Updates on Management of Papillary Thyroid Carcinoma

Recommendations

The authors recommend that a central neck dissection maximizing the number of LNs removed should be performed when factor 4 (see list above) is present and should be considered when the other factors are present as well, to reduce the chance of central compartment recurrence, and therefore, reoperation.

Unlike other lymph node dissections, the central nodal dissection has not been fully standardized in the current literature, as to the extent of resection, the expected nodal yield, and the factors that could predict positive disease in this compartment, said Dr. Farrag. Therefore, in our study, we have evaluated some of these factors to highlight their importance in the evaluation of patients with PTC undergoing primary thyroidectomy, to help in the decision-making process of their surgical treatment.

Cost-Effective Management of PTC

Dr. Shrime, a fellow in Head and Neck Oncologic and Reconstructive Surgery at the University of Toronto Health Network and Mount Sinai Hospital in Canada, spoke on the cost-effectiveness of total thyroidectomy versus hemithyroidectomy in the management of small PTCs in low-risk patients, based on published recommendations of the American Thyroid Association.

Since there appears to be no significant difference in quality of life or mortality between the two procedures, then that leaves the door open for a cost-effectiveness study to be performed, said Dr. Shrime.

For his study, Dr. Shrime conducted a systematic literature review of 1605 abstracts to pinpoint key statistics for decision analysis, including rates of: (1) recurrence, (2) complications for all interventions undertaken, and (3) death.

Within the decision tree model, each of these possible strategies leads to another branch being added to the tree and there is a cost and probability associated with each branch, said Dr. Shrime. For example, the vast majority of patients will have uncomplicated surgeries, but a smaller number will follow one of the many ‘complications’ branches.

Once the tree is drawn, we then fill in all of the costs and probabilities associated with each branch and calculate which particular branch is most cost-effective, as well as provides the best overall survival and/or recurrence-free survival.

After identifying initial results, Dr. Shrime and his colleagues also performed sensitivity and threshold analysis to assess the strength of their recommendations.

Based on their calculations, total thyroidectomy and its follow-up cost $13,910, whereas hemithyroidectomy and its follow-up cost $15,064. Cause-specific mortality was similar for both treatment strategies, whereas recurrence-free survival and recurrence/complication-free survival were both improved by total thyroidectomy. Sensitivity and threshold analyses demonstrated these results to be very robust. Initial hemithyroidectomy presents a more costly overall treatment protocol in patients with low-risk PTC.