mode ultrasound to detect gallstones in animal models [1]. In the 1960s and 1970s, researchers began using ultrasound to evaluate the thyroid gland. An early thyroid ultrasound apparatus is seen pictured in Fig. 1.1 [3]. Due to a lack of widespread ultrasound availability and expertise, thyroid ultrasonography was not routinely used in clinical practice for the next two decades [4]. By the early 2000s, more affordable equipment made the acquisition and use of ultrasound feasible for clinicians. Figure 1.2 shows the dramatic progress in ultrasound technology with regard to quality of imaging and design of ultra-compact sonographic machines over the past 15 years.

Fig. 1.1

A historical image circa 1967 of the beginning of thyroid ultrasound. Fujimoto Y, Oka A, Omoto R, Hirose M. Ultrasound scanning of the thyroid gland as a new diagnostic approach. Ultrasonics. 1967;5(3):177–80. With permission

Fig. 1.2

Improvements in ultrasound image quality are evident when comparing a right thyroid nodule image from 2005 (a) to one obtained in 2015 (b). A handheld ultrasound is capable of detecting major thyroid abnormalities though models currently available still await high-frequency transducers to provide fine imaging details (c). Author’s image

Today, ultrasound machines are found in almost every emergency room and are used for the rapid assessment of trauma patients and the bedside evaluation of a plethora of medical conditions. Ultrasonography has also been incorporated into medical care facilities at a distance from tertiary referral centers. Ultrasound probes remotely operated by technicians via robotics can be used to obtain diagnostic images in rural medical clinics or remote locations, such as the South Pole [5]. Even the International Space Station has an ultrasound machine in its Human Research Facility, the Advanced Diagnostic Ultrasound in Microgravity (ADUM). The ADUM ultrasound is a commercial ultrasound that has been modified to allow astronaut crew members to perform their own ultrasound exams, guided by ground medical personnel [6, 7] (Fig. 1.3). The utility and scope of ultrasound are expanding, and providers in all fields of medicine, working in a variety of settings, are incorporating its use into their practice.

Fig. 1.3

(a, b) Human Research Facility Ultrasound on the International Space Station 2 [6, 7]

1.1.2 What Is Point-of-Care Ultrasound?

Point-of-care ultrasound, also called bedside, provider-performed, or focused ultrasound, can be defined as the utilization of sonography to answer a specific clinical question at the time of patient presentation and examination [8]. In a 2011 New England Journal of Medicine review article, Moore defined point-of-care ultrasonography as the use of real-time dynamic images (rather than images recorded by a sonographer and interpreted later), which allow findings to be directly correlated with the patient’s presenting signs and symptoms [9]. The paradigm shift created by point-of-care ultrasound is that the clinician develops a clinical question and then performs and interprets the imaging test in real time, as opposed to the traditional practice of sending the patient for a sonogram and waiting for the results.

Point-of-care ultrasound was first utilized for trauma evaluation in Europe in the 1970s and became common in US trauma care by the mid-1980s. The first standardized point-of-care use of ultrasound was the Focused Assessment with Sonography for Trauma (FAST) exam. The FAST exam, adopted in the 1990s, includes a basic series of four views for the evaluation of free abdominal fluid and has replaced diagnostic peritoneal lavage for the evaluation of blunt abdominal trauma. FAST has now been expanded to include the evaluation for pneumothorax and fluid or blood in the thorax post trauma [10].

Today, point-of-care clinician-performed ultrasound is the standard of care in surgery, obstetrics and gynecology, emergency medicine, ophthalmology, as well as internal medicine and most of its subspecialties (cardiology, gastroenterology, endocrinology, and intensive care). The term comprehensive ultrasound, in a very traditional sense, refers to an ultrasound that is conducted in a radiology department, where the main goal is to communicate information to clinicians who themselves may not view or interpret the images and require a thorough description in order to make clinical decisions. Comprehensive ultrasound may also refer to the provision of diagnostic, interventional, and therapeutic ultrasonography for patient care, whether this occurs in a radiology department or a clinical office setting. Descriptions of point-of-care and comprehensive ultrasound contain complementary and overlapping concepts.

1.2 Point-of-Care Ultrasound of the Thyroid and Parathyroid Glands

In the late 1960s, researchers began experimenting with sonography to estimate the weight of the thyroid gland and to identify solid and cystic lesions. In 1970, the Journal of Clinical Endocrinology and Metabolism published its first paper describing thyroid ultrasound. Patients were scanned using two-dimensional B-mode and, if a lesion was detected, one-dimensional A-mode, to differentiate cystic from solid lesions. The images, which were transferred to film, were basic and of poor quality when compared to today’s standards (Fig. 1.4) [11]. Despite these shortcomings, early thyroid ultrasonography was recognized for its utility to detect and measure lesions as well as to distinguish between solid and cystic thyroid lesions. Furthermore, even in those early days of thyroid ultrasonography, investigators hypothesized that ultrasound may have the potential to distinguish between benign and malignant thyroid lesions [11].

Fig. 1.4

Early ultrasound image of normal thyroid. (a) Ultrasonic tomogram (B-scan) at low sensitivity. (b) Schematic representation: RL, right thyroid lobe; LL, left thyroid lobe; T, anterior wall of the trachea; VB, vertebral body; V, vascular sheath; S, skin and transducer artifact; and M, sternomastoid muscle. From J Clin Endocrinol Metab. 1971; (32): 709. With permission

1.3 Why Perform Point-of-Care Neck Ultrasound

The point-of-care neck ultrasound can be used to evaluate suspected anatomical or functional thyroid and parathyroid disease (Table 1.1). Along with a history and physical exam, the point-of-care neck ultrasound can be used by the provider to assess the thyroid and generate a differential diagnosis and plan of care. Whether a patient presents complaining of a neck mass or the provider palpates a lesion on neck exam, the bedside ultrasound can be utilized to identify the presence of intrathyroidal lesions, extrathyroidal lesions, or diffuse enlargement of the thyroid. In cases in which the patient presents with signs or symptoms of hyperthyroidism, a bedside ultrasound can discover a solitary nodule, leading to suspicion for a hyperfunctioning hot nodule, or recognize a diffusely enlarged and vascular gland, characteristic of Graves’ disease.

Table 1.1

Indications and information from point-of-care ultrasound

1.3.1 Nodules

Thyroid nodules are highly prevalent in the general population, and their incidence increases with age [12]. The superficial location of the thyroid gland permits the palpation and recognition of larger lesions, and the frequent use of imaging in medicine leads to the discovery of incidental small lesions. No matter the method of discovery of a thyroid nodule, bedside ultrasound can be used to evaluate and characterize the lesion. Ultrasound is used to assess a nodule’s risk of malignancy based on US characteristics, and to guide further decision-making and management by facilitating and guiding fine-needle aspiration (FNA) [13]. Ultrasound also facilitates the evaluation of cervical lymph nodes in the context of thyroid or other neck masses and guides the need for FNA.

1.3.2 Parathyroid

Hyperparathyroidism can be due to a single adenoma, multiglandular disease, or, in rare cases, parathyroid cysts or carcinoma [14, 15]. The incidence of primary hyperparathyroidism is much higher in women than in men, and the prevalence increases with age [14]. The parathyroid glands can be imaged with a variety of modalities; CT, MRI, ultrasound, and scintigraphy. The various imaging modalities for the parathyroid glands provide complementary information for the diagnosis of parathyroid disease and for surgical preparation and planning [16]. Ultrasound’s benefits are that it easily locates and defines anatomical features of superficial, enlarged, parathyroid glands as well as coexistent thyroid abnormalities. While it can be a useful tool, the practitioner must be aware of its limitations and pitfalls and be ready to utilize additional diagnostic testing to ensure the correct diagnosis and treatment. The ultrasound imaging characteristics of abnormal parathyroid glands are addressed in detail in Chap. 24 of this book.

1.4 Expanding the Traditional Use of Thyroid and Parathyroid Ultrasound: Perils and Pitfalls

Originally, in the domain of radiologists, ultrasound is now used by practitioners in almost all specialties. In the 1970s, trauma physicians became the first to employ non-radiologist-performed ultrasonography, and its application has expanded since then. Ultrasound is now utilized by a wide range of providers, from medical students to physician assistants, nurse practitioners, residents, fellows, and practicing clinicians.

Performing and interpreting ultrasound is a learned skill. As this imaging modality has moved to the bedside, a debate has ensued regarding who should be performing and interpreting point-of-care ultrasound, how these tests should be documented and billed, as well as how the accuracy and quality of the test can be assured [17, 18].

In point-of-care ultrasonography, the operator is both obtaining and interpreting images; thus, adequate operator training and experience are essential to its performance. In a prospective 2010 study by Kim et al., ultrasound diagnostic performance of radiology residents was compared to that of radiology faculty. Diagnostic performance was statistically significantly greater among faculty compared to junior and senior residents (p = 0.007 and p = 0.003, respectively) [19]. In another prospective study demonstrating the importance of sonographer experience, 52 post-thyroidectomy patients with high-risk thyroid cancer had ultrasounds performed by two different providers with different levels of experience. Neck ultrasounds performed by the less experienced provider found six proven cases of recurrent disease. In the same group of patients, an expert sonographer found 16 proven cases of recurrence, demonstrating that identification of disease recurrence is operator dependent [20]. Other studies have compared ultrasound interpretation between practitioners in different specialties. A retrospective analysis of surgeon- vs. radiologist-performed bedside ultrasounds at the University of Wisconsin found that when surgeons performed the preoperative ultrasound, they documented lymph node status more frequently (69 % vs. 20 %, p < 0.01) compared to radiologists. In postsurgical follow-up, the patients scanned by the surgeons exhibited less neck RAI uptake at the time of ablation and had lower recurrence rates (12 % vs. 0 %, p = 0.01) suggesting that surgeon-performed sonography allows for better preoperative planning and more extensive surgical resection when indicated [21]. This study which examined provider-specific point-of-care imaging vs. comprehensive ultrasonography reflects the importance of problem-focused use of ultrasound. Since the operative plan is dependent on preoperative radiologic evaluation, the surgeon is focused on gaining anatomic information that will guide surgery and minimize unexpected findings in the operating room. Radiologists face inherent limitations when presented with interpreting an ultrasound study ordered simply as a thyroid ultrasound. Images saved by a sonographer following a routine thyroid protocol may not capture anatomic areas important to the surgeon such as the tracheoesophageal groove, the recurrent laryngeal nerve, and lateral neck lymph nodes. In conclusion, the diagnostic performance of ultrasound may be dependent on both operator experience, as well as the goals and role, of the sonographer.

1.5 Radiologic Studies Complementing Thyroid/Parathyroid US

While this textbook is devoted to ultrasound imaging, other radiologic modalities may be needed to complement, clarify, and expand upon the findings of ultrasound. These imaging methods include computed tomography scanning (CT), four-dimensional computed tomography (4DCT), magnetic resonance imaging (MRI), positron emission tomography (PET), nuclear medicine applications of radioiodine scanning, and Tc99m-sestamibi scanning. These additional imaging modalities can be of assistance in: (1) Evaluating the mediastinum including cases of goiter with substernal extension, (2) Evaluating retropharyngeal cervical metastases or invasion of thyroid cancer into surrounding anatomical structures such as the trachea or esophagus, (3) Discovering distant metastases, (4) Determining the etiology of and quantifying hyperthyroidism (5) Further characterizing and localizing abnormal parathyroid glands.

Innovations in radiology techniques have expanded the options for patient evaluation and treatment. A case in point is parathyroid imaging. As minimally invasive parathyroidectomy gained popularity over the traditional bilateral neck exploration, preoperative identification of autonomously functioning parathyroid glands became crucial. While ultrasound is a sensitive modality to identify superficial parathyroid adenomas, it has limitations in identifying supernumerary, substernal, or ectopic parathyroids. Therefore, ultrasonography and scintigraphy are often utilized as complementary imaging modalities. A 2005 meta-analysis by Ruda et al. [22] found that for the detection of single parathyroid adenomas, Tc99m-sestamibi was superior to ultrasound with a sensitivity of 88.4 % vs. 78.5 %. The sensitivity of both imaging modalities in this study decreased dramatically when multiglandular disease (MGD) or double adenomas (DA) were present (sestamibi 44.46 % vs. 34.86 % for ultrasound and 29.95 % vs. 16.20 %, respectively). Contemporary practice calls for combining neck ultrasound imaging with either 4DCT or Tc99m-sestamibi prior to parathyroid surgery in all cases [23]. It is important to recognize the limitations of technology, interobserver variability, and local expertise when selecting how to combine these imaging modalities.

1.6 The Rationale for a Multidisciplinary Ultrasound Textbook

In January 2016, guidelines for the management of thyroid nodules and thyroid cancer were published by the American Thyroid Association [13], and it is anticipated that the American Association of Endocrine Surgeons will publish guidelines for the management of primary hyperparathyroidism later in 2016. This textbook has been compiled shortly following these updated guidelines. The spirit and content of the new ultrasound-related recommendations of these guidelines are illustrated in this textbook. The emphasis is on practical implementation and improved interpretation of ultrasound, as well as illustration of specific features using cine-clips and high-resolution ultrasound images. The authors of this texbook, purposefully represent the key specialists utilizing thyroid and parathyroid ultrasound—endocrinologists, surgeons, and radiologists and increasingly pathologists, internists, and emergency medicine physicians.

The ultrasound themes are covered in a comprehensive manner: logistics, technology, sonographic features of disease, US features of thyroid, parathyroid and lymph node structures, pattern recognition, interventional ultrasound, educational resources, and novel applications. While incorporating advanced concepts and cutting edge information, the themes underscore the basics of ultrasound: who performs and interprets it, how it can be optimized and performed most effectively, why and when to use ultrasound and FNA, where in the clinical setting can point-of-care ultrasound be implemented, and what future opportunities exist for ultrasound. With the accompanying, web-accessible illustration supplement of cine-clips and images, readers will hopefully find the textbook to be a valuable resource as they incorporate ultrasound into routine clinical care and professional practice.

1.7 Summary

Sonography has evolved and proven to be a valuable imaging modality in a variety of clinical settings. Specifically, ultrasound of the neck is a useful imaging modality for thyroid and parathyroid disease that can be performed at the time of a patient encounter, in order to answer a specific clinical question or direct further care. Point-of-care ultrasound can be performed by the primary care practitioner, emergency room physician, endocrinologist or surgeon, to evaluate suspected neck disease, characterize the thyroid parenchyma or lesions, and evaluate parathyroid disease. Perioperatively, the surgeon can make use of ultrasound to direct surgery for thyroid malignancy or parathyroid disease. The main challenges in the utilization of bedside ultrasound include variable operator skill and interpretation of images, as well as standardization of reporting. It is also essential that providers recognize the limitations of point-of-care ultrasound and be knowledgeable regarding which complementary radiologic imaging modalities to employ when necessary, in-order to accurately and definitively diagnose thyroid and parathyroid conditions.

References

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History of Ultrasound in Obstetrics and Gynecology, Part 1 [Internet]. [cited 2016 Jan 13]. Available from: http://​www.​ob-ultrasound.​net/​history1.​html.

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Edler I, Lindström K. The history of echocardiography. Ultrasound Med Biol. 2004;30(12):1565–644.Crossref

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Fujimoto Y, Oka A, Omoto R, Hirose M. Ultrasound scanning of the thyroid gland as a new diagnostic approach. Ultrasonics. 1967;5(3):177–80.Crossref

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Otto C, Shemenski R, Scott JM, Hartshorn J, Bishop S, Viegas S. Evaluation of tele-ultrasound as a tool in remote diagnosis and clinical management at the Amundsen-Scott South Pole Station and the McMurdo Research Station. Telemed J E Health. 2013;19(3):186–91.Crossref

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Garcia M. NASA Studies Link Genetics and Nutrition with Astronaut Vision Changes [Internet]. 2016. Available from: http://​www.​nasa.​gov/​feature/​nasa-studies-link-genetics-and-nutrition-with-astronaut-vision-changes.

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Moore CL, Copel JA. Point-of-care ultrasonography. N Engl J Med. 2011;364(8):749–57.Crossref

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Noble VE, Nelson BP. Manual of emergency and critical care ultrasound. Cambridge: Cambridge University Press; 2011.Crossref

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Thijs LG, Stroes W. Diagnostic ultrasound in clinical thyroid investigation. J Clin Endocrinol Metab. 1971;32:709.Crossref

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Guth S, Theune U, Aberle J, Galach A, Bamberger CM. Very high prevalence of thyroid nodules detected by high frequency (13 MHz) ultrasound examination. Eur J Clin Invest. 2009;39(8):699–706.Crossref

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Haugen BR, Alexander EK, Bible KC, Doherty G, Mandel SJ, Nikiforov YE, et al. 2015 American thyroid association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2015;26:1.Crossref

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Ghasemi-Rad M, Lesha E, Abkhiz S, Mohammadi A. Primary hyperparathyroidism: comparing between solid and cystic adenomas and the efficacy of ultrasound and single-photon emission computed tomography in their diagnosis. Endocr Pract. 2015;21(11):1277–81.Crossref

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Cappelli C, Rotondi M, Pirola I, De Martino E, Leporati P, Magri F, et al. Prevalence of parathyroid cysts by neck ultrasound scan in unselected patients. J Endocrinol Invest. 2009;32(4):357–9.Crossref

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Tublin ME, Pryma DA, Yim JH, Ogilvie JB, Mountz JM, Bencherif B, et al. Localization of parathyroid adenomas by sonography and technetium tc 99m sestamibi single-photon emission computed tomography before minimally invasive parathyroidectomy: are both studies really needed? J Ultrasound Med. 2009;28(2):183–90.Crossref

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Greenbaum LD. It is time for the sonoscope. J Ultrasound Med. 2003;22(4):321–2.Crossref

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Hoffenberg SR, Tayal VS, Greenbaum LD, Filly RA. Time for the sonoscope? * Replies. J Ultrasound Med. 2003;22(7):753–7.Crossref

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Kim SH, Park CS, Jung SL, Kang BJ, Kim JY, Choi JJ, et al. Observer variability and the performance between faculties and residents: US criteria for benign and malignant thyroid nodules. Korean J Radiol. 2010;11(2):149–55.Crossref

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Rosario PW. Ultrasonography for the follow-up of patients with papillary thyroid carcinoma: how important is the operator? Thyroid. 2010;20(7):833–4.Crossref

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Oltmann SC, Schneider DF, Chen H, Sippel RS. All thyroid ultrasound evaluations are not equal: sonographers specialized in thyroid cancer correctly label clinical N0 disease in well differentiated thyroid cancer. Ann Surg Oncol. 2015;22(2):422–8.Crossref

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Ruda JM, Hollenbeak CS, Stack BC. A systematic review of the diagnosis and treatment of primary hyperparathyroidism from 1995 to 2003. Otolaryngol Head Neck Surg. 2005;132(3):359–72.Crossref

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Solorzano CC, Carneiro-Pla D. Minimizing Cost and Maximizing Success in the Preoperative Localization Strategy for Primary Hyperparathyroidism. Surg Clin North Am. 2014;94(3):587–605.Crossref

© Springer International Publishing Switzerland 2017

M. Milas et al. (eds.)Advanced Thyroid and Parathyroid Ultrasoundhttps://doi.org/10.1007/978-3-319-44100-9_2

2. Key Components of a Comprehensive Thyroid and Parathyroid Ultrasound Report

Ilya Likhterov¹   and Mark L. Urken¹  

(1)

Department of Otolaryngology Head and Neck Surgery, Mount Sinai Beth Israel, 10 Union Square East 5B, New York, NY 10003, USA

Ilya Likhterov (Corresponding author)

Email: [email protected]

Mark L. Urken

Email: [email protected]

Keywords

Ultrasound reportComprehensiveStandardizationATAAACEThyroid databaseLymph nodes

2.1 Introduction

The diagnosis, the management, and the surveillance of thyroid and parathyroid pathology rely heavily on the information provided by high-resolution ultrasound (US) imaging of the neck. Ultrasonography is an established, safe, and accurate way of detection and characterization of thyroid nodules and cervical lymph nodes and localization of enlarged parathyroid glands in the workup and preparation for surgery [1]. The examination is being performed more and more commonly in an office setting by non-radiology physicians (e.g., endocrinologists, general practitioners, pathologists, and surgeons).

The report describing the findings of an US examination must be comprehensive and convey relevant information. The description of what was seen during the ultrasonographic evaluation must communicate the location and the level of clinical concern to the treating clinician. This actionable data must be accurate and consistent from patient to patient and from exam to exam. The challenge arises not only because the interpretation of US imaging findings is subjective but because the techniques for performing the examination are often varied among practitioners. The heterogeneity of the US reports that are generated often affects the clinical utility of a particular study, as well as the potential necessity to repeat that study, adding unnecessary costs to an already overburdened healthcare system. The need to subject a patient to a repeat examination in order to gain critical information is not uncommon. The clinicians should be cognizant of the variability of ultrasound reporting and be aware of how this heterogeneity influences their particular practice. Centers with a wide referral base and a larger number of US report sources will experience more variability than practices that rely on one source for their imaging needs.

Unfortunately, while a number of recommendations on what constitutes a complete US report have been published, no universal system is currently in use. In this chapter, we explore the features thought to be salient in the description of the thyroid and parathyroid pathology by professional organizations and by groups of experts focusing on this issue. In addition, we will describe a thyroid patient database that may help to track the comprehensiveness of the reports and the role it may play in the path toward standardization.

2.2 Recommendations for Thyroid Ultrasound Reporting

The evaluation of the thyroid gland may be performed for a variety of reasons. However, no matter what the indication, it is important to examine and report on all of the clinically significant areas of the neck. For patients with thyroid nodules, for whom thyroid cancer is one of the differential diagnoses, the evaluation of the gland alone is not sufficient. Papillary thyroid carcinoma has a high propensity to metastasize to the regional lymph nodes in the central and lateral cervical compartments [2]. These anatomic regions must be evaluated during the initial and surveillance ultrasound studies.

Tables 2.1, 2.2, and 2.3 highlight the recommendations on thyroid ultrasound reporting from a multidisciplinary group of experts [3] (Table 2.1), the American Thyroid Association (ATA) [4] (Table 2.2), and the American Association of Clinical Endocrinologists (AACE) [5] (Table 2.3).

Table 2.1

Multidisciplinary consensus report [3]

Table 2.2

ATA recommendations [4]

Table 2.3

AACE recommendations [5]

All three groups recommend measuring the thyroid lobes in all three dimensions.

In addition, at least two of the three guidelines recommend including the description of the gland parenchyma (heterogeneous vs. homogeneous), the general thyroid echogenicity, the vascularity patterns, and the measurement of the isthmus.

In the description of the thyroid nodules, there is agreement that the following features should be reported: size of each nodule in three dimensions, the number of nodules in each lobe, the internal architecture, the echogenicity, the presence of calcifications, vascularity patterns, whether the nodule is taller or wide, and the location in the thyroid lobe in the cranial-caudal and in the anterior/posterior orientation. In addition, there were two other features included in two of the three guidelines: suspicion for extrathyroidal extension and the contour of the nodule.

The need for evaluation of the lymphatic compartments was highlighted in all three recommendations. However, the degree of detail of the description of the lymph nodes varied. Clinical suspicion for metastatic disease in the lymph node is mentioned consistently. The high-risk features, such as size, internal architecture, the absence of a hilum, shape, calcifications, and vascular patterns of a lymph node, were not mentioned in the ATA or the AACE recommendations.

Attempts to combine the ultrasound features of each thyroid nodule and assign a measure of risk for malignancy have been made. The Thyroid Imaging Reporting and Data System (TIRADS) is modeled on the BI-RADS for breast imaging. A TIRADS category is assigned to each nodule based on how many of the following suspicious US features are identified: solidity, hypo-echogenicity or marked hypo-echogenicity, microlobulated or irregular margins, microcalcifications, and taller-than-wide shape [6]. The TIRADS classification incorporates some of the thyroid nodule features described in the recommendations above; however, it is not a comprehensive ultrasound reporting system since it does not incorporate the imaging characteristics of the thyroid gland itself, nor does it address the risk of lymphatic metastasis. This system has not been widely adopted in the United States. A committee representing the American College of Radiology (ACR) has published a list of recommended terminology and lexicon in an attempt to standardize the diagnostic approach to thyroid nodules and to develop the use of TIRADS in the United States [7].

One feature that is not mentioned in the above recommendations is real-time strain elastography. This measure of tissue stiffness has been evaluated as a tool in differentiating malignant from benign thyroid nodules [8]. Classification of nodule elastography includes the Rago [9] and the Asteria criteria [10]. Addition of elastography to the gray-scale US features appears to increase the negative predictive value of the exam [11, 12]. Technology needed to evaluate compression properties of a thyroid nodule is not routinely available; however, when elastography data is generated, it should be incorporated in the ultrasound report [13].

One of the most critical ultrasonographic findings in management of thyroid nodules is the change in size as tracked over time. A nodule that remains stable over a number of years can be monitored with repeat imaging. On the other hand, a significant change in any of the three dimensions must warrant a biopsy and possibly surgical excision. Given the inconsistencies inherent to ultrasonographic measurements, a certain margin of error must be accounted for in the clinical decision-making [14, 15]. One of the largest observational trials tracking differentiated thyroid cancers with repeat surveillance ultrasounds used a 3 mm increase in size as an indication of clinically significant growth [16]. The ATA guidelines define growth as a 20 % increase in the nodule diameter or a 50 % increase in the nodule volume [4]. The change in the size measurements of the nodule and changes in the dimensions of the lymph nodes should be reported and tracked. The rate at which these changes are occurring can be as valuable as the absolute size measurement.

Appearance of any new adverse ultrasonographic features, not noted on previous ultrasounds, must be included in the report. Development of microcalcifications, changes in the vascular patterns of a nodule, suspicion for invasion, disappearance of a lymph node hilum, and other interval changes may be indications to a change in the biology of the disease. Repeat biopsy may be warranted. Whenever possible, the repeat ultrasounds should be performed by the same practitioner to reduce the inter-rater variability.

Clinicians following patients with thyroid disease must employ a reliable system for recognizing changes on surveillance US exams. Tracking the size and the features of thyroid nodules and lymph nodes over time in a clear, easily reviewable format is imperative to initiating a timely intervention in cases of sudden change. The Thyroid Care Collaborative (TCC) is an example of a robust and user-friendly database that helps to facilitate these goals [17]. The three-dimensional location of each nodule and lymph node is tracked through schematic representation. The measurements of the size in three dimensions are reported for each nodule in a table format, which facilitates recognition of a potentially clinically significant change. Reporting change in this manner is especially helpful when following patients with multinodular disease and/or multiple lymph nodes. The program can further alert the clinician of any significant changes and make suggestions regarding additional workup by cross-referencing the ATA guidelines and its reported stratification of risk based on ultrasound features.

In addition, the TCC promotes consistency in ultrasound data recording by prompting clinicians to fill in the predetermined categories. A library of representative ultrasound images highlighting each of the key features in a user-friendly fashion is provided to assist less experienced clinicians to identify the appropriate diagnostic features. If a particular feature is not available in the ultrasound report, the clinician’s awareness is raised. Additional steps can then be taken to obtain the missing data point, if considered significant. It is our hope that a standardized and complete data entry framework, such as the one available in the TCC, can be employed by all ultrasonographers in the future.

2.2.1 Recommendations for Ultrasound Reporting of Parathyroid Pathology

Ultrasound evaluation of the central neck is often the first step in the localization of parathyroid adenoma candidates in patients with hyperparathyroidism. The hypoechoic appearance of the enlarged gland(s) is a distinguishing feature of parathyroid adenomas. Localization of the candidate for an adenoma in the superior vs. inferior and intraglandular vs. extraglandular location should be reported. The degree of localization provided by the US of the central neck facilitates performing a directed, minimally invasive parathyroidectomy. Suspected ectopic location (e.g., carotid sheath) identified on an US can be invaluable at the time of surgery. In addition, US findings may suggest presence of coexisting thyroid pathology that warrants further diagnostic workup.

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© Springer International Publishing Switzerland 2017

M. Milas et al. (eds.)Advanced Thyroid and Parathyroid Ultrasoundhttps://doi.org/10.1007/978-3-319-44100-9_3

3. Pathways to Thyroid and Parathyroid Ultrasound Certification

P. Ryan Hungerford¹   and John Woody Sistrunk²  

(1)

Rogue Valley Physicians, 2900 Doctor’s Park Drive, Medford, OR 97504, USA

(2)

Jackson Thyroid & Endocrine Clinic, PLLC, 971 Lakeland Drive, Suite 353, Jackson, MS 39216, USA

P. Ryan Hungerford (Corresponding author)

Email: [email protected]

John Woody Sistrunk

Email: [email protected]

Keywords

CertificationAccreditationCredentialUltrasound reportEndocrine Certification in Neck Ultrasound (ECNU)American Institute of Ultrasound in Medicine (AIUM)Comprehensive certification exam (CCE)Validation of Competency Process (VCP)

3.1 Introduction

As endocrinologist-performed neck ultrasound is now mainstream, formal certification and practice accreditation have become necessary as an affirmation of both quality and consistency to benefit patients and to satisfy insurance carrier requirements. Certification of endocrinologists and other specialty physicians, attesting their ability in thyroid/parathyroid ultrasound, is available through the American Association of Clinical Endocrinologist’s Endocrine Certification in Neck Ultrasound (ECNU) program. Practice accreditation is available through the American Institute of Ultrasound in Medicine (AIUM).

3.2 Background

At present, community- and university-based hospital radiology departments commonly produce thyroid ultrasound reports that have variable quality. It is not uncommon for the target audience of these reports, the clinician, to be informed of multiple thyroid nodules without provision of key descriptive details. For examples, reports can be too brief, use the unhelpful term indeterminate, or erroneously caution about microcalcifications, a very significant finding commonly associated with papillary thyroid carcinoma and often incorrectly applied to almost invariably benign colloid nodules or cysts. Furthermore, a careful cervical lymph node evaluation, essential for a comprehensive evaluation of the nodular thyroid gland, is rarely performed or documented.

Real-time ultrasound in the hands of the endocrinologist produces a study highly influenced not only by the clinician’s deep understanding of thyroid physiology and pathology but also by their awareness of the patient-specific context in which the study is being performed. The clinician is able to correlate sonographic features with laboratory findings, physical examination, and the patient’s unique medical history. This allows for a detailed and clinically relevant ultrasound study and report. The same philosophy applies to other specialists who care for patients with thyroid and parathyroid diseases.

In parallel with the widespread increase of radiographic imaging modalities, the incidence of thyroid nodules has increased, a large proportion of which are identified incidentally. The incidence of thyroid cancer is also increasing. Consequently, the ability to distinguish characteristics of both benign and malignant nodules has become increasingly recognized and has been the subject of a vast number of research studies, review articles, and lectures.

The American Thyroid Association (ATA) guidelines for the management of thyroid nodules and thyroid cancer have mirrored the developing medical literature on thyroid ultrasound, with increasing emphasis on the sonographic characteristics of thyroid nodules and their relevance to clinical thyroidology. The first version of these guidelines, published in 2006, mentions ultrasound characteristics of thyroid nodules a total of five times [1]. The 2009 ATA guidelines make 14 different references to the ultrasound characteristics of thyroid nodules [2], and a review newly released 2015 ATA guidelines mentions ultrasound characteristics of thyroid nodules and thyroid cancer an incredible 100 times [3]. As previously mentioned, thyroid ultrasound reports from radiology departments commonly lack these vital sonographic descriptions, limiting their value in clinical practice. Among many possible explanations, it may be either that these salient characteristics are not considered important or that an understanding of their relevance is not well appreciated by the interpreting radiologist.

Inherent to the understanding of thyroid ultrasound imaging is a background in anatomy, physiology, pathology, and the physics of sonography. Ultrasound/sonographic pattern recognition is a vital skill which can be developed with proper training and strict adherence to a consistent, systematic approach.

In an effort to better educate the forthcoming generation of endocrinologists in thyroid ultrasonography, the American Association of Clinical Endocrinologists (AACE), with the forethought and diligent efforts of H. Jack Baskin, MD, and Daniel S. Duick, MD, developed an extensive thyroid sonography training program as part of the Endocrine University® Program, held annually at Mayo Clinic—Rochester, Minnesota. Since its inception in 2002, Endocrine University® has trained more than 3000 endocrine fellows in performance of thyroid, neck, and parathyroid ultrasound [4]. Surgeons, furthermore, have access to continuing medical education (CME) via the American College of Surgeons (ACS). Since 2002, the ACS Thyroid and Parathyroid Ultrasound Course has granted verification of ultrasound knowledge and skill at Level 2 designation (only higher category is Level 3 of proctor ready) by the Accreditation Council for Continuing Medical Education (ACCME). The ACS course has both written exam and hands-on practical ultrasound skills testing components. Nearly 1000 surgeons have availed themselves of this educational opportunity that, while not an independent certification mechanism, affords a level of CME that is important to become an informed practitioner of thyroid and parathyroid ultrasound in patient care and relevant toward obtaining certification (https://​www.​facs.​org/​education/​accreditation/​verification/​ultrasound/​exported#thyroid).

As the practice of medicine has evolved, third-party payers, the federal government, and other licensing agencies have increased regulations and qualifications necessary for imaging procedures by non-radiologist clinicians. For this reason, the preemptive development of a certification program became necessary. To accomplish such a certification for office-based endocrinologists, a comprehensive program had to be developed to meet the compliance standards of the National Commission for Certifying Agencies (NCCA) [4].

Through the efforts of H. Jack Baskin, MD, Daniel S. Duick, MD, Donald Jones (CEO of American Association of Clinical Endocrinologists (AACE)), Carmine Valente (CEO of American Institute of Ultrasound in Medicine (AIUM)), and Lenny Greenbaum, MD (former president of AIUM), a mutual agreement was reached in the development and acceptance of the Endocrine Certification in Neck Ultrasound (ECNU) program based on 18 nationally recognized compliance standards [4].

The American Association of Clinical Endocrinologists (AACE) education arm, the American College of Endocrinology, instituted the ECNU program in 2008. Since its inception, more than 400 physicians have been certified in thyroid/parathyroid/neck ultrasonography. At present, ECNU is the only certification route available to endocrinologists. In recognition of the reality that other clinicians also perform thyroid and parathyroid ultrasound, certification via ECNU is available to eligible specialties including surgery and pathology.

3.3 Endocrine Certification in Neck Ultrasound (ECNU) Credential

Endocrine Certification in Neck Ultrasound (ECNU) was developed primarily in response to an increasing number of insurance carriers mandating either physician certification and/or practice accreditation as a condition of reimbursement [5]. To satisfy these conditions, ECNU certification is recognized by the American Institute of Ultrasound in Medicine (AIUM), one of the preeminent accreditation bodies for ultrasound practices. AIUM recognizes individuals who achieve the ECNU credential as sufficiently trained in neck ultrasonography. AIUM allows those with the ECNU credential to be directors of ultrasound laboratories and apply for AIUM practice accreditation [5]. This will be discussed further in the AIUM section of this chapter.

The ECNU certification is an objective assessment, ensuring that a physician has the prerequisite knowledge to practice competently in the field of thyroid, neck, and parathyroid sonography [5].

The ECNU Certification Committee is comprised of ECNU-certified practicing endocrinologists and exists to assure that the process for ECNU certification and the significance of this credential remain relevant to the practicing endocrinologist. The ECNU certification process has different routes available to endocrinologists, endocrinology fellows/trainees, or endocrine surgeons in training, cytopathologists, endocrine surgeons, otolaryngologists/head and neck surgeons, and radiologists [5].

As a prerequisite to beginning the ECNU certification process, attestation of performing at least 100 ultrasound studies is required (70 diagnostic ultrasound examinations and 30 ultrasound-guided FNA procedures (UGFNA)). For fellows—in training—at least 50 ultrasound studies (35 diagnostic ultrasounds and 15 UGFNA) are required at the time of initial application, with the attestation that the remaining 50 ultrasound studies will be carried out within the next 12 months after the written comprehensive certification exam (CCE) or before completing fellowship training. Additionally, 15 h of CME credit is required from one or more basic thyroid ultrasound courses within the prior 3 years [5].

The ECNU certification is composed of two primary components, the comprehensive certification exam (CCE) and the Validation of Competency Process (VCP).

The ECNU comprehensive certification exam (CCE) is a 100-question exam, administered over a 2 h period in proctored testing centers. The examination is designed to assess a candidate’s knowledge of relevant anatomy, physiology, pathology, and ultrasound physics.

The comprehensive certification exam (CCE), broken down by content, includes the following topics:

Principles of ultrasound imaging 15 %

Neck anatomy 15 %

Thyroid pathology 34 %

Parathyroid pathology 10 %

Lymph node pathology 10 %

Ultrasound-guided fine needle aspiration (USGFNA) 16 %

The ECNU Certification Committee has relied upon practicing physician sonographers for exam question content and illustrative cases [5].

Following notification of a passing score on the comprehensive certification exam (CCE), the candidate is then eligible for the Validation of Competency Process (VCP), which involves submission of ultrasound reports generated by the candidate from patients from his/her medical practice. This component of the certification process is designed to ensure quality and competence in performance of neck ultrasound and proof of the candidate’s ability to generate a high quality, meaningful report. Cases and images for VCP submission must be collected within a 2-year window, beginning from 1 year prior to and ending 1 year following successful completion of the CCE [5].

A total of 15 cases are required for the Validation of Competency Process (VCP). The first five diagnostic thyroid nodule cases are due within 3 months of passing the CCE to ensure that the candidate is following the proper reporting components as outlined in the Candidate Handbook and to provide verification that the candidate is actively pursuing certification, a prerequisite for reimbursement by some insurance companies. These five nodule reports must also include submission of 13 standard images adhering to the 2013 AIUM practice guideline for the performance of a thyroid and parathyroid ultrasound examination. The remaining ten cases are due within 1 year of passing the CCE [6]. The second portion of the Validation of Competency Process (VCP) includes the following items [5]:

Two parathyroid adenoma cases

Two malignant lymph node cases

One case of Hashimoto’s thyroiditis

Five ultrasound-guided biopsy cases

The ECNU Validation of Competency Process (VCP) has received some scrutiny for the requirement of the two lymph node and two parathyroid cases. Although this may be challenging to some candidates, it is determined that any physician performing an adequate number of neck ultrasound studies should not have difficulty identifying two malignant nodes and two parathyroid glands during the 2 year window of case collection. Remember, the ECNU credential signifies competency and quality. Not all seeking ECNU certification will achieve it.

A complete review of the requirements for the VCP cases is found in the ECNU handbook. As most endocrinology fellows have had little or no experience with writing ultrasound reports, the AACEECNU Reference CD, available complimentary upon request from the ECNU Certification Coordinator, includes a full presentation on authoring ultrasound reports, a PowerPoint® framework for case submission and the official ECNU thyroid schematic cartoon. Examples of ECNU case submissions are also included and recommended for review [7].

Upon submission, the Validation of Competency Process (VCP) cases are reviewed by the physician sonologists of the ECNU Certification Committee for quality and consistency based on the requirements in the ECNU handbook. This process is designed to be a constructive, individualized analysis of the candidate’s work. It is the hope of the ECNU Certification Committee that the candidate will benefit from the review and take heed of the advice of the reviewers. At times, VCP submissions may require revision to achieve a passing score. Upon successful completion of the VCP, the candidate is awarded the VCP designation, certificate, and lapel pin, and their name is added to a registry of ECNU-certified physicians.

Consistent with all present aspects of medicine, ECNU certification requires recertification at 10 year intervals. As the first cycle of ECNU-certified physicians will not require recertification until 2018, this process may potentially be revised, with the intent to assure relevancy to the practicing physician. At present, ECNU recertification requires these steps [5]:

1.

Performing a minimum of 70 diagnostic ultrasound examinations and 30 USGFNA procedures annually

2.

Written attestation of the total number of all diagnostic ultrasounds and UGFNA during the preceding year

3.

Documentation of a minimum of 15 h of approved CME during each 3 year cycle, with at least 50 h of approved CME during the 10 year cycle

4.

Pass the recertification exam

3.4 American Institute of Ultrasound in Medicine (AIUM) Practice Accreditation

Whereas ECNU certifies an individual physician’s ability and performance, American Institute of Ultrasound in Medicine (AIUM) Practice Accreditation is a demonstration of the global competency/consistency in all aspects of ultrasound practice operation including:

Personnel education, training, and experience

Document storage and record keeping

Policies and procedures safeguarding patients, ultrasound personnel, and equipment

Instrumentation

Quality assurance

Case studies

This is a voluntary accreditation process that allows a practice to demonstrate meeting or exceeding national standards in both the performance and interpretation of ultrasound studies. AIUM Practice accreditation cycle is 3 years. Like the ECNU Validation of Competency Process (VCP), the AIUM accreditation includes peer review of cases and insight into a different dynamic of review from the accreditation standpoint [8].

Following completion of the ECNU certification process, certificants are advised to take advantage of the fast track to AIUM practice accreditation. First and foremost, the ECNU credential is accepted by the AIUM as having adequate training in thyroid/parathyroid ultrasound. First time applicants for AIUM accreditation have the advantage of a discounted accreditation fee and are not required to submit case studies as long as the AIUM practice accreditation application is made within 12 months of achieving ECNU certification [8].

Alternatively, a physician may seek practice accreditation if the physician(s) in the practice has completed the required training specified in the training guidelines for physicians who evaluate and interpret diagnostic thyroid/parathyroid ultrasound examinations. Depending on physician background, this training guideline determines the number of cases as well as the number of CME credits needed to apply for accreditation [8].

The AIUM Standards and Guidelines for Accreditation of Ultrasound Practices specifically outlines accreditation, ultrasound practice personnel, the role of physician director of ultrasound, reaccreditation, and yearly volume requirements. This document also reviews requirements for final reports, preliminary reports, and most importantly policies and procedures safeguarding patients, ultrasound personnel, and equipment. Additionally standards are set forth including the need for policies and procedures regarding patient identification, precautions for invasive procedures, incident reporting, patient confidentiality, the ALARA principle (as low as reasonably achievable with regard to radiation exposure), quality assurance, document storage, and record keeping [9]. The quality assurance specifically addresses on-going monitoring of ultrasound personnel performance. As an example of on-going documentation of quality assurance activities, the physician who performs the ultrasound examination and generates a report for a patient who ultimately undergoes surgery should periodically correlate the surgical pathology findings with the sonographic findings. A simple form may suffice for this exercise (see Fig. 3.1).

Fig. 3.1

Sample form correlating the surgical pathology findings with the sonographic findings

Ultrasound equipment maintenance is an important component of AIUM practice accreditation. All ultrasound machines must be in good operating condition, with documentation of calibration and servicing at least once a year [9]. Additionally, the AIUM has very specific guidelines addressing cleaning of probes between patients and proper high-level disinfection. A background and knowledge of these guidelines is imperative to all who perform ultrasound studies [10].

Specific guidelines do exist for performance of thyroid and parathyroid ultrasound examinations, as outlined by practice parameters from the American College of Radiology, the American Institute of Ultrasound in Medicine, the Society of Pediatric Radiology (SPR), and the Society of Radiologists in Ultrasound (SRU) [11]. An inherent understanding of these practice parameters