Cost analysis of thyroid lobectomy and intraoperative frozen section versus total thyroidectomy in patients with a cytologic diagnosis of “suspicious for papillary thyroid cancer”

Cost-Effectiveness of the ACR TIRADS Compared to the ATA 2015 Risk Stratification Systems in the Evaluation of Incidental Thyroid Nodules

RATIONALE AND OBJECTIVES

Thyroid nodules are a common incidental imaging finding and prone to overdiagnosis. Several risk stratification systems have been developed to reduce unnecessary work-up, with two of the most utilized including the American Thyroid Association 2015 (ATA2015) and the newer American College of Radiology Thyroid Imaging, Reporting and Data System (TIRADS) guidelines. The purpose of this study is to evaluate the cost-effectiveness of the ATA2015 versus the TIRADS guidelines in the management of incidental thyroid nodules.

METHODS

A cost-utility analysis was conducted using decision tree modeling, evaluating adult patients with incidental thyroid nodules < 4 cm. Model inputs were populated using published literature, observational data, and expert opinion. Single-payer perspective, Canadian dollar currency, five-year time horizon, willingness to pay (WTP) threshold of $50,000, and discount rate of 1.5% per annum were utilized. Scenario, deterministic and probabilistic sensitivity analyses were performed. The primary outcome was the incremental cost-effectiveness ratio (ICER) expressed as incremental cost per quality-adjusted life year (QALY) gained.

RESULTS

For the base case scenario, TIRADS dominated the ATA2015 strategy by a slim margin, producing 0.005 more QALYs at $25 less cost. Results were sensitive to the malignancy rate of biopsy and the utilities of a patient with a benign nodule/subclinical malignancy or under surveillance. Probabilistic sensitivity analysis showed that TIRADS was the more cost-effective option 79.7% of the time.

CONCLUSION

The TIRADS guidelines may be the more cost-effective strategy by a small margin compared to ATA2015 in most scenarios when used to risk stratify incidental thyroid nodules.

Cost-effectiveness of active surveillance versus early surgery for thyroid micropapillary carcinoma based on diagnostic and treatment norms in China

Objectives

In this study, we compared the cost-effectiveness comparison of the active surveillance (AS) and early surgery (ES) approaches for papillary thyroid microcarcinoma (PTMC) from the perspective of the Chinese healthcare system.

Methods

We performed a cost-effectiveness analysis using a Markov model of PTMC we developed to evaluate the incremental cost-effectiveness ratio of AS and ES. Our reference case was of a 40-year-old woman diagnosed with unifocal (<10 mm) PTMC. Relevant data were extracted after an extensive literature review, and the cost incurred in each state was determined using China Medicare data on payments for ES and AS. The willingness-to-pay threshold was set at ¥242,928/quality-adjusted life-year (QALY) gained. Sensitivity analyses were performed to account for any uncertainty in the model's variables. Additional subgroup analyses were performed to determine whether AS was cost-effective when different initial monitoring ages were used.

Results

ES exhibited an effectiveness of 5.2 QALYs, whereas AS showed an effectiveness of 25.8 QALYs. Furthermore, the incremental cost-effectiveness ratio for ES versus AS was ¥1,009/QALY. The findings of all sensitivity analyses were robust. Compared with ES, AS was found to be the cost-effective strategy at initial monitoring ages of 20 and 60 years, with an incremental cost-effectiveness ratio of ¥3,431/QALY and -¥1,316/QALY at 20 and 60 years, respectively. AS was a more cost-effective strategy in patients with PTMC aged more than 60.

Conclusions

With respect to the norms of the Chinese healthcare system, AS was more cost-effective for PTMC over lifetime surveillance than ES. Furthermore, it was cost-effective even when the initial monitoring ages were different. In addition, if AS is incorporated into the management plan for PTMC in China at the earliest possible stage, a predicted savings of ¥10 × 108/year could be enabled for every 50,000 cases of PTMC, which indicates a good economic return for future management programs. The identification of such nuances can help physicians and patients determine the best and most individualized long-term management strategy for low-risk PTMC.

Strategies for Treatment of Thyroid Cancer

More people are diagnosed with thyroid cancer than any other endocrine tumor. Differentiated thyroid cancer is often treated by removing the thyroid gland (thyroidectomy), iodizing radiation, or inhibiting thyroid stimulating hormone (TSH). Advanced thyroid carcinomas are notoriously resistant to chemotherapy, thus the pursuit of alternative treatments is vital. The best methods for treating individuals with advanced nonmedullary and medullary thyroid carcinomas are discussed in this post. Numerous tyrosine kinase inhibitors and antiangiogenic inhibitors, two types of novel target therapy, have shown promise in studies for individuals with thyroid cancer. Both the positive and unfavourable outcomes of clinical studies of these drugs were addressed. The findings presented here are encouraging, but more study is required to establish whether or not this method is effective in the treatment of thyroid cancer.

If the price is right: Cost-effectiveness of radiofrequency ablation versus thyroidectomy in the treatment of benign thyroid nodules

BACKGROUND

Radiofrequency ablation is an emerging technology in the United States to treat benign thyroid nodules. The cost-effectiveness of radiofrequency ablation in comparison with traditional thyroidectomy is unknown.

METHODS

A patient-level state transition microsimulation decision model was constructed comparing radiofrequency ablation with lobectomy in the management of benign thyroid nodules. Our base case was a 45-year-old woman with a solitary 30-cm³ nodule. Estimates of health utilities, complications, and mortality were obtained from the literature, and costs were estimated using Medicare reimbursement data. The primary outcomes of interest included total cost, quality-adjusted life years, and incremental cost-effectiveness ratios. All model estimates were subjected to 1-way sensitivity analyses to identify factors that strongly influence cost-effectiveness. A probabilistic sensitivity analysis was run across 1 million simulations to gauge outcome confidence with a willingness-to-pay threshold set at $100,000/quality-adjusted life year.

RESULTS

Radiofrequency ablation was assumed to cost $5,000, with an initial success rate of 78%. Patients with volume reduction ratio <50% underwent a second treatment of radiofrequency ablation. Radiofrequency ablation represented the dominant strategy, yielding 21.31 quality-adjusted life years for a total cost of $16,563 in comparison to lobectomy, which yielded 21.13 quality-adjusted life years for a total cost of $19,262. In a 1-way sensitivity analysis varying the cost of radiofrequency ablation across of range of values, the radiofrequency ablation strategy remained cost-effective until the cost of radiofrequency ablation exceeded $12,330 at willingness-to-pay $50,000 or $17,950 at willingness-to-pay $100,000.

CONCLUSION

Radiofrequency ablation is a cost-effective strategy in the treatment of benign thyroid nodules but is most sensitive to the cost of radiofrequency ablation.

Cost-Effectiveness Analysis of Ultrasound Screening for Thyroid Cancer in Asymptomatic Adults

Objectives: This study evaluated the long-term cost-effectiveness of ultrasound screening for thyroid cancer compared with non-screening in asymptomatic adults.

Methods: Applying a Markov decision-tree model with effectiveness and cost data from literature, we compared the long-term cost-effectiveness of the two strategies: ultrasound screening and non-screening for thyroid cancer. A one-way sensitivity analysis and a probabilistic sensitivity analysis were performed to verify the stability of model results.

Results: The cumulative cost of screening for thyroid cancer was $18,819.24, with 18.74 quality-adjusted life years (QALYs), whereas the cumulative cost of non-screening was $15,864.28, with 18.71 QALYs. The incremental cost-effectiveness ratio of $106,947.50/QALY greatly exceeded the threshold of $50,000. The result of the one-way sensitivity analysis showed that the utility values of benign nodules and utility of health after thyroid cancer surgery would affect the results.

Conclusions: Ultrasound screening for thyroid cancer has no obvious advantage in terms of cost-effectiveness compared with non-screening. The optimized thyroid screening strategy for a specific population is essential.

Thyroid lobectomy as a cost-effective approach in low-risk papillary thyroid cancer versus active surveillance

BACKGROUND

An ongoing debate exists over the optimal management of low-risk papillary thyroid cancer. The American Thyroid Association supports the concept of active surveillance to manage low-risk papillary thyroid cancer; however, the cost-effectiveness of active surveillance has not yet been established. We sought to perform a cost-effectiveness analysis comparing active surveillance versus surgical intervention for patients in the United States.

METHODS

A Markov decision tree model was developed to compare active surveillance and thyroid lobectomy. Our reference case is a 40-year-old female who was diagnosed with unifocal (<15 mm), low-risk papillary thyroid cancer. Probabilistic outcomes, costs, and health utilities were determined using an extensive literature review. The willingness-to-pay threshold was set at $50,000/quality-adjusted life year gained. Sensitivity analyses were performed to account for uncertainty in the model's variables.

RESULTS

Lobectomy provided a final effectiveness of 21.7/quality-adjusted life years, compared with 17.3/quality-adjusted life years for active surveillance. Furthermore, incremental cost effectiveness ratio for lobectomy versus active surveillance was $19,560/quality-adjusted life year (<willing-to-pay threshold of $50,000/quality-adjusted life year), and thus surgical intervention proved to be cost-effective in patients between 40 and 69 years old. Further analysis revealed that, at the age of 69 years, active surveillance is more cost-effective than lobectomy, with a final effectiveness of 17.3/quality-adjusted life years. Compared to active surveillance, the incremental cost effectiveness ratio for lobectomy at the age of 69 was $27,235/quality-adjusted life year, which decreases quality-adjusted life years by 1.5.

CONCLUSION

Lobectomy is a cost-effective strategy in middle-aged patients with low-risk papillary thyroid cancer. In contrast, active surveillance is cost-effective beginning at the age of 69. Identification of such nuances can help physicians and patients determine the best, most individualized long-term management strategy for low-risk papillary thyroid cancer.

Thyroid cancer, recent advances in diagnosis and therapy

Over the past several decades, the approach to the diagnosis and management of patients with follicular cell-derived thyroid cancer has evolved based on improved classification of patients better matching clinical outcomes, as well as advances in imaging, laboratory, molecular technologies and knowledge. While thyroid surgery, radioactive iodine therapy and TSH suppression remain the mainstays of treatment, this expansion of knowledge has enabled de-escalation of therapy for individuals diagnosed with low-risk well-differentiated thyroid cancer; better definition of treatment choices for patients with more aggressive disease; and improved ability to optimize treatments for patients with persistent and/or progressive disease. Most recently, the advancement of knowledge regarding the molecular aspects of thyroid cancer has improved thyroid cancer diagnosis and has enabled individualized therapeutic options for selected patients with the most aggressive forms of the disease. Guidelines from multiple societies across the world reflect these changes, which focus on taking a more individualized approach to clinical management. In this review, we discuss the current more personalized approach to patients with follicular cell-derived thyroid cancer and point toward areas of future research still needed in the field.

Preoperative ultrasound characteristics in determining the likelihood of cytologically confirmed (Bethesda VI), 1-4 cm papillary thyroid tumours requiring completion thyroidectomy

BACKGROUND

Papillary thyroid carcinoma (PTC) is the most commonly diagnosed differentiated thyroid carcinoma. There is controversy about performing upfront lobectomy vs thyroidectomy for smaller well differentiated thyroid carcinoma.

METHODS

A retrospective study from 2015 to 2020 was conducted consisting of consecutive patients with a preoperative malignant (Bethesda VI) cytology on fine needle aspirate (FNA) consistent with PTC. Specific ultrasonographic features such as taller than wide, hypoechogenicity, irregular margins, internal vascularity and microcalcifications were recorded. Criteria for exclusion was the presence of positive lymph nodes, extrathyroidal extension, familial thyroid carcinoma and bilateral disease detected preoperatively. Outcome was defined as a lobectomy being adequate treatment or a completion thyroidectomy recommended based on current 2015 ATA guidelines.

RESULTS

Preoperative malignant cytological nodules (Bethesda VI) with irregular margins on sonography were significantly (p = 0.025) at increased risk (OR = 2.48) of requiring a completion thyroidectomy. There was also no statistically significant difference between groups when stratified by size with 50% of tumours between 1 and 2 cm requiring a completion thyroidectomy.

CONCLUSIONS

The presence of irregular margins on ultrasound predicts an increased risk of requiring a completion thyroidectomy. Specific consideration of this sonographic finding should be made when counselling patients who have cytologically confirmed papillary thyroid carcinoma regarding the best choice of thyroid operation.

Cost-effectiveness of computed tomography nodal scan in patients with papillary thyroid carcinoma

OBJECTIVES

This study evaluates the cost-effectiveness of ultrasound (US) only; computed tomography (CT) only; and combined US-CT in a base-case that underwent total thyroidectomy for a newly diagnosed papillary thyroid carcinoma (PTC) (scenario I) or surgery for recurrent disease (scenario II).

MATERIALS AND METHODS

Markov chain model was developed comparing the above modalities. Follow-up time was set as 10 years. Costs and probabilities values are obtained from literature and the National Cancer Database.

RESULTS

Nodal mapping of the central compartment in both primary and recurrent PTC scenarios demonstrated combined utilization of preoperative US and CT is preferred over the use of US or CT separately; the final incurred management cost was [scenario I: U.S.$10,548.25 - scenario II: U.S.$11.197.88] and effectiveness was [scenario I: 6.875 Quality-adjusted-life-year (QALY) - scenario II: 6.871 QALY]. Nodal mapping of the lateral compartments favored US alone as the cost-effective modality in both scenarios; the final incurred management cost was [scenario I: U.S.$10,716.60 - scenario II: U.S.$11,247.92] and effectiveness was [scenario I: 6.879 QALY - scenario II: 6.883 QALY]. Sensitivity analysis demonstrated that for combined utilization of US and CT scans to remain cost-effective, the cost of a CT scan should be less than U.S.$1,127.54.

CONCLUSIONS

Based on the model, combined utilization of US and CT is cost-effective in nodal mapping patients with PTC.

Differentiated Thyroid Cancer: A Health Economic Review

Simple Summary

This review reflects on health economic considerations associated with the increasing diagnosis and treatment of differentiated thyroid cancer. Analysis of different relevant health economic topics, such as overdiagnosis, overtreatment, surgical costs, and costs of follow-up are being addressed. Several unanswered research questions such as optimising molecular markers for diagnosis, active surveillance of primary tumours, and improved risk stratification and survivorship care all influence future healthcare expenditures.

Abstract

The incidence of differentiated thyroid cancer (DTC) is rising, mainly because of an increased detection of asymptomatic thyroid nodularity revealed by the liberal use of thyroid ultrasound. This review aims to reflect on the health economic considerations associated with the increasing diagnosis and treatment of DTC. Overdiagnosis and the resulting overtreatment have led to more surgical procedures, increasing health care and patients’ costs, and a large pool of community-dwelling thyroid cancer follow-up patients. Additionally, the cost of thyroid surgery seems to increase year on year even when inflation is taken into account. The increased healthcare costs and spending have placed significant pressure to identify potential factors associated with these increased costs. Some truly ground-breaking work in health economics has been undertaken, but more cost-effectiveness studies and micro-cost analyses are required to evaluate expenses and guide future solutions.

Hemithyroidectomy for Thyroid Cancer: A Review

Thyroid cancer incidence is on the rise; however, fortunately, the death rate is stable. Most persons with well-differentiated thyroid cancer have a low risk of recurrence at the time of diagnosis and can expect a normal life expectancy. Over the last two decades, guidelines have recommended less aggressive therapy for low-risk cancer and a more personalized approach to treatment of thyroid cancer overall. The American Thyroid Association (ATA) and National Comprehensive Cancer Network (NCCN) thyroid cancer guidelines recommend hemithyroidectomy as an acceptable surgical treatment option for low-risk thyroid cancer. Given this change in treatment paradigms, an increasing number of people are undergoing hemithyroidectomy rather than total or near-total thyroidectomy as their primary surgical treatment of thyroid cancer. The postoperative follow-up of hemithyroidectomy patients differs from those who have undergone total or near-total thyroidectomy, and the long-term monitoring with imaging and biomarkers can also be different. This article reviews indications for hemithyroidectomy, as well as postoperative considerations and management recommendations for those who have undergone hemithyroidectomy.

Cost-effectiveness of routine calcitonin screening and fine-needle aspiration biopsy in preoperative diagnosis of medullary thyroid Cancer in the United States

OBJECTIVES

examine the cost-effectiveness of routine Calcitonin (Ctn) screening test in the United States.

MATERIALS AND METHODS

Markov chain model was developed that compares fine-needle aspiration biopsy (FNAB) with Ctn screening vs. FNAB-only in the evaluation of a thyroid nodule with non-highly suspicious findings. Follow-up time was set as 10 years. Costs and probabilities values were obtained from literature, and National Cancer Database. Cost data is expressed in U.S$ and effectiveness is expressed in Quality-adjusted-life-year (QALY). Incremental cost-effectiveness ratio (ICER) was calculated comparing both study arms.

RESULTS

Routine Ctn screening was cost-effective compared to FNAB-only in all tested categories except when cutoff value of 10 pg/ml was applied. Among the tested categories, the application of universal routine Ctn screening with Ctn value > 50 pg/ml considered a positive test produced the most cost-saving scenario. The final accrued cost at the end of 10 years in the FNAB-only arm was $4238.93 with a final effectiveness of 8.717 QALY. While the final cost in the FNAB-with routine Ctn screening was $4345.04 with a final effectiveness of 8.722 QALY. ICER of routine Ctn screening compared to FNAB-only was $23278.61/QALY (<Willing-To-Pay threshold of $50,000/QALY). Based on sensitivity analyses, Ctn testing is cost-effective if the test cost is less than $236.03.

CONCLUSIONS

Routine Ctn screening is a cost-effective strategy in US if the cost is less than $236.03. Although Ctn screening is not perfect in detecting MTC at early stages, it is a cost-effective alternative of discovering MTC after thyroid lobectomy or on follow-up of a thyroid nodule.

Is Less More? A Microsimulation Model Comparing Cost-effectiveness of the Revised American Thyroid Association's 2015 to 2009 Guidelines for the Management of Patients With Thyroid Nodules and Differentiated Thyroid Cancer

OBJECTIVE

To assess relative clinical and economic performance of the revised American Thyroid Association (ATA) thyroid cancer guidelines compared to current standard of care.

BACKGROUND

Diagnosis of thyroid cancer in the United States has tripled whereas mortality has only marginally increased. Most patients present with small papillary carcinomas and have historically received at least a total thyroidectomy as a treatment. In 2015, the ATA released the revised guidelines recommending an option for active surveillance (AS) of small papillary thyroid carcinoma and thyroid lobectomy for larger unifocal tumors.

METHODS

We created a Markov microsimulation model to evaluate the performance of the ATA's 2015 guidelines compared to the ATA's 2009 guidelines. We modeled a cohort of simulated patients with demographic and thyroid nodule characteristics representative of those presenting clinically in the United States. Outcome measures include life expectancy, quality-adjusted life years, costs, and frequency of surgical adverse events.

RESULTS

In our base case analysis, the ATA 2015 strategy dominates the ATA 2009 strategy. The ATA 2015 strategy delivers greater discounted average quality-adjusted life years (13.09 vs 12.43) at a lower discounted average cost ($14,752 vs $20,126). Deaths due to thyroid cancer under the 2015 strategy are higher than the 2009 strategy but this is offset by a reduction in surgical deaths, leading to greater average life expectancy under the ATA 2015 strategy. The optimal strategy is sensitive to patients who experience a greater decrement in quality of life while undergoing AS.

CONCLUSIONS

The ATA 2015 Guidelines represent a cost-effective strategy regarding AS and extent of surgery.

Total Thyroidectomy Versus Lobectomy in Small Nodules Suspicious for Papillary Thyroid Cancer: Cost-Effectiveness Analysis

OBJECTIVES/HYPOTHESIS

Recent American Thyroid Association Guidelines recommend either near-total/total thyroidectomy or lobectomy for patients with a thyroid nodule suspicious for papillary thyroid cancer (PTC) on fine-needle aspiration (FNA) biopsy (Bethesda V). In this analysis, we aim to assess the cost-effectiveness of lobectomy in comparison to total thyroidectomy.

STUDY DESIGN

Cost-effectiveness analysis.

METHODS

A Markov model cost-effectiveness analysis was performed for a base case followed for 20 years postoperatively. Cost and probabilities data were retrieved from the current literature. Effectiveness was represented by quality-adjusted life year (QALY).

RESULTS

Total thyroidectomy protocol produced an incremental cost of $2,681.36 and incremental effectiveness of -0.24 QALY as compared to lobectomy protocol (incremental cost-effectiveness ratio [ICER] = -$11,188.85/QALY). Sensitivity analysis demonstrated that total thyroidectomy becomes a cost-effective strategy only if the risk of stages III and IV PTC is 82.4% among patients with suspicious PTC on preoperative FNA. Lobectomy is cost effective and preferred over total thyroidectomy as long as lobectomy complications are less than 50%.

CONCLUSIONS

Total thyroidectomy is not just cost prohibitive but also associated with a lower effectiveness compared to lobectomy.

LEVEL OF EVIDENCE

2c Laryngoscope, 2020.

Need for Completion Thyroidectomy in Patients Undergoing Lobectomy for Indeterminate and High-Risk Nodules: Impact of Intra-Operative Findings and Final Pathology

INTRODUCTION

Current guidelines increasingly suggest the use of thyroid lobectomy for indeterminate (Bethesda 3 and 4) and high-risk (Bethesda 5 and 6) thyroid nodules; however, the clinical reality is often very different.

MATERIALS AND METHODS

The aim of this study was to determine the rate of completion thyroidectomy (CTx) for indeterminate and high-risk thyroid nodules which are pre-operatively classified as suitable for unilateral resection (lobe eligible) based on current guidelines. Seven hundred consecutive patients with thyroid nodules and FNA cytology over four years (2015-2018) were reviewed.

RESULTS

Distribution of the dominant nodules by Bethesda was: non-diagnostic 3.9%, benign 28.1%, atypia of unknown significance 19.0%, follicular neoplasm 23.6%, suspicious for malignancy 6.1% and malignancy 19.3%. Of 298 indeterminate nodules, 68.8% (205/298) had relative but independent indications for a total thyroidectomy (TTx) and the remainder were candidates for lobectomy. For these lobe eligible patients, the overall risk of ultimately needing a TTx was 19.4% (18/93), comprising 4.3% (4/93) from intra-operative findings and 15.7% (14/89) from final pathology. Similarly, of 170 high-risk nodules, 63.5% (108/170) had upfront indications for a TTx and the remaining 62 nodules were lobe eligible. Of the patients taken to the operating room for a lobectomy, 21.0% (13/62) were upgraded to a TTx intra-operatively and 26.5% (13/49) post-operatively. The lobe success rate for indeterminate nodules was 25.2% and for high-risk nodules was 21.2%. The rate of CTx, or the proportion of patients needing a second operation was 15.7% (14/89) and 26.5% (13/49), respectively.

CONCLUSIONS

In counselling a patient for surgery, the risk of needing a more radical initial procedure or second surgery needs to be accurately explained. There are three points of care that can influence operative strategy, pre-operatively by way of high-risk clinical factors, intra-operatively via anatomical findings and post-operatively in response to unrecognized pathological features. Additionally, the patient's personal value judgment and level of risk aversion should be taken into consideration.

Extent of Surgery for Low-Risk Differentiated Thyroid Cancer

Although the incidence of thyroid cancer is increasing, survival remains unchanged. Due to concern for overtreatment, surgical management of thyroid cancer has evolved. Papillary thyroid microcarcinoma measuring 1 cm or smaller are considered very low risk and can be managed with either thyroid lobectomy or active surveillance. Total thyroidectomy is no longer recommended for these cancers unless there is evidence of metastasis, local invasion, or aggressive disease. Recommendations for low-risk differentiated thyroid cancer measuring 1 cm to 4 cm remain controversial. This article explores the controversies over the extent of surgery for patients with very low-risk and low-risk differentiated thyroid cancer.

Lymph Node Metastases Papillary Thyroid Carcinoma and their Importance in Recurrence of Disease

Background

The purpose of this study is to establish whether the lymph node metastases of the papillary thyroid carcinoma are a significant factor in recurrence of the disease by analyzing the time until recurrence of the disease and frequency of recurrence of the disease.

Methods

From 1 January 1995 until 30 June 2017, 102 patients were treated at the Public Health Institute Hospital “Sveti Vracevi” in Bijeljina for PTC. In all patients, surgery of the thyroid gland and/or lymph nodes of the neck was performed. Total thyroidectomy (TT) was performed in 20 patients and near-total thyroidectomy leaving <1 g thyroid tissue adjacent to the recurrent laryngeal nerve in 7 patients. TT and lymph nodes dissection were performed in 71 patients. Palliative surgery and biopsy due to locally advanced disease were performed in 3 patients.

Results

In our study, 102 patients with PTC were analyzed. 82 patients experienced pure PTC (80.4%), the other 20 patients (19.6%) experienced other variants of PTC. 24 patients (23.5%) experienced multi centric or bilateral tumors. 71 patients (69.6%) experienced histologically verified metastases in the lymph nodes of the neck. 7 patients (6.8%) experienced distant metastases. 20 patients underwent total thyroidectomy (TT), and 7 near-total thyroidectomy. Total thyroidectomy + dissection of central and lower jugular lymph nodes with frozen section histopathology verification was performed in 71 patients (69.6%). Out of these 71 patients, in 50 patients (70.4%) metastases were verified in the lower jugular lymph nodes. A modified lymph node dissection (MRND) was also performed in these patients.

Conclusion

Lymph node metastases of the papillary thyroid carcinoma are a plausible prognostic factor. They are important for recurrence of the disease, but not for survival.

Utility of Intraoperative Frozen Section in Large Thyroid Nodules

OBJECTIVE

To determine if the routine use of intraoperative frozen section (iFS) results in cost savings among patients with nodules >4 cm with nonmalignant cytology undergoing a thyroid lobectomy.

STUDY DESIGN

Case series with chart review; cost minimization analysis.

SETTING

Single academic center.

SUBJECTS AND METHODS

Records were reviewed on a consecutive sample of 48 patients with thyroid nodules >4 cm and nonmalignant cytology who were undergoing thyroid lobectomy in which iFS was performed between 2010 and 2015. A decision tree model of thyroid lobectomy with iFS was created. Comparative parameters were obtained from the literature. A cost minimization analysis was performed comparing lobectomy with and without iFS and the need for completion thyroidectomy with costs estimated according to 2014 data from Medicare, the Bureau of Labor Statistics, and the Nationwide Inpatient Sample.

RESULTS

The overall malignancy rate was 25%, and 33% of these malignancies were identified intraoperatively. When the malignancy rates obtained from our cohort were applied, performing routine iFS was the less costly scenario, resulting in a savings of $486 per case. When the rate of malignancy identified on iFS was adjusted, obtaining iFS remained the less costly scenario as long as the rate of malignancies identified on iFS exceeded 12%. If patients with follicular lesions on cytology were excluded, 50% of malignancies were identified intraoperatively, resulting in a savings of $768 per case.

CONCLUSIONS

For patients with nodules >4 cm who are undergoing a diagnostic lobectomy, the routine use of iFS may result in decreased health care utilization. Additional cost savings could be obtained if iFS is avoided among patients with follicular lesions.

Cost Effectiveness of Routine Laryngoscopy in the Surgical Treatment of Differentiated Thyroid Cancer

BACKGROUND

Some surgeons perform flexible fiberoptic laryngoscopy (FFL) in all patients prior to thyroid cancer operations. Given the low likelihood of recurrent laryngeal nerve (RLN) or aerodigestive invasion in clinically low-risk thyroid cancers, the value of routine FFL in this group is controversial. We hypothesized that routine preoperative FFL would not be cost effective in low-risk differentiated thyroid cancer (DTC).

METHODS

A decision model was constructed comparing preoperative FFL versus surgery without FFL in a clinical stage T2 N0 DTC patient without voice symptoms. Total thyroidectomy and definitive hemithyroidectomy were both modeled as possible initial surgical approaches. Outcome probabilities and their corresponding utilities were estimated via literature review, and costs were estimated using Medicare reimbursement data. Sensitivity analysis was conducted to examine the uncertainty of cost, probability, and utility estimates in the model.

RESULTS

When the initial surgical strategy was total thyroidectomy, routine preoperative FFL produced an incremental cost of $183 and an incremental effectiveness of 0.000126 quality-adjusted life-years (QALYs). The incremental cost-effectiveness ratio (ICER) for routine FFL prior to total thyroidectomy was $1.45 million/QALY, exceeding the $100,000/QALY threshold for cost effectiveness. Routine FFL became cost effective if the preoperative probability of asymptomatic vocal cord paralysis increased from 1.0% to 4.9%, or if the cost of preoperative FFL decreased from $128 to $27. Changing the extent of initial surgery to hemithyroidectomy produced a higher ICER for routine FFL of $1.7 million/QALY.

CONCLUSION

Routine preoperative FFL is not cost effective in asymptomatic patients with sonographically low-risk DTC, regardless of the initial planned extent of surgery.

Economic Impact of Frozen Section for Thyroid Nodules with "Suspicious for Malignancy" Cytology

Objective To perform a cost analysis of the routine use of intraoperative frozen section (iFS) among patients undergoing a thyroid lobectomy with "suspicious for malignancy" (SUSP) cytology in the context of the 2015 American Thyroid Association guidelines. Study Design Case series with chart review; cost minimization analysis. Setting Academic. Subjects and Methods Records were reviewed for patients with SUSP cytology who underwent thyroid surgery between 2010 and 2015 in which iFS was utilized. The diagnostic test performance of iFS and the frequency of indicated completion/total thyroidectomies based on the 2015 guidelines were calculated. A cost minimization analysis was performed comparing lobectomy, with and without iFS, and the need for completion thyroidectomy according to costs estimated from 2014 data from Medicare, the Bureau of Labor Statistics, and the Nationwide Inpatient Sample. Results Sixty-five patients met inclusion criteria. The malignancy rate was 61.5%, 45% of which was identified intraoperatively. The specificity and positive predictive value were 100%. The negative predictive value and sensitivity were 83% and 95%, respectively. Completion/total thyroidectomy was indicated for 9% of patients; 83% of these individuals had findings on iFS that would have changed management intraoperatively. Application of the new guidelines would have resulted in a significant reduction in the frequency of conversion to a total thyroidectomy when compared with the actual management (26.1% vs 7.7%, P = .005). Performing routine iFS was the less costly scenario, resulting in a savings of $474 per case. Conclusion For patients with SUSP cytology undergoing lobectomy, routine use of iFS would result in decreased health care utilization.

Cost-effectiveness of intraoperative nerve monitoring in avoidance of bilateral recurrent laryngeal nerve injury in patients undergoing total thyroidectomy

Background

Intraoperative nerve monitoring (IONM) provides dynamic neural information and is recommended for high-risk thyroid surgery. In this analysis, the cost-effectiveness of IONM in preventing bilateral recurrent laryngeal nerve (RLN) injury was investigated.

Methods

A Markov chain model was constructed based on IONM use. The base-case patient was defined as a 40-year-old woman presenting with a 4·1-cm left-sided papillary thyroid cancer who developed RLN injury with loss of monitoring signal during planned bilateral thyroidectomy. It was hypothesized that, if the surgeon had used IONM, the RLN injury would have been detected and the operation would have been concluded as a thyroid lobectomy to avoid the risk of contralateral RLN injury. Cost in US dollars was converted to euros; probabilities and utility scores were identified from the literature and government resources. Length of follow-up was set as 20 years, and willingness-to-pay (WTP) as €38 000 (US $50 000) per quality-adjusted life-year (QALY).

Results

At the end of year 20, the not using IONM strategy accrued €163 995·40 (US $215 783·43) and an effectiveness of 14·15 QALYs, whereas use of the IONM strategy accrued €170 283·68 (US $224 057·48) and an effectiveness of 14·33 QALYs. The incremental cost–effectiveness ratio, comparing use versus no use of IONM, was €35 285·26 (US $46 427·97) per QALY, which is below the proposed WTP, indicating that IONM is the preferred and cost-effective management plan. A Monte Carlo simulation test that considered variability of the main study factors in a hypothetical sample of 10 000 patients showed IONM to be the preferred strategy in 85·8 per cent of the population.

Conclusion

Use of IONM is cost-effective in patients undergoing bilateral thyroid surgery.

Thyroid nodules and cancer management guidelines: comparisons and controversies

Thyroid cancer is an increasingly prevalent malignancy throughout the world. Management guidelines for both thyroid nodules and thyroid cancer have been published and updated by a number of societies internationally. All of these guidelines recognize this increasing incidence, particularly of small papillary thyroid cancers, due in part to improved technology enabling early or even 'over' diagnosis. Recent advances in molecular imaging and molecular methods have been developed to better characterize thyroid nodules, and a number of studies that have clarified risk stratification systems that can be modified over time allow for individualization of diagnosis, initial treatment, and subsequent follow-up strategies. Advances in surgical approaches and new treatments for patients with the most aggressive forms of thyroid cancer have all influenced management guidelines. Despite substantial similarities, there also are important differences between recent guidelines for some of the common clinical scenarios encountered by physicians in clinical practice. In the present manuscript, we will highlight similarities and differences between several of the most recently published guidelines focused on key areas of importance to clinical care and controversy. These are key areas for future research to strengthen the data to support future guideline recommendations.

Frequency of High-Risk Characteristics Requiring Total Thyroidectomy for 1-4 cm Well-Differentiated Thyroid Cancer

BACKGROUND

The extent of thyroidectomy for low-risk well-differentiated thyroid cancer (WDTC) remains controversial. Historically, total thyroidectomy (TT) has been recommended for WDTC ≥1 cm in size. However, recent National Comprehensive Cancer Network and American Thyroid Association guidelines recognize unilateral thyroid lobectomy as a viable alternative for 1-4 cm cancers due to their otherwise favorable prognosis, with TT remaining the preferred option for tumors with unfavorable pathological characteristics. This study sought to determine how often a completion TT would be recommended based on these guidelines if lobectomy was initially performed in patients with 1-4 cm WDTC without preoperatively known risk factors.

METHODS

Patients who underwent thyroidectomy for 1-4 cm WDTC (January 2000 to January 2010) were retrospectively reviewed. Patients with preoperatively known high-risk characteristics, including gross extrathyroidal extension (ETE) on preoperative imaging, clinically apparent lymph node metastases, distant metastases, history of radiation, and positive family history, were excluded. The pathology specimens from the cancer-containing lobe were evaluated for features that would lead to a recommendation for TT based on current guidelines, including aggressive histology, vascular invasion, microscopic ETE, positive margins, and any positive lymph nodes within the specimen.

RESULTS

Of 1000 consecutive patients operated for WDTC, 287 would have been eligible for lobectomy as the initial operation. The mean age in this cohort was 45 years, and 80% were women. Aggressive tall-cell variant histology was found in one patient (0.5%), angio-invasion in 34 (12%), ETE in 48 (17%), positive margins in 51 (18%), and positive lymph nodes in 49 (18%) patients. Completion TT would have been recommended in 122/287 (43%) patients. Even in those with 1-2 cm cancers, completion TT would have been recommended in 52/143 (36%) patients.

CONCLUSIONS

Nearly half of the patients with 1-4 cm WDTC who are eligible for lobectomy under current guidelines would require completion TT based on pathological characteristics of the initial lobe. Surgeons, endocrinologists, and patients need to balance the relative benefits, risks, and costs of initial TT versus the possible need for reoperative completion TT.

Analysis of an institutional protocol for thyroid lobectomy: Utility of routine intraoperative frozen section and expedited (overnight) pathology

BACKGROUND

Intraoperative frozen section (FS) often is performed in patients who undergo thyroid lobectomy to determine the need for completion thyroidectomy. At our institution, if FS pathology is benign, final pathology is expedited overnight. The aim of this study was to determine the utility of FS and to identify a cost-effective management algorithm for thyroid lobectomy.

METHODS

A retrospective review was performed of patients who underwent thyroid lobectomy between January 2009 and May 2013. Preoperative cytology ranged from "benign" to "suspicious for malignancy." Clinically significant cancers were defined as >1 cm in size, or multifocal microcarcinomas.

RESULTS

Of the 192 patients who underwent thyroid lobectomy with FS, FS was suspicious for malignancy in 5 (3%) patients; 1 (0.5%) underwent immediate completion thyroidectomy. On final pathology, 9 (5%) patients had clinically significant cancers and underwent completion thyroidectomy. FS had a sensitivity and positive predictive value of 22% and 40%, respectively, in identifying clinically significant thyroid cancer. Cost of thyroid lobectomy at varying rates of same-day discharge favored thyroid lobectomy without FS but with expedited pathology for all scenarios.

CONCLUSION

At our institution, there appears to be limited utility of FS at the time of thyroid lobectomy given the low predictive value for diagnosing a clinically significant thyroid cancer. In patients who are admitted overnight, expedited pathology is slightly less costly and may improve patient quality-of-life and decrease costs by avoiding delayed completion thyroidectomy. Overnight pathology for patients who undergo thyroid lobectomy may achieve modest cost-savings depending on institutional FS results and rates of malignancy.