1. Primary Care direct access to thyroid ultrasound: Audit of clinical efficiency & governance Bravis V ¹ , Lingam R ² , Haroon M ² , Devendra D 1,3,4 Dept. of Endocrinology ¹ & Radiology ² , Central Middlesex Hospital, Brent tPCT 3 & Imperial College 4 , London.

4. Prevalence of Goitres Hatton & Devendra, BMJ 2008 submitted 60.0 n/a n/a Belarus [w16] 50.5 n/a n/a Mayo, USA [w10] n/a 14.5 n/a France [w15] n/a 25.0 n/a Belgium [w14] n/a 23.4 n/a Germany [3] n/a 21.3 3.2 Finland [w20] n/a 67.0 21.0 North America [w9] n/a 14.8 8.9 Poland [w13] n/a n/a 4.2 Framingham, USA [w8] n/a n/a 3.2 Whickham, England [2] Prevalence of nodules on autopsy (%) Prevalence of nodules on ultrasound (%) Prevalence of nodules on palpation (%) Country of study conducted

6. Caveats to Ultrasound 85.7-97.4 24.0-41.9 78.6-80.8 54.3-74.2 Central blood flow on colour Doppler 38.9-97.4 9.3-60.0 38.9-85.0 17.5-77.5 Irregular margins/no halo 73.5-93.8 11.4-68.4 43.4-94.3 26.5-87.1 Echogenicity 41.8-94.2 24.3-70.7 85.8-95.0 26.1-59.1 Microcalcifications Negative predictive value (%) Positive predictive value (%) Specificity (%) Sensitivity (%) US feature

7. Caveats in Cytology reports Obtained in around 3-5% of cases. Malignant Follicular adenomas and carcinomas are indistinguishable on cytology and so often produce a ‘suspicious’ cytology result. These nodules are managed as carcinomas. Suspicious Obtained in around 70% cases. No evidence of malignancy Benign 20% cases, even if FNA is ultrasound guided.Contain too few epithelial cells for a diagnosis to be made. Particularly common when aspirating cystic nodules. The presence of too much cyst fluid or blood, or inadequate technique in performing FNA and preparing the slide for cytology can all produce a non diagnostic sample Non-diagnostic Explanation Cytology results

12. TUS result according to reason for referral 77 44 1 2 12 18 Total 17 12 0 1 1 3 Dysphagia (17) 15 8 1 0 0 6 Abnormal TFTs (15) 45 24 0 1 11 9 ? Goitre (45) Normal gland Hypothyroid Gland Thyroiditis Solitary / Dominant Nodule MNG Total TUS Result Referral Reason

13. FNA cytology (n=13) neoplasm n=0 13 4 1 8 Total 11 4 0 7 Solitary/ Dominant nodule (11) 2 0 1 1 MNG (2) Insufficient Thyroiditis Benign Total FNA Result FNA

14. Insufficient samples for FNA- outcome (n=4) 1 (adenocarcinoma) Insufficient re-FNA, suspicious USS features 2 Insufficient re-FNA, normal USS features 1 Insufficient FNA Normal USS features Surgery Lost to F/U Discharged

15. Audit Cycle 1. Identify issue TUS access 5. Implementing change One stop clinic 4. Compare 3. Data collection 2. Set criteria Malignancy pick-up rate & Follow up of inconclusive FNA

16. Refer to Endocrine surgeon GP referral – thyroid swelling/goitre/nodules TSH, FT4, FT3, TPO Abs, Ca Sample inadequate /poor to comment but normal US and no increase in nodule size Suspicious or abnormal Abnormal – Endcorine clinic appointment given Normal – refer to one stop diagnostic clinic Clinical assessment USS neck US guided FNA , if suspicious nodule by US criteria Cytology Normal cytology & USS characteristics Sample inadequate/ poor to comment but suspicious USS features Sample inadequate /poor to comment on Discharge Repeat USS- guided FNA within 6 months Sample inadequate /poor to comment but suspicious US features Suspicious or abnormal BRENT RAPID ACCESS ONE STOP THYROID DIAGNOSTIC CLINIC

22. FNA cytology (n=23) neoplasm (n=7) 23 1 7 3 12 Total 2 0 0 2 0 Other 12 1 5 1 5 Solitary/ Dominant nodule 9 0 2 0 7 MNG Insufficient Malignancy Reactive LN Benign Total FNA Result FNA

23. Neoplasm (n=7) 1 (female) 6 (5 female) FNA Papillary Follicular