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

Learning curve of trans-areola single-site endoscopic thyroidectomy in a high-volume center: A CUSUM-based assessment

BACKGROUND

Limited attempts have been made in trans-areola single-site endoscopic thyroidectomy (TASSET) due to technical challenges and the lengthy time for proficiency. This study aimed to define the learning curve of TASSET and to describe improvements in operative performance over time.

METHODS

Based on 222 consecutive TASSET procedures, the learning curve was established according to the operation time by using cumulative sum analysis (CUSUM). The end-point of learning curve was defined as the number of cases necessitated to reach the initial surgical proficiency stage. The demographic information, surgical and oncological outcomes, surgical stress, and postoperative complications were also analyzed.

RESULTS

There were 70 cases of simple lobectomy for benign nodules and 152 cases of lobectomy with central neck dissection (CND) for malignancy. The mean operative time was 106.54 ± 38.07 min (range: 46-274 min). The learning curve identified two phases: the skill acquisition phase (Case 1-Case 41) and the proficiency phase (Case 42-Case 222). There were no significant differences in demographic information, drainage amount and duration, oncological outcomes, and postoperative complications between the two phases (p > 0.05). Both operation time and postoperative hospitalization decreased significantly in Phase 2 (154.63 ± 52.21 vs. 95.64 ± 22.96 min, p < 0.001; 4.12 ± 0.93 vs. 3.65 ± 0.63 days, p < 0.001). Additionally, the mean variations of surgical stress factors (C-reactive protein and erythrocyte sedimentation rate) decreased significantly as the phase progress. The case number required for proficiency phase in benign and malignant tumor were 18 and 33, respectively, and lymph node resection posed a significant impact on the endpoint of the learning curve (p < 0.001). Meanwhile, the size of nodule showed no significant impact (p = 0.622). For right-handed surgeons, 16 cases and 25 cases were required for technical competence in left-sided and right-sided lesions, respectively, and no significant difference reached (p = 0.266).

CONCLUSIONS

TASSET has demonstrated safe and technically feasible with comparable oncological outcomes. Experience of 41 cases was required for surgical competence and proficiency. The initial learning stage could be more quickly adopted by high-volume thyroid surgeons with standardized procedures.

Selective laryngoscopy before thyroidectomy: a risk assessment

BACKGROUND

Patients presenting for thyroidectomy may have an unrecognized pre-existing vocal cord palsy (VCP). This raises the danger of bilateral VCP if a patient sustains an injury to the RLN on the sole functioning side. Part of the rationale for routine preoperative laryngoscopy is to eliminate such a risk. This paper endeavours to quantify the relevant potential risk.

METHODS

Patients who underwent laryngoscopy prior to thyroid or parathyroid surgery in an endocrine surgical unit over a 5 year period were identified. Literature review revealed four papers in which VCP prevalence in patients without risk factors was reported. Using our data, combined with that of these other authors, the background rate of pre-existing VCP was ascertained, and the subsequent risk of bilateral VCP estimated.

RESULTS

Of our 632 patients who underwent preoperative laryngoscopy, there were four patients (0.63%) who were found to have a unilateral VCP, but all had voice symptoms or previous neck surgery. When patients with these risk factors are excluded, our data combined with the published data provides a pre-existing VCP rate of 0.2%. Calculations estimate that if preoperative laryngoscopy is omitted in patients with no risk factors, the risk of bilateral VCP, due to the nerve on the sole functioning side being injured, would be between 1/50000 and 1/150000, depending on an individual surgeon's level of experience.

CONCLUSION

Selective use of laryngoscopy prior to thyroidectomy would result in an acceptably low statistical risk of bilateral VCP. Routine laryngoscopy for all patients is not necessary.

Care and Management of Voice Change for Thyroid Surgery: Korean Society of Laryngology, Phoniatrics and Logopedics Clinical Practice Guideline

Voice change is a common complaint after thyroid surgery and has significant impacts on quality of life. The Korean Society of Laryngology, Phoniatrics, and Logopedics set up a task force team to establish guideline recommendations on education, care, and management related to thyroid surgery. The guideline recommendations include preoperative voice education, management of anticipated voice change during surgery, and comprehensive voice care after thyroid surgery, including in-depth information and up-to-date knowledge based on validated literature. The committee constructed 14 key questions (KQ) in three categories: preoperative (KQ1-2), intraoperative (KQ 3-8), and postoperative (KQ 9-14) management and developed 18 evidence-based recommendations. The Delphi survey reached an agreement on each recommendation. Detailed evidence profiles are presented for each recommendation. The level of evidence for each recommendation is classified into high, moderate, and low-quality. The recommendation's strengths are adjusted to consider the level of evidence resulting in the recommendation and are divided into strong and weak. The guidelines are primarily targeted toward physicians who treat thyroid surgery patients and speech-language pathologists participating in patient care. These guidelines will also help primary care physicians, nurses, healthcare policymakers, and patients improve their understanding of voice changes and voice care after thyroid surgery.

Thyroidectomy for thyroid cancer via transareola single-site endoscopic approach: results of a case-match study with large-scale population

BACKGROUND

Due to technical challenges, single-site endoscopic thyroidectomy (SSET) is seldom reported and has been attempted in only limited cases. This large-scale study aimed to compare the clinical outcomes of standardized transareola SSET (TASSET) with those of conventional open thyroidectomy (COT) for thyroid cancer.

METHODS

The data were prospectively collected, and case-match study was performed at a ratio of 1:1 according to age, sex, body mass index, lesion size, number of lesion foci, lesion side, recurrent laryngeal nerve (RLN) exploration and pathology. Two hundred eligible patients underwent TASSET, and the same number of patients was selected for propensity score matching from 2256 patients who underwent COT. Perioperative data, including surgical profile, oncological and traumatic burdens, and cosmetic satisfaction, were analyzed.

RESULTS

No significant differences were observed in blood loss or drainage between TASSET and COT groups. There were no differences in operation time between TASSET and COT (106.39 ± 28.44 vs 102.55 ± 23.10 min, p = 0.154). A total of 3.63 ± 1.82 lymph nodes (LNs) were retrieved from CND with 0.96 ± 1.42 positive in TASSET. In COT, the total and positive LN yields were 3.77 ± 1.91 and 0.99 ± 1.40 (p = 0.445, p = 0.802). Cancer recurrence was not observed in either group. There were no differences in the occurrence of permanent and transient hoarseness or RLN injuries. Postoperative flap seroma or hematoma occurred in 12 TASSET patients and 58 COT patients (p < 0.001). The pain score, CRP level and ESR in TASSET group were lower than those in COT group. TASSET yielded significantly better incision recovery and cosmetic scores than did COT at both the proliferation and stabilization stages.

CONCLUSIONS

TASSET is technically feasible and yields enhanced recovery with minimally invasive and cosmetic advantages without compromising the level of safety or cancer eradication.

Association of Hypocalcemia and Magnesium Disorders With Thyroidectomy in Commercially Insured Patients

Importance

Hypocalcemia is a common complication of total thyroidectomy.

Objectives

To identify factors associated with hypocalcemia after total thyroidectomy and to explore the association between hypocalcemia, magnesium disorders, and costs of care.

Design, Setting, and Participants

A retrospective cross-sectional analysis was performed using data from the MarketScan Commercial Claim and Encounters database on 126 766 commercially insured patients younger than 65 years undergoing total thyroidectomy between January 1, 2010, and December 31, 2012. Statistical analysis was performed from January 1, 2016, to May 30, 2019.

Main Outcomes and Measures

Short- and long-term hypocalcemia and the costs of care were examined using multivariable regression modeling.

Results

Among the 126 766 patients in the study (81.6% women; mean age, 46.5 years [range, 18-64 years]), postoperative hypocalcemia was present in 19.1% of patients in the initial 30-day postoperative period and in 4.4% of patients at 1 year. Magnesium disorders were present in 2.1% of patients at the time of surgery. Short- and long-term hypocalcemia were significantly more likely in women (short-term: odds ratio [OR], 1.39 [95% CI, 1.29-1.50]; long-term: OR, 1.69 [95% CI, 1.52-1.89]), those younger than 40 years (short-term: OR for ages 40-64 years, 0.83 [95% CI, 0.78-0.87]; long-term: OR for ages 40-64 years, 0.73 [95% CI, 0.67-0.79]), those with a diagnosis of thyroiditis (short-term: OR, 1.48 [95% CI, 1.16-1.89]; long-term: OR, 1.60 [95% CI, 1.13-2.26]) or cancer (short-term: OR, 1.32 [95% CI, 1.05-1.67]; long-term: OR, 1.17 [95% CI, 0.83-1.63]), vitamin D deficiency (short-term: OR, 1.96 [95% CI, 1.74-2.21]; long-term: OR, 3.72 [95% CI, 3.30-4.18]), concurrent lateral neck dissection (short-term: OR, 1.51 [95% CI, 1.37-1.66]; long-term: OR, 1.95 [95% CI, 1.69-2.26]), concurrent central neck dissection (short-term: OR, 1.15 [95% CI, 1.07-1.24]; long-term: OR, 1.25 [95% CI, 1.12-1.40]), intraoperative parathyroid (short-term: OR, 1.58 [95% CI, 1.46-1.71]; and long-term: OR, 2.05 [95% CI, 1.82-2.31]) or recurrent laryngeal nerve injury (short-term: OR, 1.49 [95% CI, 1.27-1.74]; long-term: OR, 2.04 [95% CI, 1.64-2.54]), and magnesium disorders (short-term: OR, 8.40 [95% CI, 7.21-9.79]; long-term: OR, 25.23 [95% CI, 19.80-32.17]). Compared with the initial postoperative period, the odds of hypocalcemia decreased by 90.0% (OR, 0.10 [95% CI, 0.09-0.11]) at 6 months and 93.0% (OR, 0.07 [95% CI, 0.06-0.08]) at 1 year. After controlling for all other variables, magnesium disorders were associated with the highest odds of short- and long-term postoperative hypocalcemia. Hypocalcemia ($3392) and magnesium disorders ($14 314) were associated with increased mean incremental 1-year costs of care.

Conclusions and Relevance

Hypocalcemia is common after total thyroidectomy but resolves in most patients by 1 year. Magnesium disorders are significantly independently associated with short- and long-term hypocalcemia and are associated with greater costs of care. These data suggest a potentially modifiable target to reduce the incidence and cost of long-term hypocalcemia at patient and systemic levels.

Cost-effectiveness of fiberoptic laryngoscopy prior to total thyroidectomy for low-risk thyroid cancer patients

BACKGROUND

Flexible fiberoptic laryngoscopy is performed prior to thyroid surgery to evaluate the function of the recurrent laryngeal nerve. We assess the cost-effectiveness of preoperative laryngoscopy prior to total thyroidectomy for a low-risk thyroid cancer patient without dysphonia.

METHODS

A decision tree analysis was performed from a third-party payer perspective. We assessed the cost-effectiveness of fiberoptic laryngoscopy prior to total thyroidectomy for T2N0M0 papillary thyroid carcinoma, such that an ipsilateral vocal fold paralysis alters the surgical plan to hemi-thyroidectomy, when permissible, to avoid the risk of bilateral vocal fold paralysis.

RESULTS

Performing preoperative laryngoscopy to assess vocal fold function has an incremental cost-effectiveness ratio (ICER) of 45 193 USD/QALY compared to no laryngoscopy. At a willingness-to-pay of 100 K/QALY, the intervention is cost-effective if the incidence of vocal fold paralysis is at least 0.57%, or when the permissible rate of hemithyroidectomy in cases of incidental paralysis is at least 41%. Probabilistic sensitivity analysis shows that laryngoscopy is cost-effective in 90.9% of cases.

CONCLUSIONS

Fiberoptic laryngoscopy is a cost-effective prior to total thyroidectomy in asymptomatic, low-risk thyroid cancer patients.

The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Thyroid Disease in Adults

OBJECTIVE

To develop evidence-based recommendations for safe, effective, and appropriate thyroidectomy.

BACKGROUND

Surgical management of thyroid disease has evolved considerably over several decades leading to variability in rendered care. Over 100,000 thyroid operations are performed annually in the US.

METHODS

The medical literature from 1/1/1985 to 11/9/2018 was reviewed by a panel of 19 experts in thyroid disorders representing multiple disciplines. The authors used the best available evidence to construct surgical management recommendations. Levels of evidence were determined using the American College of Physicians grading system, and management recommendations were discussed to consensus. Members of the American Association of Endocrine Surgeons reviewed and commented on preliminary drafts of the content.

RESULTS

These clinical guidelines analyze the indications for thyroidectomy as well as its definitions, technique, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Fine Needle Aspiration Biopsy Diagnosis, Molecular Testing, Indications, Extent and Outcomes of Surgery, Preoperative Care, Initial Thyroidectomy, Perioperative Tissue Diagnosis, Nodal Dissection, Concurrent Parathyroidectomy, Hyperthyroid Conditions, Goiter, Adjuncts and Approaches to Thyroidectomy, Laryngology, Familial Thyroid Cancer, Postoperative Care and Complications, Cancer Management, and Reoperation.

CONCLUSIONS

Evidence-based guidelines were created to assist clinicians in the optimal surgical management of thyroid disease.

Contemporary Evaluation and Management of Parathyroid Carcinoma

Parathyroid carcinoma is a rare malignancy, representing 0.005% of all cancers and 0.5%-1% of all parathyroid disorders. Parathyroid carcinoma occurs equally in males and females, as opposed to primary hyperparathyroidism, which has a female predominance. Patients with parathyroid carcinoma present with symptoms of hypercalcemia, similar to those with benign primary hyperparathyroidism. Parathyroid carcinoma should be suspected when calcium or parathyroid hormone levels are high. Because of the difficulty of discerning parathyroid carcinoma from adenoma preoperatively, the diagnosis of carcinoma is often made only after parathyroidectomy. The goals of surgery are resection with negative margins because surgery represents the only opportunity for cure. Adjuvant therapy with chemotherapy or external beam radiation has not been proven to affect disease-free or overall survival for these patients. Recurrence is common, with reoperation recommended for resectable recurrent disease. Palliation with calcimimetic pharmacotherapy can aid with management of symptomatic hypercalcemia in recurrent or persistent disease after parathyroidectomy. Ultimately, patients succumb to sequelae of hypercalcemia rather than tumor burden.

Laryngeal paralysis detected in preoperative laryngoscopy in malignant and benign thyroid disease. Systematic review and meta-analysis

There is controversy regarding the performance of preoperative laryngoscopy (LP) in thyroid surgery, with different recommendations being made, based on observational studies, in various publications. The aim of the study was to know the prevalence of laryngeal paralysis found in the LPs of patients who underwent thyroidectomy in benign and malignant pathology. A systematic review was carried out with 29 articles included for the qualitative study and a meta-analysis of 13 articles in which the data could be obtained to evaluate the same effect (in all patients in which an LP was carried out, those with preoperative laryngeal paralysis were included, and assigned to malignant or benign postoperative histology groups). The pooled prevalence of preoperative paralysis in benign pathology was 1.1% (95% CI 0.7 to 1.7%, 71% I²) and in 6.3% malignant pathology (95% CI 3.8 to 9.4%; I² 85%). The prevalence was significantly higher among patients with malignant pathology with an estimated effect RR 5.66, 95% CI, 2.48, 12.88. The studies analyzed present biases that will need to be corrected in future research, eliminating blinding biases in the selection and allocation of patients or in the laryngoscopy technique used. The LP in thyroid surgery evaluates possible disorders of laryngeal motility. The prevalence of laryngeal paralysis in thyroid pathology found in LPs in patients with a postoperative diagnosis of malignant pathology was higher than in the benign pathology group. This information is necessary for interpreting the intraoperative neuromonitoring signal and for making informed decisions.

Health Utility Book (HUB)-Cancer: Protocol for a Systematic Literature Review of Health State Utility Values in Cancer

Background. Treatment options in oncology are rapidly advancing, and public payer systems are increasingly under pressure to adopt new but expensive cancer treatments. Cost-utility analyses (CUAs) are used to estimate the relative costs and effects of competing interventions, where health outcomes are measured using quality-adjusted life years (QALYs). Health state utility values (HSUVs) are used to reflect health-related quality of life or health status in the calculation of QALYs. To support reimbursement agencies in the appraisal of oncology drug submissions, which typically include a CUA component, we have proposed a systematic literature review of published HSUV estimates in the field of oncology. Methods. The following databases will be searched: MEDLINE, EMBASE, EconLit, and CINAHL. A team of reviewers, working independently and in duplicate, will evaluate abstracts and full-text publications for eligibility against broad inclusion criteria. Studies using a direct, indirect, or combination approach to eliciting preferences related to cancer or cancer treatments are eligible. Data extraction will capture details of study methodology, participants, health states, and corresponding HSUVs. We will summarize our findings with descriptive analyses at this stage. A pilot review in thyroid cancer is presented to illustrate the proposed methods. Discussion. This systematic review will generate a comprehensive summary of the oncology HSUV literature. As a component of the Health Utility Book (HUB) project, we anticipate that this work will assist both health economic modelers as well as critical reviewers in the development and appraisal of CUAs in oncology.