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Excerpt
Over the past 20 years, advances in engineering and electronics technology have resulted in real-time ultrasound equipment using phased-array 7.5- to 10-megahertz transducers that greatly improved the quality of ultrasound imaging. Certain ultrasound characteristics such as microcalcifications, irregular borders, and enlarged cervical lymph nodes correlate with malignancy and often complement the FNA results in deciding when a patient needs surgery [1]. Indeed, Marqusee and her colleges at Brigham and Women’s Hospital found that ultrasound altered the clinical management in 63% of the patients seen in their thyroid nodule clinic [2].
The most significant improvement in ultrasound has been the drastic reduction in the cost of quality ultrasound equipment, which now enables it to be cost-effective to dedicate an instrument at the bedside to be used by the endocrinologist at the time of examination and FNA biopsy. This reduction in equipment cost and the elimination of another level of specialty consultation have made thyroid ultrasound much more cost-effective. In addition, an endocrinologist with knowledge of the patient’s history and physical examination and viewing the ultrasound in real-time will acquire more information than a sonographer who takes spot films and submits them to a radiologist for later interpretation. Imaging the nodule before FNA allows the clinician to choose the proper needle size and length, determine the dominant nodule if multiple nodules are present, and decide if the FNA should be performed with ultrasound guidance [3]. Ultrasound-guided FNA is indicated when nodules are small (<1.5 cm), difficult to palpate, complex (cystic), and necessary for all unsatisfactory FNAs that require repeating. There are many reports in the recent literature showing that the incidence of unsatisfactory biopsies is reduced from 15% to 20% to less than 5% when FNA is performed with ultrasound guidance [4–6]. Yang et al. [7] reported on 1,135 ultrasound-guided FNAs with an unsatisfactory rate of only 0.7%.
Because most nodules are not sent to surgery, it is important to record the initial baseline size and volume to determine if the nodule is stable or if it continues to grow and requires a follow-up biopsy. In summary, the use of office ultrasound by the clinician has become an indispensable tool for the evaluation of thyroid nodules. To re-fuse to incorporate its use solely on the basis of cost containment is ill advised.
