Use of a low-cost telecytopathology method for remote assessment of thyroid FNAs.

BACKGROUND: Rapid on-site evaluation is a great tool for optimizing the adequacy and quality of cytologic samples. The objective of the current study was to analyze a low-cost telecytopathology method for the remote assessment of thyroid fine-needle aspiration biopsies (FNABs), with comparison of the primarily rendered adequacy and diagnosis with the final conventional analysis. METHODS: Material collected from thyroid FNABs was immediately smeared onto glass slides and stained with Diff-Quik. A conventional microscope attached to a smart device was operated on-site by either a medical student or a pathology resident for Wi-Fi transmission of the images by Skype. The cytopathologist would remotely guide the screening of the slides, zooming in and out of areas of interest. Remote assessment included an analysis of material adequacy and a preliminary diagnosis. The quality of the transmission and the number of slides also were recorded. After a washout period of 3 weeks, final diagnosis and adequacy were assigned by conventional microscopy. RESULTS: The final agreement rate for adequacy between remote and conventional analysis was 90.5%. For diagnosis, the final agreement rate was 83.3%. The diagnosis agreement rate varied, depending on the quality of transmission: there was 88% agreement when the quality was excellent, 77.8% agreement when it was good, and 62.5% agreement when it was poor. CONCLUSIONS: Low-cost telecytopathology is an efficient method for the remote assessment of thyroid FNAB adequacy and diagnosis. The wide use of such technology in low-resource or remote centers may have a positive impact on the number of adequate or satisfactory samples, optimizing the management of patients who have thyroid nodules.

[Application of fibrin sealant in patients operated on for differentiated thyroid cancer. What do we improve?]. / Aplicación de sellante de fibrina en pacientes operados por cáncer diferenciado de tiroides. ¿Qué mejoramos?

BACKGROUND: In recent years, several publications have shown that new adhesives and sealants, like Tissucol(®), applied in thyroid space reduce local complications after thyroidectomies. STUDY AIMS: To demonstrate the effectiveness of fibrin glue Tissucol(®) in reducing the post-operative hospital stay of patients operated on for differentiated thyroid carcinoma in which total thyroidectomy with central and unilateral node neck dissection was performed (due to the debit drains decrease), with consequent cost savings. MATERIAL AND METHODS: A prospective randomised study was conducted during the period between May 2009 and October 2013 on patients with differentiated thyroid carcinoma with cervical nodal metastases, and subjected to elective surgery. Two groups were formed: one in which Tissucol(®) was used (case group) and another where it was not used (control group). Patients were operated on by surgeons specifically dedicated to endocrine surgical pathology, using the same surgical technique in all cases. RESULTS: A total of 60 total thyroidectomies with lymph node dissection were performed, with 30 patients in the case group, and 30 patients in control group. No statistically significant differences were observed in most of the studied variables. However, the case group had a shorter hospital stay than the control group with a statistically significant difference (p<0.05). CONCLUSION: Implementation of Tissucol(®) has statistically and significantly reduced the hospital stay of patients undergoing total thyroidectomy with neck dissection, which represents a significant reduction in hospital costs. This decrease in hospital stay has no influence on the occurrence of major complications related to the intervention.

Attributable costs of differentiated thyroid cancer in the elderly Medicare population.

BACKGROUND: Little is known about costs associated with differentiated thyroid cancer (DTC) and follow-up care. This study used data from the Surveillance Epidemiology and End Results (SEER) database to examine cumulative costs attributable to disease stage and treatment options of DTC in elderly patients over 5 years. METHODS: We identified 2,823 patients aged >65 years with DTC and 5,646 noncancer comparison cases from SEER Medicare data between 1995 and 2005. Cumulative costs were obtained by estimating average costs/patient in each month up to 60 months after diagnosis. We performed multivariate analyses of costs by fitting each monthly cost to linear models, controlling for demographics and comorbidities. Marginal effects of covariates were obtained by summing coefficients over 60 months. RESULTS: Cumulative costs were $17,669/patient the first year and $48,989/patient 5 years after diagnosis. Regional disease was associated with higher costs at 1 year ($9,578) and 5 years ($8,902). Distant disease was associated with 1-year costs of $28,447 and 5-year costs of $20,103. Patients undergoing surgery and radiation had a decrease in cost of $722 at 5 years. CONCLUSION: DTC in the elderly is associated with significant economic burden largely attributable to patient demographics, stage of disease, and treatment modalities.

Cost effectiveness of intraoperative pathology examination during diagnostic hemithyroidectomy for unilateral follicular thyroid neoplasms.

BACKGROUND: The use of intraoperative pathology examination (IPE) during diagnostic hemithyroidectomy for a follicular neoplasm is controversial. Although this service rarely alters intraoperative decision making, it does provide patients with the possibility of avoiding reoperation for completion thyroidectomy if malignancy is detected. We hypothesized diagnostic hemithyroidectomy with IPE for a unilateral follicular thyroid neoplasm diagnosed on fine-needle aspiration is not cost effective compared with diagnostic hemithyroidectomy alone. STUDY DESIGN: Cost-effectiveness analysis with a Markov decision model was performed comparing diagnostic hemithyroidectomy without IPE, diagnostic hemithyroidectomy with IPE, and total thyroidectomy. Treatment outcomes and their probabilities were identified based on literature review. Costs were estimated using data from Medicare, the US Bureau of Labor Statistics, and the Nationwide Inpatient Sample. Sensitivity analysis and a 1,000-iteration Monte Carlo simulation were used to examine the uncertainty of cost, probability, and utility estimates in the model. RESULTS: Diagnostic hemithyroidectomy without IPE had an expected cost of US$7,665 and an effectiveness of 23.95 quality-adjusted life years and dominated both the IPE and total thyroidectomy strategies. Intraoperative pathology examination became cost effective during one-way sensitivity analysis if the sensitivity of IPE increased from 14.3% to 34.4%, the specificity increased from 98.6% to 99.8%, or the pretest probability of malignancy increased from 25% to 43%. Monte Carlo simulation demonstrated that the intraoperative pathology strategy was not cost effective in 92.7% of iterations. CONCLUSIONS: Intraoperative pathology examination is not cost effective in the diagnosis of follicular thyroid neoplasms during diagnostic hemithyroidectomy. Improvements in both the sensitivity and specificity of this service would be needed to justify its use.

Cost savings of patients with a MACIS score lower than 6 when radioactive iodine is not given.

OBJECTIVE: To assess the cost savings if the current policy of treating patients with a MACIS (metastases, age, completeness of resection, invasion, and size) score lower than 6 using radioactive iodine (RAI) was changed to reflect the findings of recent studies. DESIGN: Retrospective medical record review. SETTING: Mount Sinai Hospital, Toronto, Ontario. PATIENTS: Between January 1, 2002, and July 1, 2005, 199 consecutive patients with a MACIS score lower than 6 who received RAI treatment after total thyroidectomy. MAIN OUTCOME MEASURES: Patient demographics were analyzed. Costs for the dose of RAI, hospital stay, and health insurance claims were included in the calculations. RESULTS: For 199 consecutive patients, the cost for sodium iodide 131 treatment totaled Can$161 588, and the required 2-day stay in isolation totaled Can$764 558. The overall cost to the health care system was Can$934 106, which translates into approximately Can$4694 per patient. CONCLUSIONS: By following the recommendations of recent evidence-based studies and by ceasing to treat patients with a MACIS score lower than 6 after total thyroidectomy using RAI, cost savings can be accrued for health care systems involved in the treatment of thyroid cancer. Alternate strategies, such as treating patients who need RAI therapy on an outpatient basis and reducing the dose of RAI, can lower costs as well.

The relative roles of endemic goiter and socioeconomic development status in the prognosis of thyroid carcinoma.

BACKGROUND: It generally is accepted that the prognosis of thyroid carcinoma is more severe in areas in which goiter is endemic. It could be assumed that this prognosis also is less favorable in developing countries. METHODS: Clinical features and tumor histology of 1000 consecutive patients were studied: Patient data from the endemic area (EA) were compared with those from the nonendemic area (NEA). In addition, patients from the years 1966-1981 (P1) were compared with those from 1982-1991 (P2). It is obvious that the country's socioeconomic status and health care system improved between the two periods. RESULTS: The anaplastic and follicular types of thyroid carcinoma were more frequent in EAs (14% and 42.13%, respectively) than in NEAs (6.25% and 38.40%, respectively). The frequency of the anaplastic carcinoma during P1 (16.03%) decreased by half during P2 (7.79%), whereas the frequency of follicular carcinoma remained stable (35.85% and 40.46%, respectively). Clinically, more advanced stages (tumor size, local and distant disseminations) were observed in the study country than in developed countries. A clearcut improvement was observed during P2 whereas differences between the EA and NEAs were few. Survival rates (follicular and papillary types only) were not found to be different between EAs and NEAs (5-year survival: 81.44% and 75.32%, respectively; 10-year survival: 67.93% and 69.52%, respectively). A significant (P < 0.01) increase was observed between P1 and P2 (5-year survival: 72.69% and 84.80%, respectively; 10-year survival: 58.77% and 83%, respectively). CONCLUSIONS: Compared with endemic goiter, low socioeconomic status appeared to be the major factor accountable for the high prevalence of advanced stage cases and anaplastic carcinomas. Iodine deficiency appeared to play a specific role in the increased prevalence of follicular types of thyroid carcinoma.