RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE KARNATAKA

ANNEXURE II

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1. / Name of the candidate and address (in block letters) / Dr.J.S.KISHORE
S/O J.Venkateswarlu
29-337-1A,Saraswati Nagar
Nandyal,Andhra Pradesh.518501.
2. / Name of the Institution / J.J.M. MEDICAL COLLEGE,
DAVANGERE - 577004
3. / Course of study and subject / POST GRADUATE
M. S. in GENERAL SURGERY
4. / Date of admission to course / 31 – 5 – 2008
5. / Title of the topic / “ ROLE OF DUPLEX SONOGRAPHY IN PRE-OPERATIVE EVALUATION OF THYROID SWELLINGS AND ITS HISTOPATHOLOGICAL CORRELATION”
6. / Brief resume of the intended work:
6.1 Need for the study:
·  Thyroid swellings are one of the common problems in surgical practice. The management of thyroid nodules is multi-disciplinary and involves surgeons, pathologists and radiologists.
·  The current approach to thyroid swellings has been revolutionised with the introduction of Fine Needle Aspiration Cytology (FNAC) and Thyroid ultrasonography (USG).
·  The role of FNAC in pre-operative assessment of thyroid swellings has been well established in several studies.
·  High resolution real time Gray Scale and Color Doppler sonography of thyroid is an emerging and promising pre-operative investigatory modality for thyroid diseases at present .
·  Ultrasound is easy to perform, widely available, does not involve ionizing radiation and is readily combined with FNAC. Because of superficial location and good vascularisation of thyroid gland high resolution real time grey scale and color Doppler sonography can delineate and demonstrate the normal thyroid anatomy and pathlogical conditions with remarkable clarity.
·  It is therefore ideal investigation of choice for evaluating thyroid nodules. It can determine the nature of thyroid swelling and help in designing a rationale treatment strategy. In addition following thyroid surgery, ultrasonography provides a safe tool for disease surveillance.
·  The purpose of this study is to assess the spectrum of diseases affecting thyroid gland by color assisted duplex sonography and correlate the findings to histo-pathological outcome of the same, there by establishing efficacy of thyroid ultrasound as important adjunct in pre-operative assessment of thyroid swellings.
6.2 Review of literature:
The term Thyroid is derived from Greek word ‘thyreoeides’ meaning shield shaped. The name was given by Thomas Wharton in 1656.
Goitre is defined as enlargement of thyroid gland and has been recognized from 2007 B.C. Emil Theodor Kocher and Theodor Bilroth were the pioneers of thyroid surgery in 19th century. The progress achieved by them was consolidated and taken forward by William Halstead ,Frank Lahey and George Criles (1).
In 20th century introduction of FNAC and High Resolution Real Time Grey scale and Color Doppler Sonography revolutionalised the approach towards thyroid swellings reducing number of unnecessary surgeries and increasing the detection of ,malignancies in surgically resected nodules.
One of the earliest uses of thyroid USG was in epidemiology. It was found that volume of thyroid in grade school children closely correlates to urinary iodine excretion and thus with iodine content of diet. So thyroid USG was used by WHO to map iodine deficient areas in the world (2).
A more dramatic use of thyroid USG occurred after the Chernobyl Nuclear Accident in 1986 where USG was used to screen thyroid cancer in pre-school children in whom the cancer incidence had increased several folds following exposure (2).
A seldom mentioned use of USG is for defining anatomy of the neck. Often patients present with neck mass thought to be of thyroid origin but USG quickly and easily identifies its extra-thyroidal origin.
At present the value of USG is only exceeded by its use combined with FNA.
With the advent of high resolution probes and color Doppler , sonographic characters can be used to prioritize the nodules for FNAC (3) .USG-guided FNAC has much higher sensitivity, specificity and positive predictive value than palpation guided FNA (4) .
Mostly thyroid nodules are benign, usually as a part of multinodular changes. Clinical methods are poor at detecting small as well as posteriorly located nodules, highlighted by the fact that approximately 70% of normal thyroid glands contain nodules of less than 1cm when examined sonographically (5).
High resolution grey scale and color Doppler sonography by assessing margin, shape, echostructure, echogenicity, calcification and vascularization can judge malignant or benign nature of thryoid swelling and help in identifying the patients who genuinely require surgery (6).
Thyroid duplex sonography can also determine early local invasion and regional nodal metastasis and be useful in staging and prognosticating a case of thyroid carcinoma.
In comtemporary surgical practice, most of the patients are treated with partial or near total thyroidectomy for thyroid carcinoma. In such cases USG forms a cornerstone for surveillance and follow-up of cases.
Other thyroid disorders which would derive benefits from duplex sonography are Graves disease (7), DeQuervain’s thyroiditis (8),Congenital Hypothyroidism (9), Ectopic thyroid, Amiodarone induced thyrotoxicosis (10) etc.
Thyroid Elastography is a newly developed dynamic technique that uses USG to provide an estimation of tissue stiffness by measuring the degree of distortion under external force (11).
Thyroid Elastography is being successfully used to differentiate benign and malignant thyroid swellings, cervical lymph node metastasis (12), and investigate thyroid swellings with suspicious or indeterminate reports on FNAC.
6.3 Aims and objectives of the study:
1.  To use USG of neck to confirm clinically suspected thyroid swellings.
2.  To study the pattern of duplex sonography of confirmed thyroid swellings .
3.  To determine the nature of thyroid swellings using duplex sonogaphy.
4.  To correlate the duplex sonography findings thus obtained with histo-pathological findings in surgically resected specimens and thus demonstrate the specificity, sensitivity and efficacy of high resolution duplex sonography as a pre-operative investigatory tool for thyroid disorders.
7. Materials and methods:
7.1 Source of data:
Cases for the study will be sourced from admissions to Bapuji Hospital, Chigateri Hospital attached to J.J.M. Medical College, Davangere.
7.2 Method of data collection:
This is a time bound prospective study in which patients presenting with clinical suspicion of thyroid disease in Bapuji hospital and Chigateri hospital will be taken into study.
·  The period of study is from November 2008 to May 2010
·  A minimum of 40 cases shall be taken up for study with a scope of increasing the number of cases depending on availability with in study period
·  The study will be performed with Color Doppler ultrasound machine having high frequency (L12-3 MHz) linear transducer.
·  Obtaining a detailed history and clinical examination.
·  Relevant investigations performed on the patient.
A detailed structured proforma will be used to collect this information.
Inclusion criteria :
·  Patients with clinically suspected thyroid diseases.
·  As a pre-requisite before surgery in patients with thyroid disease.
Exclusion criteria :
·  Pregnant women with thyroid swellings.
·  Patients not willing to undergo ultrasonography
7.3 Does the study require any investigations or interventions to be conducted on patients, other humans or animals? If so, please describe briefly.
YES.
·  All patients will undergo Ultrasonography and Doppler ultrasonography as a basic tool investigation.
·  Informed consent will be taken in all cases before examination
·  Other investigations required include FNAC and Histo-Pathology following surgical resection.
7.4 Has ethical clearance been obtained from your institution in case of 7.3?
YES.
8. References:
1.  Geeta L, Orlo HC. Thyroid, Parathyroid, and Adrenal. In: Bruicardi FC, editor. Schwartz’s principles of surgery. 8th edition. NewYork: Mcgraw Hill;2005: 1395-97.
2.  Baskin JH. Thyroid ultrasound- just do it. Thyroid. 2004;14(2): 91-92.
3.  Frates MC, Benson CB, Doubilet PM, Kunreuther E, Contreras M, Cibas ES, et al. Prevalance and distribution of carcinoma in patients with solitary and multiple thyroid nodules on sonography. J Clin Endocrinol Metab.2006; 91(9): 3411-7.
4.  Izquierdo R, Arekat MR, Knudson PE, Kartun KF, Khurana K, Kort K, et al.Comparision of palpation versus ultrasound-guided fine needle aspiration biopsies of thyroid nodules in an out-patient endocrinology practice. Endocr Pract. 2006;12(6): 609-14.
5.  Wong KT, Ahuja AT. Ultrasound of thyroid cancer .Cancer Imaging.2005; 5(1): 157-166.
6.  Moon WJ, Jung SL, Lee JH, Na DG, Baek JH, Lee YH, et al.Benign and malignant thyroid nodules : US differentiation-multicenter retrospective study. Radiology. 2008;247(3): 762-70.
7.  Baldini M , Orsatti A, Bonfanti MT, Castagnone D, Cantalamessa L. Relationship between the sonographic appearance of the thyroid and clinical course and autoimmune activity of Graves’ disease. J Clin Ultrasound. 2005;33(8): 381-5.
8.  Kunz A, Blank W, Barun B. De Quervain’s subacute thyroiditis- color Doppler sonography findings. Ultraschall Med. 2005;26(2): 102-6.
9.  Ohnishi H, Sato H, Noda H, Inomata H, Sasaki N. Color Doppler ultrasonography: diagnosis of ectopic thyroid gland in patients with congenital hypothyroidism caused by thyroid dysgenesis. J Clin Endocrinol Metab. 2003;88(11): 5145-9.
10. Loy M, Perra E, Melis A, Cianchetti ME, Piga M, Serra A, et al. Color-flow Doppler sonography in differential diagnosis and management of amiodarone-induced thyrotoxicosis. Acta Radiol. 2007;48(6): 628-39.
11. Rago T, Santini F, Scutari M, Pinchera A, Vitti P. Elastography: new developments in ultrasound for predicting malignancy in thyroid nodules. J Clin Endocrinol Metab. 2007;92(8): 2917-22.
12. Lyshchik A, Higashi T, Asato R, Tanaka S, Ito J, Hiraoka M, et al. Cervical lymph node metastases : diagnosis at sonoelastography – initial experience. Radiology. 2007;243(1): 258-67.
9. / Signature of the
Candidate
10. / Remarks of the guide / The duplex sonography is a valuable investigation in evaluating thyroid nodules. This study is intended to compare sonogarphic findings with histo-pathology findings. This helps in over all management of thyroid nodule.
11. / Name and designation of
(in block letters)
11.1 Guide
11.2 Signature
11.3 Co guide (if any)
11.4 Signature
11.5 Head of Department
11.6 Signature / DR. R. M. SHEKHAR M. S.
PROFFESOR
GENERAL SURGERY
J. J. M. MEDICAL COLLEGE,
DAVANGERE – 577004
None
DR. B.PRADEEP M. S.
PROFFESOR AND HEAD OF DEPARTMENT
GENERAL SURGERY
J. J. M. MEDICAL COLLEGE,
DAVANGERE - 577004
12. / 12.1 Remarks of the
Chairman & Principal
12.2 Signature