Surgical-office-based versus radiology-referral-based breast ultrasonography: a comparison of efficiency, cost, and patient satisfaction

Australian breast surgeons and ultrasound usage: Have practices changed?

BACKGROUND

A recent survey of surgeon performed ultrasound usage was conducted amongst registered members of the Breast Surgeons of Australia and New Zealand Society (BreastSurgANZ) and was compared with a previous survey undertaken in 2010 to determine whether patterns of utilization had changed.

METHODS

From July to September 2019, members of BreastSurgANZ were invited to complete an electronic online survey of personal usage of breast ultrasound focusing on ultrasound equipment access, use of office and intraoperative ultrasound, biopsy interventions and training expectations.

RESULTS

There were 73 respondents to the survey with 45 (61.6%) members indicating access to ultrasound within their practices. Whilst current regular ultrasound usage (68.1%) was only slightly greater than in 2010 (66%), the proportion of respondents not performing any form of needle intervention had increased (62.5% compared to 53% in 2010) and with the proportion of surgeons currently performing >10 biopsies per month decreasing from 10% to only 5.56%. However the percentage of surgeons utilizing intraoperative ultrasound had notably increased since 2010 with 49.3% currently using ultrasound in the operating room compared with only 17% previously. The majority of respondents believed that breast ultrasound training should be conducted through BreastSurgANZ post fellowship training programs.

CONCLUSION

The overall utilization of surgeon-performed ultrasound amongst BreastSurgANZ members has remained similar over the past 9 years with the performance of needle interventions declining slightly, but with the application of intraoperative ultrasound having increased. An ultrasound training curriculum as part of the BreastSurgANZ post fellowship training program is a necessary imperative.

Surgeon-performed ultrasound in a head and neck surgical oncology clinic: saving time and improving patient care

INTRODUCTION

Surgeon-performed ultrasound (SUS) for head and neck masses is increasingly being performed by head and neck surgeons. This is the first study assessing its impact in a head and neck surgical oncology clinic, examining the effect on various parameters.

METHODS

Retrospective analysis was conducted on a database, analysing and comparing all new patients reviewed 6 months prior to (pre-SUS group) and 6 months following (post-SUS group) the introduction of SUS to the outpatient head and neck surgical oncology clinic. The numbers of radiology imaging investigations (ordered through a medical imaging department), fine-needle aspirations (FNAs) performed, clinical appointments and time to definitive treatment decision were analysed and compared.

RESULTS

A total of 365 patients were included: 169 in the pre-SUS group and 196 in the post-SUS group. There was a statistically significant difference in the number of total radiological imaging investigations performed (1.60 vs. 0.70, p < 0.00001), radiologist-performed FNAs (0.24 vs. 0.10, p = 0.0234), time for definitive treatment decision being made (16.4 days vs. 11.6 days, p = 0.04338), and number of clinical encounters (3.03 vs. 2.29, p < 0.00001). No statistically significant difference was observed in the number of head and neck surgical oncology clinic appointments (1.70 vs. 1.66, p = 0.6672).

CONCLUSION

Surgeon-performed ultrasound reduces the number of radiological imaging investigations and FNAs performed, reduces time for definitive treatment decision being made, and reduces the number of clinical encounters for patients. This supports its use in head and neck cancer setting and has important implications for both patients and the health-care system.

The next frontier of office-based inferior vena cava filter placement

OBJECTIVE

There is an increasing number of procedures that traditionally were performed in the inpatient setting that are now becoming office-based procedures. These include peripheral endovascular procedures such as angiograms, angioplasties, dialysis access interventions, and treatment for venous insufficiency. We chose to evaluate the feasibility, safety of inferior vena cava (IVC) filter placement in the office-based setting.

METHODS

All procedures were performed using local anesthesia, and ultrasound guidance for puncture. All venograms were performed with manual injection of iodinated contrast. An IVC filter was placed in the cases (except one failure of placement) using fluoroscopy in the infrarenal position. Patients were observed in a recovery area and then discharged. Follow-up data were obtained through an interview, physical examination, and 24-hour postoperative phone call.

RESULTS

Over the course of 27 months, 29 Greenfield filters (Boston Scientific, Marlborough, Mass) and three Celect temporary filters (Cook, Bloomington, Ind) were placed in the infrarenal IVC for 18 women and 14 men, with an average age of 75.3 ± 15.6 years (range, 38-97 years). Twenty-four acute, 6 recent (<6 months ago) and three subacute lower extremity deep vein thromboses (DVTs) were identified. The indications for the procedure were patients with: DVT who were to undergo surgery (n = 6), acute large free-floating iliofemoral DVT (deemed high-risk for long-term anticoagulation) (n = 7), new DVT during anticoagulation therapy (n = 6), DVT with gastrointestinal bleeding (n = 4), DVT with hematuria (n = 2), recent DVT (which extended during full dose anticoagulation treatment) while undergoing a long flight (n = 1) (temporary filter placement), DVT with arm hematoma (n = 1), DVT with unsteady gait and history of falls (n = 2), DVT with nose bleeding (n = 1), DVT with dementia and inability to receive anticoagulation treatment (n = 1), DVT and receiving chemotherapy and with thrombocytopenia (n = 1), and DVT and refusal to take anticoagulation medication (n = 1). One patient had a failure to place a filter because of chronic IVC occlusion found on venogram. One patient with history of gastrointestinal bleeding, acute DVT, and atrial fibrillation suffered IVC filter thrombosis 1 month after the procedure. We attempted removal of the temporary filters in the hospital in two patients but failed to retrieve the filter in these two cases. We noted no insertion site DVT, extension of DVT, or pulmonary embolism.

CONCLUSIONS

Our preliminary experience suggests that placement of IVC filters for treatment of venous thrombotic events in an office-based facility is safe and efficacious with basic endovascular equipment. Long-term outcome cannot be determined at this point.

Otolaryngologist-performed head and neck ultrasound: outcomes and challenges in learning the technique

Objective:

To assess the feasibility and accuracy of otolaryngologist-performed ultrasound in evaluating head and neck pathology.

Method:

An ENT trainee, who had undergone basic training in neck ultrasonography, performed this on patients referred with suspected neck pathology. The trainee recorded the presence and nature of any abnormality. Findings were compared with those from a repeated scan performed by an experienced head and neck radiologist.

Results:

The study included 250 patients. The absence or presence of lesion as reported by the trainee correlated with the radiologist's findings in 207 cases (83 per cent). There were 144 true positives, 63 true negatives, 32 false negatives and 11 false positives, yielding a sensitivity of 82 per cent, specificity of 85 per cent and accuracy of 83 per cent. Of the 144 true positive lesions, 81 per cent were interpreted concordantly with the radiologist.

Conclusion:

Neck ultrasonography performed by an otolaryngologist is less accurate than that performed by an experienced radiologist, but is still a useful adjunct to clinical assessment, facilitating assessment in a ‘one-stop’ clinical setting.

Evaluation of office ultrasound usage among Australian and New Zealand breast surgeons

BACKGROUND

Surgeon performed ultrasound (US) is being increasingly embraced by breast surgeons worldwide as an integral part of patient assessment. The extent of its application within Australia and New Zealand is not well documented. The present study aimed to evaluate its current usage patterns and to determine suitable future training models.

METHODS

An online survey was sent to members of Breast Surgeons of Australia and New Zealand (BreastSurgANZ) between July and September 2010, with emphases on practice demographics, access to US equipment, usage, biopsy patterns, and training.

RESULTS

Of the 126 surveys sent, 59 were returned. The majority of respondents were metropolitan based (64 %), worked in both public and private sectors (71 %), and practiced endocrine or general surgery (85 %), as well as breast surgery. A preponderance of surgeons had access to equipment (63 %), performed at least 1 US monthly (63 %), but did not perform regular guided biopsies. Rural practice did not affect access or usage patterns. Most respondents underwent structured US training (73 %), which was associated with greater US and biopsy usage, biopsy complexity, intraoperative applications, and cross discipline applications (p < 0.03). Most surgeons favored a structured training program for future trainees (83 %).

CONCLUSIONS

The majority of breast surgeons from Australia and New Zealand have adopted office US to varying degrees. Geographic variation did not lead to access inequity and variation in scanning patterns. Formal US training may result in a wider scope of clinical applications by increasing operator confidence and is the preferred model within a specialist breast surgical curriculum.

Surgeon-performed touch preparation of breast core needle biopsies may provide accurate same-day diagnosis and expedite treatment planning

BACKGROUND

We aimed to determine the accuracy of surgeon-performed touch-preparation cytology (TPC) of breast core-needle biopsies (CNB) and the ability to use TPC results to initiate treatment planning at the same patient visit.

METHODS

A single-institution retrospective review of TPC results of ultrasound-guided breast CNB was performed. All TPC slides were prepared by surgeons performing the biopsy and interpreted by the pathologist. TPC results were reported as positive/suspicious, atypical, negative/benign, or deferred; these were compared with final pathology of cores to calculate accuracy. Treatment planning was noted as having taken place if the patient had requisition of advanced imaging, referrals, or surgical planning undertaken during the same visit.

RESULTS

Four hundred forty-seven CNB specimens with corresponding TPC were evaluated from 434 patient visits, and 203 samples (45.4 %) were malignant on final pathology. When the deferred, atypical, and benign results were considered negative and positive/suspicious results were considered positive, sensitivity and specificity were 83.7 % (77.9-88.5 %) and 98.4 % (95.9-99.6 %), respectively; positive and negative predictive values were 97.7 % (94.2-99.4 %) and 87.9 % (83.4-91.5 %), respectively. In practice, patients with atypical or deferred results were asked to await final pathology. An accurate same-day diagnosis (TPC positive/suspicious) was hence feasible in 83.7 % (170 of 203) of malignant and 79.5 % (194 of 244) of benign cases (TPC negative). Of patients who had a same-day diagnosis of a new malignancy, 77.3 % had treatment planning initiated at the same visit.

CONCLUSIONS

Surgeon-performed TPC of breast CNB is an accurate method of same-day diagnosis that allows treatment planning to be initiated at the same visit and may serve to expedite patient care.

Surgeon-performed ultrasound in patients referred for thyroid disease improves patient care by minimizing performance of unnecessary procedures and optimizing surgical treatment

BACKGROUND

Ultrasonography has become an indispensable tool in the evaluation of thyroid nodular disease, and most patients will have had a thyroid ultrasound prior to initial surgical evaluation. This study examines the added benefit of office-based, surgeon-performed ultrasonography in patients referred for thyroid disease.

METHODS

All patients referred to a single endocrine surgeon for evaluation of thyroid disease over a 2-year period were reviewed. Outside ultrasonographic findings were compared to the surgeon-performed ultrasound that was used to formulate treatment decisions.

RESULTS

Of 286 consecutive patients referred for surgical evaluation of thyroid disease, 261 had an outside ultrasound available for comparison. There were 239 women and 47 men. Mean age was 54.7 +/- 16.6. In 46 patients (17.6%), differences between the two ultrasounds were significant enough to alter treatment plans. For 18 patients no distinct nodule was identified and biopsy was avoided. Nine of these patients had ultrasound characteristics of Hashimoto's disease. In five patients the nodule was significantly smaller than reported and biopsy was not warranted. Twelve patients had nonpalpable, enlarged lymph nodes not previously identified; these were biopsied. Three were positive for metastatic thyroid cancer, which prompted the addition of neck dissection to the operative procedure. In 8 of 132 patients undergoing thyroidectomy, the surgical procedure was significantly altered by the ultrasound findings.

CONCLUSIONS

This study demonstrates a clear advantage for patients who undergo a surgeon-performed ultrasound. For many, unnecessary procedures were prevented. For others, substantial modifications to the extent of surgery were made when new ultrasonographic findings were identified during the preoperative investigation.