Incomplete US radiology reports lead to confusion, unnecessary biopsies

Incomplete thyroid ultrasound (US) radiology reports cause "confusion and discrepancy" among specialists about the risk of malignancy and the necessity of biopsy, according to findings reported in the American Journal of Roentgenology.

“At our institution, specialists who manage patients with thyroid disease have expressed dissatisfaction regarding the quality of thyroid US reports from radiologists in our region and have emphasized the need for more comprehensive risk assessment and clear recommendations regarding the need for fine-needle aspiration biopsy (FNAB),” wrote Manolhas Karkada, department of science at Dahousie University in Halifax, Nova Scotia, Canada, and colleagues. “The purpose of the present study was to evaluate the proportion of incomplete thyroid US reports in our region, to determine the variability in how specialists interpret such reports as well as the subsequent biopsy and cancer detection rates.”

Karkada et al. retrospectively reviewed thyroid US reports performed from January to June 2013. Baseline exams that included the identification of a nodule were evaluated for several reporting elements: thyroid gland dimensions; thyroid parenchymal architecture and vascularity; the number of significant nodules; size, location and composition; echogenicity of the dominant or most suspicious nodule; the presence or absence of any suspicious feature, such as microcalcifications; and comment on the presence or absence of any suspicious lymph nodes in the neck.

Researchers also examined if each report evaluated for malignancy risk or commented on the need for FNAB—if neither was present, the reported nodule was deemed “unclassified” and graded by an endocrinologist, an ear, nose and throat (ENT) surgeon and a radiation oncologist. A radiologist also reviewed images of unclassified nodules and assessed both biopsy rates and pathologic findings.

Overall, 478 of 971 first-time thyroid US studies detected a nodule. Forty-six percent of nodules were labeled unclassified. Ninety-one percent of the reports did not include information about the presence or absence of suspicious features in the nodule. Also, 83 percent of the reports did not include comments on the patient’s lymph nodes, and 71 percent did not include the size of the dominant or most suspicious nodule in 3D.

While 127 biopsies were performed, the radiologists found that only 57 were performed on nodules that warranted biopsy. In addition, the three specialists’ grading of unclassified nodules would have resulted in biopsies for four (the radiation oncologist), 10 (the endocrinologist) and 40 (the ENT surgeon) patients receiving a biopsy.

“The results of our study show that a very large percentage of thyroid US examinations reported in our region are missing important data elements required by current reporting guidelines and that reports that fail to classify thyroid nodules or comment on the need for FNAB are interpreted very differently by clinical thyroid specialists regarding the actual risk of malignancy,” the authors wrote. “The implications of this uncertainty are that a small number of nodules that do not warrant FNAB would undergo biopsy, particularly if under the care of the ENT surgeon.”

These findings, the team concluded, reinforce that there is a need to adhere to standardized reporting guidelines in radiology reports “to ensure completeness and appropriate recommendations.”