Audit of thyroid U-classification and subsequent fine needle aspiration cytology

The aim of this audit is to assess the investigation and management of thyroid nodules compared with the current guidelines. Specifically the purpose is to review whether thyroid ultrasound reports have included a U-score for nodule classification and whether fine needle aspiration cytology (FNAC) was subsequently performed in the appropriate patients based on the U-score in line with the current British Thyroid association (BTA) guidelines 2014.

Thyroid nodules are detected in up to 50% of the general population. However, the risk of malignancy of a nodule detected on ultrasound is 4-7%. The BTA 2014 guidelines recommend assigning a u-score to thyroid nodules based on their sonographic characteristics and advise which nodules require ultrasound-guided FNAC based on the U-score. They also recommend which sampled nodules require further management, including repeat FNAC, based on their cytology results (Thy-score). This has implications in terms of time, cost and on the TWR pathway.

The standard: 

The BTA guidelines 2014 recommend that all thyroid ultrasounds should include a u-score.

U1-U2 should not have FNAC.

U3-U5 nodules should have FNAC.

Target: 

100% ultrasound reports identifying a thyroid nodule should include a U-score.

U1-U2 should not have FNAC.

U3-U5 nodules should have FNAC (unless adequate clinical reason is provided).

Indicators: 

U-score in initial ultrasound report.

Review whether FNAC performed in initial ultrasound report and review subsequent cytology reports.

Data items to be collected: 

Perform search on RIS-PACS  for all thyroid and/or neck ultrasounds within the last 12 months. Include all ultrasounds identifying at least one thyroid nodule. Exclude non-thyroid ultrasounds.

Review ultrasound report for a thyroid nodule U-score or alternative classification system eg TiRads.

If no U-score available, retrospective U-score can be assigned following image review by consultant radiologist to assess appropriateness of subsequent management.

Review whether thyroid ultrasound report confirms if FNAC has been performed or not, and any reason for not following guidance.

Review cytology reports to see whether subsequent FNAC has been performed.

Suggested number: 

100

Laminated educational U-scoring guidelines with corresponding ultrasound examples placed in all ultrasound rooms (please see image attached).

Departmental teaching presentation for all staff performing thyroid ultrasound and FNA.

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Emily Guilhem

Co-authors

Tharsi Sarvananthan

Puja Patel

Nicholas Hughes