Vriens D, Adang E M M, Netea-Maier R T, Smit J W A, de Wilt J H W, Oyen W J G, de Geus-Oei L F
Departments of Radiology and Nuclear Medicine (D.V., W.J.G.O., L.F.d.G.-O.), Health Evidence (E.M.M.A.), Internal Medicine Section of Endocrinology (R.T.N.-M.), Internal Medicine (J.W.A.S.), and Surgery (J.H.W.d.W.), Radboudumc, 6500 HB Nijmegen, The Netherlands.
J Clin Endocrinol Metab. 2014 Sep;99(9):3263-74. doi: 10.1210/jc.2013-3483. Epub 2014 May 29.
Patients with thyroid nodules of indeterminate cytology undergo diagnostic surgery according to current guidelines. In 75% of patients, the nodule is benign. In these patients, surgery was unnecessary and unbeneficial because complications may occur. Preoperative fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) was found to have a very high negative predictive value (96%) and might therefore avoid futile surgery, complications, and costs. In the United States, two molecular tests of cytology material are routinely used for this purpose.
Five-year cost-effectiveness for routine implementation of FDG-PET/CT was evaluated in adult patients with indeterminate fine-needle aspiration cytology and compared with surgery in all patients and both molecular tests.
A Markov decision model was developed to synthesize the evidence on cost-effectiveness about the four alternative strategies. The model was probabilistically analyzed. One-way sensitivity analyses of deterministic input variables likely to influence outcome were performed.
The model was representative for adult patients with cytologically indeterminate thyroid nodules.
The discounted incremental net monetary benefit (iNMB), the efficiency decision rule containing outcomes as quality-adjusted life-years and (direct) medical cost, of implementation of FDG-PET/CT is displayed.
Full implementation of FDG-PET/CT resulted in 40% surgery for benign nodules, compared with 75% in the conventional approach, without a difference in recurrence free and overall survival. The FDG-PET/CT modality is the more efficient technology, with a mean iNMB of €3684 compared with surgery in all. Also, compared with a gene expression classifier test and a molecular marker panel, the mean iNMB of FDG-PET/CT was €1030 and €3851, respectively, and consequently the more efficient alternative.
Full implementation of preoperative FDG-PET/CT in patients with indeterminate thyroid nodules could prevent up to 47% of current unnecessary surgery leading to lower costs and a modest increase of health-related quality of life. Compared with an approach with diagnostic surgery in all patients and both molecular tests, it is the least expensive alternative with similar effectiveness as the gene-expression classifier.
根据现行指南，甲状腺细针穿刺活检结果不确定的患者需接受诊断性手术。75%的此类患者结节为良性。对这些患者而言，手术并无必要且无益处，因为可能会出现并发症。术前氟脱氧葡萄糖 - 正电子发射断层扫描/计算机断层扫描（FDG - PET/CT）具有非常高的阴性预测值（96%），因此可能避免不必要的手术、并发症及费用。在美国，为此目的通常对细胞学材料进行两种分子检测。
评估FDG - PET/CT在甲状腺细针穿刺活检结果不确定的成年患者中常规应用的五年成本效益，并与所有患者均接受手术以及两种分子检测的情况进行比较。
构建马尔可夫决策模型以综合关于四种替代策略成本效益的证据。对该模型进行概率分析。对可能影响结果的确定性输入变量进行单向敏感性分析。
该模型代表甲状腺细针穿刺活检结果不确定的成年患者。
展示FDG - PET/CT实施的贴现增量净货币效益（iNMB），这是一种包含以质量调整生命年和（直接）医疗成本作为结果的效率决策规则。
全面实施FDG - PET/CT后，良性结节患者接受手术的比例为40%，而传统方法为75%，无病生存率和总生存率无差异。FDG - PET/CT模式是更有效的技术，与所有患者均接受手术相比，平均iNMB为3684欧元。此外，与基因表达分类器检测和分子标记物组合相比，FDG - PET/CT的平均iNMB分别为1030欧元和3851欧元，因此是更有效的替代方案。
在甲状腺结节结果不确定的患者中全面实施术前FDG - PET/CT可避免高达47%目前不必要的手术，从而降低成本并适度提高健康相关生活质量。与所有患者均接受诊断性手术以及两种分子检测的方法相比，它是成本最低的替代方案，与基因表达分类器具有相似的有效性。
