Lobectomy is a more Cost-Effective Option than Total Thyroidectomy for 1 to 4 cm Papillary Thyroid Carcinoma that do not Possess Clinically Recognizable High-Risk Features
Lobectomy is a more Cost-Effective Option than Total Thyroidectomy for 1 to 4 cm Papillary Thyroid Carcinoma that do not Possess Clinically Recognizable High-Risk Features
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DOI：
10.1245/s10434-016-5280-6
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发表时间：
2016-10-01
影响因子：
3.7
通讯作者：
Wong, Carlos K. H.
中科院分区：
文献类型：
--
作者：
Lang, Brian Hung-Hin;Wong, Carlos K. H.
虽然在低风险的1 - 4 cm甲状腺乳头状癌（PTC）中，肺叶切除术是甲状腺全切除术（TT）的可行替代方案，但肺叶切除术与较高的局部复发风险相关，并且在发现先前未识别的组织学高危特征（HRF）时需要完成TT。本研究评估了肺叶切除术和TT之间的长期成本效益。我们的基础病例是一个假设的40岁女性队列，患有低风险的2.5 cm PTC。建立马尔可夫决策树模型，比较25年后肺叶切除术和TT的成本-效果。未被识别的HRF患者（包括侵袭性组织学、显微镜下甲状腺外延伸、淋巴血管浸润、切缘阳性、淋巴结转移> 5 mm和多灶性）在肺叶切除术后接受了完整TT。结果概率，效用和成本估计从文献。成本效益的阈值定为50，000美元/质量调整生命年（QALY）。25年后，每个接受肺叶切除术而不是TT的患者的成本增加了772.08美元，但获得了额外的0.300 QALY。增量成本效益比为2577.65美元/质量调整生命年。在敏感性分析中，肺叶切除术组仅在3年后才开始具有成本效益。尽管报告的临床未识别的HRF的患病率、手术并发症、年复发率、手术或并发症的单位成本和效用评分不同，但肺叶切除术仍然比TT更具成本效益。尽管局部复发风险较高，并且几乎一半的患者在发现先前未识别的HRF后进行肺叶切除术后完成TT，对于1至4 cm的PTC，初始肺叶切除术是一种比初始TT更具成本效益的长期选择，而临床上没有公认的HRF。
Although lobectomy is a viable alternative to total thyroidectomy (TT) in low-risk 1 to 4 cm papillary thyroid carcinoma (PTC), lobectomy is associated with higher locoregional recurrence risk and need for completion TT upon discovery of a previously unrecognized histologic high-risk feature (HRF). The present study evaluated long-term cost-effectiveness between lobectomy and TT.Our base case was a hypothetical female cohort aged 40 years with a low-risk 2.5 cm PTC. A Markov decision tree model was constructed to compare cost-effectiveness between lobectomy and TT after 25 years. Patients with an unrecognized HRF (including aggressive histology, microscopic extrathyroidal extension, lymphovascular invasion, positive resection margin, nodal metastasis > 5 mm, and multifocality) underwent completion TT after lobectomy. Outcome probabilities, utilities, and costs were estimated from the literature. The threshold for cost-effectiveness was set at US$50,000/quality-adjusted life-year (QALY). Sensitivity and threshold analyses were used to examine model uncertainty.After 25 years, each patient who underwent lobectomy instead of TT cost an extra US$772.08 but gained an additional 0.300 QALY. The incremental cost-effectiveness ratio was US$2577.65/QALY. In the sensitivity analysis, the lobectomy arm began to become cost-effective only after 3 years. Despite varying the reported prevalence of clinically unrecognized HRFs, complication from surgical procedures, annualized recurrence rates, unit cost of surgical procedure or complication, and utility score, lobectomy remained more cost-effective than TT.Despite the higher locoregional recurrence risk and having almost half of the patients undergoing completion TT after lobectomy upon discovery of a previously unrecognized HRF, initial lobectomy was a more cost-effective long-term option than initial TT for 1 to 4 cm PTCs without clinically recognized HRFs.