Thyroid Nodule Management and Compliance With Guidelines in a District General Hospital in London: A Retrospective...

Thyroid nodules affect a small number of adults. Progress has been made to streamline and create a structured approach for evaluating and managing thyroid nodules, such as the use of ultrasound (US) U-scores (U1-U5) to stratify risk and guide the need for fine needle aspiration cytology (FNAC). This audit aimed to evaluate the adherence to the British Thyroid Association (BTA) 2014 guidelines in local practice at our local hospital.

This retrospective audit included 50 thyroid US reports over 12 months, identifying nodules and assessing compliance with BTA 2014 guidelines. Reports were evaluated for inclusion of a U-score or equivalent classification, such as the Thyroid Imaging Reporting and Data System score. Four patients did not have a U-score provided initially, which was retrospectively assigned by a consultant radiologist. FNAC performance was assessed based on U-score risk stratification: FNAC was expected for U3-U5 nodules, not U1 and U2. Cytology results were reviewed and classified using the THY system. The audit also analyzed reasons for deviation from guidelines by reviewing patients' medical notes for any documented reasons and the outcomes of histological analysis where surgical intervention occurred.

Of the 50 US reports reviewed, 49 (98%) included a U-score. Distribution was as follows: U2 (13 cases), U3 (18 cases), U2/U3 (12 cases), U4 (five cases), and U3/U4 (one case). FNAC was indicated in 37 cases based on the U-score and was performed in 31. Despite being shown, six instances did not receive FNAC, often due to valid clinical reasons such as comorbidities, patient refusal, or alternative diagnoses. A total of 28 cases were classified cytologically using the THY system: THY 1 (one case), THY 2 (nine cases), THY 2c (one case), THY 3 (one case), THY 3A (seven cases), THY 3F (six cases), mixed THY 2/3 (one case), and THY 4 (two cases). Two cases had indeterminate THY 3 cytology, and one FNAC attempt was unsuccessful due to vascularity. Among the 31 cases assessed via FNAC, five were diagnosed with malignancy; four underwent hemithyroidectomy, and one had a local excision. Additionally, three patients who had hemithyroidectomy were found to have benign adenomas, most commonly follicular adenomas. Overall, 80% of cases adhered to BTA guidelines regarding FNAC indication. All U2 and U4 cases were managed in accordance with guidelines.

This audit demonstrates high compliance with the BTA 2014 guidelines, with near-universal documentation of U-scores and appropriate use of FNAC in most cases. While deviations were minimal and often clinically justified, there remains scope to improve standardization and adherence through targeted education and resource support. Continued emphasis on guideline-driven practice is essential to ensure optimal management of thyroid nodules and efficient use of clinical resources.