American Thyroid Association 88th Annual Meeting:

Thyroid Surgeries Avoidable with Comprehensive Ultrasound Protocol

With Gary Clayman, DMD, MD

“Despite established ultrasound guidelines,1-3 there is an urgency to establish better guidance and criteria regarding consistent implementation of preoperative ultrasound in patients presenting with non-malignant thyroid nodules,” according to Gary Clayman, DMD, MD, founder and surgeon-in-chief of the Clayman Thyroid Center in the Thyroid and Parathyroid Institute of Tampa General Hospital in Tampa, Florida, who raised this concern at the American Thyroid Association (ATA) 88th Annual Meeting in Washington, DC.


“Commonly, the ultrasonography testing falls short because the lateral neck and central lymph nodes are not captured or not reported, which is likely to result in avoidable additional surgery for that patient in the future,” Dr. Clayman told EndocrineWeb.

Calling the current situation a “national epidemic,” Dr. Clayman presented data to support the need for a concerted effort to address this problem, which if not corrected, promises to result in more incomplete surgeries, inadequate evaluations, and persistent thyroid disease with the potential for avoidable complications, or specifically unnecessary surgeries.

Building a Case for Improved Ultrasound Imaging Practices

Dr. Clayman and his team prospectively evaluated  217 patients (66 men; 151 women), ages 14 to 87 years, who were referred to their center for treatment of primary thyroid cancer in 2017; they all arrived with CD documentation of their imaging tests from their preoperative ultrasounds.4

In staging the thyroid cancer status of these patients, 101 were diagnosed with small thyroid nodules (T1), 39 were at T2, and the remaining 35% of patients were at T3 or T4.4

When evaluating these cases, only 2% of the patients prior operative analysis included an assessment of lateral neck lymph nodes.

"As such, we conducted our own high-resolution ultrasound examination of all patients ahead of their surgical planning," said Dr. Clayman. 

These new imaging studies resulted in the following impact on surgical decisions:4

  • Lateral neck metastases in 18% of cases
  • Lymph node involvement of the central compartment in 28% of the group
  • Contralateral secondary thyroid cancer in four (2%) of patients

“Sometimes, imaging of the lymph nodes may have been conducted but not reported, but in nearly all instances, imaging of the lateral neck was not examined whatsoever, delivering an incomplete assessment,” Dr. Clayman said.

Validating Benefits of Consistent and Comprehensive Thyroid Imaging 

“The data support the necessity of establishing standards that require high-quality, comprehensive ultrasound imaging,”4 Dr. Clayman said. “Based on our findings,4 there are four factors that are integral to the accuracy in delivering a preoperative comprehensive high-resolution thyroid ultrasound: 

  • the right transducers;
  • a machine calibrated for the thyroid gland and cervical lymph nodes;
  • an experienced imaging technician; and
  • a thyroid-focused diagnostician.”

Here’s why it matters.

Comprehensive thyroid ultrasound must be done by an experienced technician, on a properly calibrated machine.Transducers and ultrasound machines need to be appropriately and regularly calibrated for the thyroid because when the imaging equipment has been used, for example, to conduct a breast or an abdominal ultrasound, then used for a thyroid assessment, the penetration is significantly different, and will affect the sensitivity of the thyroid ultrasound study. Therefore, appropriate calibration prior to conducting a thyroid evaluation is essential,” he said.

“Additionally, the expertise of the ultrasound technician as well as the experience of the diagnostic physician—be it a radiologist, an endocrinologist, or a surgeon—who is interpreting the imaging findings—will directly impact the accuracy of the report,” Dr. Clayman said.

“All of those factors together will make the difference between providing a useful or inferior ultrasound report; and, a breakdown at any one of these points is likely to adversely impact the quality and therefore of the value of ultrasound in guiding the treating clinician to choose the correct treatment approach.”

Applying the Findings to Clinical Management of Thyroid Nodules

“We propose that the ATA and American Academy of Clinical Endocrinology jointly address the American College of Radiology, American Society of Neuroradiology, and American Society of Radiology, to evolve structured guidelines that clearly establishes a protocol for a comprehensive cervical ultrasound evaluation in the analysis of the thyroid gland," he said.

A final point, “When endocrinologists commonly ask: “Aren’t biopsies enough? The simple answer is no,” Dr. Clayman told EndocrineWeb. It is important to be both realistic and thorough in requiring a comprehensive high-resolution ultrasound assessment as the basis for making an accurate diagnosis and then determining the most appropriate treatment plan.   

While clinicians will benefit from adjusting their practices to prioritize the need for a preoperative high-resolution imaging evaluation of every patient with a benign symptomatic thyroid nodule, as the basis for initiating a course of treatment. 

Patients, too, will benefit from education regarding the steps needed for an accurate diagnosis to inform their treatment.To meet this need, we have developed a website and app to address risk assessment and next steps including testing, referral, and surgery.

"To meet this need, we have developed a consumer website and an app as a means of informing patients about thyroid nodule risk assessment and management steps including testing, referral, and surgery.  

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