Consistency in Reporting and Communication: Thyroid Ultrasound Imaging

Impression: 1) Complex nodule left lobe of thyroid.
                       2) Very small solid nodule right lobe of thyroid.

The above is an excerpt from my mother’s thyroid ultrasound report. Last week my mother noticed a lump in her neck while brushing her teeth. She was concerned about this finding and called me to inquire how to proceed. I advised her to go and see her primary care doctor. I knew her doctor would perform a physical exam and that he would likely order some imaging if he felt that the lump was suspicious.

As expected, after my mother’s visit to her primary care doctor, her physician recommended imaging: a thyroid ultrasound due to his localization of the lesion to the thyroid gland. The above report was returned to my mother’s doctor who was somewhat confused with how to proceed, and after my full review of the report I can understand why.

The report included a measurement of the complex nodule in the left lobe of the thyroid, but no explicit comment on whether the nodule had a solid component, the nature of the borders of the lesion (i.e. well defined vs. infiltrative), presence or absence of microcalcifications, or the presence of flow.

The solid nodule on the right described in the impression, in addition to excluding the aforementioned descriptors, also failed to accurately gauge the size of the lesion only noting that it was “very small.” No recommendation on whether biopsy was necessary or feasible was included.

As a radiologist who routinely reads thyroid ultrasound, I understand that these mundane studies with high likelihood of a benign result regardless of the imaging findings can become the bane of a radiologist’s existence. The sloppiness of the report, nevertheless, bothered me. Due to the size (> 2cm) of the so called “complex” nodule, my mother will proceed with a biopsy this week. However, I still do not know enough details about the lesion to justify whether the procedure is even necessary.

Clearly there is confusion in our field about how to accurately report and follow thyroid nodules detected on ultrasound. This is best illustrated by the fact that the Society of Radiologists in Ultrasound consensus conference statement on the management of thyroid nodules published in 2005 remains in the top three most read articles published in the journal Radiology.

If mammography results were reported in the inconsistent way that thyroid ultrasound reports are currently dictated there would be outrage in the medical community. The breast imaging community recognized the need to standardize their reports long ago by creating the BI-RADS system. This simple-to-interpret seven point scale gives explicit instructions to referring providers on how to proceed with management of detected lesions. BI-RADS also roughly quantifies the suspicion of malignancy of a detected finding as determined by the radiologist.

Thyroid ultrasound imaging is becoming more common as a result of the detection of thyroid lesions on neck and chest CT exams. Moreover, thyroid ultrasound detects nodules in up to two-thirds of all patients while less than 10 percent of nodules harbor malignancy.

It is important for radiologists to be consistent with their approach and management of these lesions when imaged with ultrasound to prevent unnecessary biopsies, and just as important, undue fear on the part of patients.

One such solution has recently been proffered and evaluated by a group from Korea whose results are published in this month’s issue of Radiology. In a study that involved more than 1,500 patients with over 1,600 path proven biopsied nodules, the investigators developed and validated a scoring and management system for thyroid nodules that they dubbed, TIRADS (Thyroid Imaging Reporting and Data System). My hope is that one day such a system will become embraced by the radiology community in the same manner that BI-RADS is accepted. This type of system could easily be integrated into speech recognition software with macro driven templates for consistency.

Despite the radiology report my mother received from her radiologist, I am confident that her nodule will likely be benign; and the statistics would back me up. However, if her radiologist spent more due diligence in crafting his report, we may not have even had to go down this path and I could give my mom more reassurance that she will be fine.