Impact of high-quality ultrasound following community ultrasound on surgical planning and active surveillance in patients with thyroid cancer

Objective: Ultrasound (US) has gained a critical role in thyroid cancer treatment planning, yet it is limited by its user-dependent nature. The aim of this study was to compare the impact of US performed by radiologists specializing in thyroid imaging (hqUS) and US performed by radiographers in the community (cUS) on treatment plans of patients diagnosed with well-differentiated thyroid malignancies. Design: Retrospective single-centre case series with chart review. Patients: Patients diagnosed with thyroid cancer during 2017-2019 that had cUS followed by hqUS pre-operative counselling were included in this retrospective analysis. Measurements: The main outcome was management alternations based on one of two sonographic measures: (1) extrathyroid extension (ETE); (2) The presence of central or lateral lymph nodes suspicious for metastases (LNM), which were compared with the final pathology. Results: Among those with non-recurrent tumour (n = 76), ETE was reported 22 times more by hqUS compared with cUS (28.9% vs 1.3%, P <.001). Central and lateral LNM were reported approximately 6.5 and 1.5 times more by hqUS, respectively (25.0% vs 3.9%, P <.001 and 15.8% vs., 9.2%, P =.227, respectively). Overall, hqUS altered the initial treatment plan of 35.5% of patients. In 27.6% of patients, hqUS and its subsequent surgery resulted in a change to the patients' 2015 ATA risk stratification system. In 40% of patients with microcarcinomas, hqUS findings mandated surgery according to findings that were not reported by cUS. False-positive rate was 5.2%. Conclusions: Community US may under-diagnose important features such as ETE and LNM, leading to potential under-treatment in many patients. High-quality US of the neck should be considered in patients with differentiated thyroid carcinoma before making any treatment decisions.