Incidental Thyroid Abnormalities on Carotid Color Doppler Ultrasound: Frequency and Clinical Significance

Prevalence and characterization of asymptomatic thyroid nodules in Assin North District, Ghana

Background

Ultrasound is now the initial imaging modality of choice for detection and characterization of lesions of the thyroid gland. Ultrasound imaging studies of the thyroid gland report varied prevalence of asymptomatic thyroid nodules (ATN), ranging from 20 to 67%. This study estimated the prevalence, characterized and determined factors associated with ATN in selected communities in the Assin North Municipality, Central Region, Ghana.

Methods

The study was a cross-sectional design, involving 320 participants from six (6) communities in the Assin North District of the Central Region of Ghana. Socio-demographic data and data from ultrasound examination of the thyroid gland were analyzed using descriptive and inferential statistical techniques.

Results

The prevalence of ATN was 11.3% among 320 participants with the mean age of 56.53(±16.5) years. ATNs were common in the left lobe (69%) and predominantly solitary (64%). ATNs increased with age and body mass index (BMI). Those aged 60 years and above had significantly higher odds (OR = 24.40, 95% CI = 2.59–229.86) of having ATNs, likewise overweigh (OR = 5.32, 95% CI = 1.12–25.20) and obese (OR = 12.51, 95% CI = 1.47–106.58) individuals.

Conclusion

The prevalence of ATN in our study population was relatively low, and more predictable among those 60 years or older, those in unhealthy BMI categories. There is the need for the reinforcement and intensification of educational campaigns on the consumption of iodized dietary salt as well as the consumption of foods rich in iodine content, particularly among older individuals.

Laboratory and Clinical Implications of Incidental and Secondary Germline Findings During Tumor Testing

CONTEXT.—

Next-generation sequencing is a powerful clinical tool for cancer management but can produce incidental/secondary findings that require special consideration.

OBJECTIVE.—

To discuss clinical and laboratory issues related to incidental or secondary germline findings in the clinical setting of tumor testing and inform future guidelines in this area.

DESIGN.—

A College of American Pathologists workgroup including representation from the American Society of Clinical Oncology, the Association for Molecular Pathology, and the American College of Medical Genetics and Genomics created a review of items that should be considered when developing guidelines for incidental or secondary findings when performing clinical tumor testing.

RESULTS.—

Testing recommendations should be cognizant of the differences among anticipated incidental, unanticipated incidental, and secondary findings, and whether normal tissue is also tested. In addition to defining which variants will be reported, robust recommendations must also take into account test design and validation, reimbursement, cost, infrastructure, impact on reflex testing, and maintenance of proficiency. Care providers need to consider the potential of a test to uncover incidental or secondary findings, the recommendation of upfront counseling, the need for consent, the timing of testing and counseling, and that the exact significance of a finding may not be clear.

CONCLUSIONS.—

As clinical oncology testing panels have become a mainstay of clinical cancer care, guidelines addressing the unique aspects of incidental and secondary findings in oncology testing are needed. This paper highlights clinical and laboratory considerations with regard to incidental/secondary findings and is a clarion call to create recommendations.

Active surveillance for prostate and thyroid cancers: evolution in clinical paradigms and lessons learned

The adverse effects of overdiagnosis and overtreatment observed in men with clinically insignificant prostate cancers after the introduction of prostate-specific antigen-based screening are now being observed in those with thyroid cancer, owing to the introduction of new imaging technologies. Thus, the evolving paradigm of active surveillance in prostate and thyroid cancers might be valuable in informing the development of future active surveillance protocols. The lessons learned from active surveillance and their implications include the need to minimize the use of broad, population-based screening programmes that do not incorporate patient education and the need for individualized or shared decision-making, which can decrease the extent of overtreatment. Furthermore, from the experience in patients with prostate cancer, we have learned that consensus is required regarding the optimal selection of patients for active surveillance, using more-specific evidence-based methods for stratifying patients by risk. In this Review, we describe the epidemiology, pathology and screening guidelines for the management of patients with prostate and thyroid cancers; the evidence of overdiagnosis and overtreatment; and provide overviews of existing international active surveillance protocols.

The effect of routine radiological reporting of thyroid incidentalomas on rates of thyroid needle biopsy, thyroid surgery and detection of thyroid malignancy

OBJECTIVE

This study looked at the effect of a changing radiology reporting policy to routinely review the thyroid gland where visible and report on any thyroid lesion, recommending further investigation as appropriate.

CONTEXT

Incidentaloma is a term used to describe a lesion found on imaging unrelated to the clinical issue under investigation. There is variability in the radiological reporting of thyroid incidentalomas and conflicting recommendations as to how these lesions should be managed.

DESIGN

Data were collected retrospectively during a two-year period, including 12 months before and 12 months after the change in reporting policy and categorized according to whether the lesion under investigation was a thyroid incidentaloma or a symptomatic thyroid lesion.

PATIENTS

All patients undergoing ultrasound-guided fine-needle aspiration cytology or core biopsy were included.

MEASUREMENTS

The effects of the change in policy were analysed including rates of needle biopsy, rates of malignancy and subsequent surgical intervention.

RESULTS

There was a 122% increase in thyroid incidentalomas undergoing needle biopsy, the majority of these were detected on computed tomography. The number of malignancies increased from 1 to 4 from year 1 to year 2. All patients were >35 years old. One patient had a positron emission tomography (PET)-detected cancer, two of four of the non-PET-detected malignancies were <1.5 cm.

CONCLUSION

This study posits that routine radiological reporting of thyroid incidentalomas, with further investigation when clinically appropriate, is warranted. The results suggest that lesion size and CT characteristics are not reliable criteria to triage patients for investigation/biopsy.

The Incidental Thyroid Lesion in Parathyroid Disease Management

Objective

The incidental thyroid lesion is a common finding during general imaging studies. Their management has been the subject of numerous studies and recommendations. Parathyroid disease workup necessitates imaging investigation of the adjacent thyroid gland and therefore provides a unique window to the perioperative management of thyroid incidentaloma. The specific prevalence of incidental thyroid lesions in the context of parathyroid disease is unknown. We seek to investigate its prevalence during parathyroid workup and surgery and to ascertain if there was a change in management of these patients.

Study Design

Five-year retrospective database review.

Setting

Tertiary care medical center.

Subjects and Methods

The source and indication for referral, preoperative investigation findings, and management of the incidental thyroid lesions were examined. The actual procedure performed and final pathology results were assessed.

Results

A total of 98 patients and 106 operations, including revision surgeries, were identified. There were 21 incidental thyroid lesions (21.4%) detected, whereby 15 patients underwent fine-needle aspirations and 12 subsequently had diagnostic hemithyroidectomies. This decision was made preoperatively in 5 patients and intraoperatively in 7 patients at the time of parathyroid surgery. Along with other pathologies, there were 7 patients with micropapillary thyroid carcinoma identified.

Conclusions

In our series, the prevalence of incidental thyroid lesion and thyroid malignancy is comparable to the general population. The management of the initial parathyroid disease in our patients was altered by the imaging and cytological findings of these thyroid lesions. This has implications on perioperative counseling of the thyroid and parathyroid disease.

Improving Access to Image-guided Procedures at an Integrated Rural Critical Access Hospital: Ultrasound-guided Thyroid Biopsy Program

PURPOSE

Critical access hospitals face difficulty providing all services locally and may need to refer patients off-site for additional care. Providing on-site minimally invasive biopsies, may obviate visits to tertiary or quaternary care centers. This study aims to assess feasibility and outcomes of an ultrasound-guided thyroid biopsy program in a critical access hospital.

METHODS

In this HIPAA compliant, IRB approved study, the Interventional Radiology (IR) database of a 19-bed, island, rural, critical access hospital without onsite pathology services affiliated with our quaternary care institution was retrospectively reviewed to identify all thyroid biopsies that were performed on site since inception of the service in April 2014 through August 2016. A specialized biopsy and specimen collection protocol was created as each specimen was transferred to and analyzed by the pathology department at our affiliated quaternary care institution.

RESULTS

Two IR physicians carried out thyroid biopsies on 34 nodules in 29 patients during the study period. The mean age of patients was 56.5 ± 14.0, with a range of 35-85 and 86% female, 14% male. 94.1% of nodules had adequate material for interpretation on the first biopsy and 97.1% upon repeat biopsy. Ultimately, 5 patients (with 6 nodules) underwent surgical resection at the integrated quaternary care center. Surgical resection identified one atypical follicular adenoma, one follicular variant of papillary thyroid carcinoma, two papillary carcinomas, and two Hürthle cell tumors.

CONCLUSION

IR thyroid biopsy services may be successfully provided in the rural setting without onsite pathology analysis and adequacy checks, enhancing patient access and streamlining care while also expanding the reach of tertiary care centers.

Cardiovascular Testing in Asymptomatic Patients: Carotid Duplex, Cardiac Stress Testing, Screen for Peripheral Arterial Disease

Approximately one-third of deaths in the United States are from cardiovascular disease. Managing modifiable risk factors is paramount to reducing risk of heart disease and stroke. It is logical to try to identify patients with silent disease that may predispose them to significant morbidity and mortality. Unfortunately, it is unclear if routine screening for the presence of carotid stenosis, coronary artery disease, and peripheral arterial disease is beneficial. Many of these tests are expensive. This review explores the evidence behind screening tests, costs associated with the tests, and the implications of positive screening for each of the 3 listed conditions.