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Objectives: There is no standardized protocol for performing educational point-of-care ultrasonography (POCUS) that addresses patient-centered ethical issues such as obtaining informed consent. This study sought to define principles for ethical application of educational POCUS and develop consensus-based best practice guidance. Methods: A questionnaire was developed by a trained ethicist after literature review with the help of a medical librarian. A diverse panel including experts in medical education, law, and bioethics; medical trainees; and individuals with no medical background was convened. The panel voted on their level of agreement with ethical principles and degree of appropriateness of behaviors in three rounds of a modified Delphi process. A high level of agreement was defined as 80% or greater consensus. Results: Panelists voted on 38 total items: 15 related to the patient consent and selection process, eight related to practices while performing educational POCUS, and 15 scenarios involving POCUS application. A high level of agreement was achieved for 13 items related to patient consent and selection, eight items related to performance practices, and 10 scenarios of POCUS application. Conclusions: Based on expert consensus, ethical best practices include obtaining informed consent before performing educational POCUS, allowing patients to decline educational POCUS, informing patients the examination is not intended to be a part of their medical evaluation and is not billed, using appropriate draping techniques, maintaining a professional environment, and disclosing incidental findings in coordination with the primary team caring for the patient. These practices could be implemented at institutions to encourage ethical use of educational POCUS when training physicians, fellows, residents, and medical students.
RESUMEN
BACKGROUND: After initial surgical treatment of differentiated thyroid cancer (DTC) residual lymph node metastases are often found at the time of radioactive iodine (131I) therapy. Recurrence of DTC is due to persistent disease not removed at initial surgery which also did not respond to 131I treatment. This study aimed at determining locations of, and reasons for, residual nodal metastases detected by 131I scans with single-photon emission computed tomography (SPECT/CT) obtained prior to radioiodine therapy following surgical treatment of DTC. METHODS: This is a retrospective study of 352 patients with intermediate and high-risk DTC treated with 131I therapy at the University of Michigan from 2007 to 2014. All patients underwent total thyroidectomy with or without lymph node dissection followed by radioiodine therapy. Pre-ablation diagnostic 131I scans with SPECT/CT were used postoperatively to localize nodal metastases, which were then compared with the cervical lymph node basins dissected at the time of surgery to determine the reason for residual nodal metastases: incomplete nodal dissection versus preoperative unrecognized nodal metastases. RESULTS: Of the 352 patients in the study, 146 (41.5%) had residual nodal metastases detected on 131I scans with SPECT/CT following initial surgery but prior to 131I therapy. Among the 146 patients with residual disease, there were a total of 218 distinct nodal metastases. Relative to the primary tumor, 71.6% (n = 156) of metastases were ipsilateral, 22.0% (n = 48) were contralateral, and 6.4% (n = 14) were non-sided in the central neck (level VI/VII). Cervical lymph node levels VI, III, and II had the greatest frequencies of residual metastases (33.9%, 22.9%, 18.8%, respectively). Residual metastases occurred because of incomplete nodal dissection (49.3%), lack of preoperative identification (37.7%), or a combination of both (13%). CONCLUSION: Residual nodal metastasis following initial surgical treatment for regionally advanced differentiated thyroid cancer is rather common on highly sensitive 131I scans with SPECT/CT and is due to both unrecognized nodal involvement preoperatively and incomplete removal of metastatic lymph nodes during compartment-orientated nodal dissection. The surgical management of high-risk DTC should include preoperative imaging to evaluate for nodal metastases in the central and lateral neck and compartment-orientated nodal dissection of involved compartments. Attention should be given to complete dissection in levels VI, III, and II, particularly when dissecting compartments ipsilateral to the primary tumor.
