Mount Sinai Beth Israel Beth Israel medical center Thyroid Cancer Care Collaborative: A Computerized Clinical Decision Support System for Management of Thyroid Nodules eEdE-167 Vivian Mai-Tran, MD Jody Shen, MD Mark urken, MD Azita Khorsandi, MD Mount Sinai Beth Israel Beth Israel medical center New York, New York

Disclosure Neither we nor our immediate family members have a financial relationship with a commercial organization that may have a direct or indirect interest in the content.

Goals and Objectives To review current issues with and guidelines for thyroid ultrasound reporting To describe a computerized clinical decision support system using sonographic thyroid nodule characteristics To describe the advantages of a computerized database and clinical support system

Background Ultrasound is the imaging modality of choice for thyroid nodule characterization However, variation in reporting can lead to confusion about recommendations Efforts to standardize reporting for risk stratification to inform clinical decision making have been made with the Thyroid Imaging Reporting and Data System (TIRADS) and the American Thyroid Association (ATA) guidelines

TIRADS Ultrasound Categories Composition: *solid, cystic, spongiform Echogenicity: hyper-, iso-,*hypo-,*very hypoechoic Shape: *taller-than-wide Size: max diameter longitudinal, A-P, and transverse in cm Margins: smooth, *irregular, *lobulated, ill-defined, halo, extension Echogenic Foci: *microcalcifications, macrocalcifications, peripheral calcifications, comet-tail artifact *Kwak’s five suspicious ultrasound features for risk stratification

TIRADS Category Risk of Malignancy TIRADS 1 Negative TIRADS 2 Benign TIRADS 3 Probably Benign 1.7 TIRADS 4 a-c with increasing Risk of Malignancy 4a:3.3 4b:9.2 4c: 44.4-72.4 TIRADS 5 Highly Suggestive of Malignancy 87.5 Risk stratification based upon number of suspicious ultrasound features: TIRADS 3- 0/5 TIRADS 4a- 1/5 TIRADS 4b- 2/5 TIRADS 4c- 3-4/5 TIRADS 5- 5/5

ATA Guidelines Incorporates the TIRADS lexicon, stratifies risk based upon similar sonographic features, and offers recommendations on when to perform Fine-Needle Aspiration (FNA) Additional high suspicion features include rim calcifications with small extrusive soft tissue component, evidence of extrathryoidal extension (ETE), and new suspicious lymph nodes FNA for nodules ≥1-1.5 cm depending on sonographic features

Thyroid Cancer Care Collaborative Database funded by the Thyroid, Head and Neck Cancer (THANC) Foundation available to patients and doctors to improve management and tracking of thyroid disease Thyroid Cancer Care Collaborative (TCCC) applies TIRADS to a HIPAA- compliant Internet-based algorithm that generates patient-specific recommendations in accordance to the ATA guidelines for the purposes of risk stratification and individualized treatment

TCCC The multidisciplinary clinical decision-making module has been designed collaboratively by physicians experienced in thyroid cancer diagnosis and treatments to coordinate care and guide patient-specific decisions Endocrinologist Surgeon Oncologist Nuclear Medicine

TCCC Advantages Provides user friendly database for searching Displays tabs to organize medical information for medical team Organizes individualized treatment plan with an imaging and cytology module and a timeline of care Standardizes care regarding response to last treatment, total TSH suppression, and ATA risk of recurrence Provides documents and playlists of videos for active patient participation in treatment plans

Search and Add New Patients Modern technology allows for quick and easy searching capabilities

Multiple Tabs For Organizing Information General Information Molecular Analysis Prior Treatment History Thyroid History Directed PMH Review of Systems Current Exam and Work Up Prior Imaging Data Current Lab Results Current Medications Inherited Genetic Disorders Treatment Plan *Indicated minimum required data for first encounter

Patient-Specific Treatment Molecular Analysis and Thyroid Specific Labs

Imaging and Cytology Module Includes: An interactive diagram of the anatomical structures in the neck region Multiple icons to differentiate thyroid nodules from lymph nodes and parathyroid glands Predetermined ATA characteristics for thyroid nodule assessment with example images A summative pictorial representation which may aid preoperative planning

Extrathyroidal Extension ATA Characteristics Calcifications Echogenicity Contour Extrathyroidal Extension

Example of Thyroid Nodule with High Suspicion

Example of Tumor with ETE

Educational Videos for Patients Physicians can create playlists of videos to send to patients pertaining to specific thyroid conditions, treatments, surgeries, and possible recurrence

Computerized Clinical Decision Support System In a systematic review, Garg demonstrates that many CDSSs improve practitioner performance Practitioners noted improvements in 1) diagnosis of acute cardiac ischemia, 2) prevention of cancer with routine screening reminders, 3) management of chronic disease, and 4) reduction of health care costs by minimizing unnecessary diagnostic tests Systems employing automatic prompts to facilitate diagnosis, disease management, and prescribing helped improve practitioner performance and reduce medical errors

Conclusion Studies have demonstrated improvement in practitioner performance with the use of CDSSs The TCCC is a powerful internet-based database that helps provide patient-specific treatment in keeping with the ATA clinical practice guidelines based on patient and sonographic characteristics Given that the user selects from a predetermined menu of sonographic characteristics, the database helps standardize thyroid ultrasound reporting The use of CDSSs using evidence-based recommendations may help minimize potential harm from overtreatment while appropriately identifying and treating higher risk patients In addition, the graphic depiction of nodules and lymph nodes with respect to anatomic structures in a visual model helps aid preoperative planning

References Grant EG, Tessler FN, Hoang JK et-al. Thyroid Ultrasound Reporting Lexicon: White Paper of the ACR Thyroid Imaging. Reporting and Data System (TIRADS) Committee. J Am Coll Radiol. 2015;12 (12): 1272-9 Kwak JY, Han KH, Yoon JH et-al, Thyroid imaging reporting and data system for US features of nodules: a step in establishing better stratification of cancer risk. Radiology. 2011;260 (3): 892-9 Garg AX, Adhikari NK, McDonald H et-al. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. JAMA. 2005;292 (10): 1223-38 Images provided by https://www.thyroidccc.org/

Contact Information Vivian Mai-Tran, MD Mount Sinai Beth Israel Department of Radiology 16th Street at 1st Avenue New York, New York 10003 Email: ViMai-Tran@chpnet.org