1. 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

2. 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.

3. 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

4. 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

5. 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

6. 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:
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

7. 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

8. 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

9. 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

10. 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

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

12. 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

13. Patient-Specific Treatment
Molecular Analysis and Thyroid Specific Labs

14. 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

15. Extrathyroidal Extension
ATA Characteristics
Calcifications
Echogenicity
Contour
Extrathyroidal Extension

16. Example of Thyroid Nodule with High Suspicion

17. Example of Tumor with ETE

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

19. 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

20. 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

21. 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):
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):
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22. Contact Information
Vivian Mai-Tran, MD Mount Sinai Beth Israel Department of Radiology 16th Street at 1st Avenue New York, New York