Assessing national trends in indications for pediatric total thyroidectomy.

PURPOSE: The most common indications for total thyroidectomy (TT) in children are malignancy and thyrotoxicosis due to Graves' disease (GD). However, the incidence of patients with GD among patients undergoing TT is unknown. This study aims to examine trends in pediatric TT. MATERIALS AND METHODS: The US Agency for Health Research and Quality Healthcare Cost and Utilization Project (HCUP) Kids' Inpatient Database (KID) was queried to identify patients who underwent TT between 1997 and 2019. Weighted national estimates were obtained. Statistical analysis was completed using univariate logistic regression and one-sided Mann-Kendall Test. RESULTS: An estimated 4803 pediatric patients underwent TT within the study years. GD was the indication in 25 % of cases. Mann-Kendall testing showed a trend toward an increasing proportion of TT for GD without reaching statistical significance (z = 1.3609, S = 12, p = 0.0688). Statistically significant univariate associations were found among those who underwent thyroidectomy for GD compared to other indications, as they were more likely to be female (ß = 0.286, 95 % CI [0.058, 0.514], p = 0.014), Black, or Hispanic (ß = 1.392 [1.064, 1.721], p < 0.001; and ß = 0.562 [0.311, 0.814], p < 0.001, respectively). Additionally, they were less likely to have private insurance (ß = -0.308 [-1.076, -0.753], p = 0.002) and more likely to live in a ZIP code associated with a median household income below the 50th percentile (ß = 0.190 [0.012, 0.369], p = 0.036). The associations with the female sex, Black race, and Hispanic race persisted in multivariate analysis. CONCLUSION: GD appears to be an increasingly prevalent indication for TT. Patient characteristics differ from those who undergo TT for other diagnoses.

Evolution in the management of thyroid surgery over a period of 15 years in a Belgian center.

BACKGROUND: Guidelines for thyroid surgery have evolved to reflect advances in medical knowledge and decrease the overdiagnosis of low-risk thyroid cancer. Our goal was to analyze the change made in operative thyroid management and the impact on thyroid cancer diagnosis. BACKGROUND: Guidelines for thyroid surgery have evolved to reflect advances in medical knowledge and decrease overdiagnosis of low risk thyroid cancer. Our goal was to study the evolution, over a long period, of pre- and postoperative management and the influence on histological cancer diagnosis and, more particularly, microcancer. METHODS: In this retrospective cohort study, we included 891 consecutive patients who underwent thyroid surgery between 2007 and 2020. RESULTS: Respectively 305, 290 and 266 patients underwent surgery over the 3 periods of 2007-2010, 2011-2015 and 2016-2020. In all three periods, women represented approximately 70% of the population, and the mean age was 54 years old (range: 67). Most surgeries (90%) involved total thyroidectomies. Over the study period, the proportion of preoperative fine needle aspiration (FNA) increased from 13 to 55%, p < 0,01. Cancer was found in a total of 116 patients: 35 (11%) patients between 2007 and 2010, 50 (17%) between 2011 and 2015 and 32 (12%) between 2016 and 2020 (p = 0.08). For all 3 periods, papillary thyroid cancer (PTC) was the most prevalent, at approximately 80%. The proportion of thyroid cancer > T1a increased significantly from 37% (2011-2015 period) to 81% (2016-2020 period), p = 0.001. Patients treated with radioiodine remained relatively stable (approximately 60%) but were more frequently treated with a low dose of radioiodine (p < 0.01) and recombinant human TSH (p < 0.01). Operative thyroid weight decreased over time in all but the low-risk T1a PTC cases. CONCLUSIONS: Over a period of 15 years and according to the evolution of recommendations, the care of patients who underwent thyroid surgery changed with the increased use of preoperative FNA. This change came with a decrease in low-risk T1a PTC.

Association of Medicaid expansion with access to thyroidectomy for benign disease at high-volume centers.

BACKGROUND: Insurance-based disparities in access to thyroidectomy are well established. Patients undergoing thyroidectomy by high-volume surgeons have fewer complications and better postoperative outcomes. The aim of this study was to evaluate the association of Medicaid expansion with access to high-volume centers for thyroidectomy for benign disease. METHODS: The Vizient Clinical Data Base was queried for adult operations for benign thyroid disease from 2010 to 2019. Centers were sorted by volume into quartiles. Difference-in-difference analysis evaluated changes in insurance populations in expansion and non-expansion states after Medicaid expansion. Odds of patients undergoing operations in the 4 volume quartiles after stratifying by insurance and Medicaid expansion status were calculated. RESULTS: A total of 82,602 patients underwent operations at 364 centers. Expansion states increased Medicaid coverage in all volume quartiles compared to non-expansion states after Medicaid expansion (Q1, +4.87%, Q2, +5.35%, Q3, +8.57%, Q4, +4.62%, P < .002 for all). After Medicaid expansion, Medicaid patients had higher odds of undergoing operation at lower volume hospitals compared to the highest volume centers in both expansion states (Q1, ref, Q2, 1.82, Q3, 1.76, Q4, 1.67, P < .001) and non-expansion states (Q1, ref, Q2, 1.54, Q3, 2.04, Q4, 1.44, P < .001). Privately insured patients were most likely to undergo their operation at the highest volume centers in all states (E: Q1, ref, Q2, 0.78, Q3, 0.74, Q4, 0.66, P < .001; NE: Q1, ref, Q2, 0.89, Q3, 0.58, Q4, 0.85, P < .001). CONCLUSION: Medicaid expansion increased Medicaid coverage in expansion states, but Medicaid patients in both expansion and non-expansion states were less likely to be operated on at the highest volume centers compared to privately insured patients. Persistent barriers to accessing high-volume care still exists for Medicaid patients.

Investigating potential disparities by exploring time to surgical thyroid cancer treatment.

(1) Delays in initial treatment have been a frequently used metric for assessing disparities in medicine; however, there has been sparse literature on treatment delays in thyroid cancer. We therefore aimed to assess disparities by investigating the association between race/ethnicity, insurance type, and socioeconomic status and time to surgical treatment of thyroid cancer. (2) A retrospective chart review was conducted to collect demographic and clinical data from 443 surgical thyroid cancer patients at Mount Sinai Hospital in 2018-2019. We investigated the time between thyroid cancer diagnosis and surgery by race/ethnicity, insurance, and income groups. (3) Univariate analysis showed that race/ethnicity, insurance type, and SES alone were not statistically significant predictors of earlier time to treatment (p = 0.766, 0.339, 0.435, respectively). On multivariable linear regression, time between diagnosis and surgical treatment was not significantly different for racial minorities compared to non-Hispanic White patients, patients with Medicare/Medicaid compared to private insurance, and patients with lowest income quartile (<$54,585) compared to those with the highest (≥$116,560). (4) Present study showed no significant delays in treatment for different racial/ethnic, insurance, and income groups.

National Trends and Outcomes in the Operative Management of Thyroid Storm.

BACKGROUND: Thyroid storm is a rare but potentially lethal manifestation of thyrotoxicosis. Guidelines recommend nonoperative management of thyroid storm, but thyroidectomy can be performed if patients fail medical therapy or need immediate resolution of the storm. Outcomes of thyroidectomy for management of thyroid storm remain ill-defined. METHODS: Using the National Inpatient Sample from 2016 to 2020, a retrospective analysis was conducted of patients admitted with thyroid storm. Outcomes of interest included operative complications and mortality. Multivariable logistic regression was performed to assess factors associated with receiving thyroidectomy and mortality. RESULTS: An estimated 16,175 admissions had a diagnosis of thyroid storm. The incidence of thyroid storm increased from .91 per 100,000 people in 2016 to 1.03 per 100,000 people in 2020, with a concomitant increase in mortality from 2.9% to 5.3% (P < .001). Operative intervention was pursued in 635 (3.9%) cases with a perioperative complication rate of 30%. On multivariable regression, development of acute decompensated heart failure (adjusted odds ratio [AOR] 1.66, 95% Confidence Interval [CI] 1.03-2.68, P = .037) and acute renal failure (AOR 2.10, 95% CI 1.17-3.75, P = .013) increased odds of receiving surgery. The same multivariable model did not show a significant association between thyroidectomy and mortality. DISCUSSION: The incidence of thyroid storm and associated mortality increased during the study period. Thyroidectomy is rarely performed during the same admission, with an overall perioperative complication rate of 30% and no effect on mortality. Patients with acute decompensated heart failure and renal failure were more likely to receive an operative intervention.

Factors affecting the rates of incidental parathyroidectomy during thyroidectomy.

BACKGROUND: The most important factors affecting the development of postoperative hypocalcaemia (PH) include intraoperative trauma to the parathyroid glands, incidental parathyroidectomy (IP), and the surgeon's experience. In this study, we aimed to determine the incidence of IP, evaluate its effect on postoperative calcium levels and investigate the effect of surgeon experience and volume on IP incidence and postoperative calcium levels. METHODS: This retrospective study included 645 patients who underwent thyroid surgery at the Department of General Surgery, Kütahya Health Sciences University between September 2016 and March 2020. All patients underwent surgery at a single clinic by general surgeons experienced in thyroid surgery and their residents (3-5 years). RESULTS: Normal parathyroid glands were reported in 58 (8.9%) of 645 patients. In 5 (8.6%) of 58 patients the parathyroid gland was detected in the intrathyroidal region. PH developed in ten patients (17.2%) with incidental removal of the parathyroid glands. A statistically significant difference was found between the number of incidentally removed parathyroid glands and the development of hypocalcaemia (p<0.05). Normal parathyroid glands were reported in the pathology of 37 (7.9%) patients operated on by general surgeons and 22 (12.6%) patients operated on by their residents. PH developed in 39 (8.2%) patients operated on by general surgeons and in 8 (4.5%) patients operated on by their residents. CONCLUSIONS: We found that the complication rate during the resident training process was the same as that of experienced general surgeons. A thyroidectomy can be safely performed by senior residents during residential training.

Racial implications of time to surgery in disparities in thyroid cancer survival.

INTRODUCTION: The influence of time to surgery on racial/ethnic disparities in papillary thyroid carcinoma (PTC) survival remains unstudied. MATERIALS AND METHODS: The National Cancer Database (2004-2017) was queried for patients with localized PTC. Survival data was compared by time to surgery, patient demographics, and multivariable Cox regression was performed. RESULTS: Of 126,708 patients included, 5% were Black, 10% Hispanic. Of all patients, 85% had no comorbidities. Non-Hispanic White (NHW) patients had a shorter median time to surgery than Black and Hispanic patients (36 vs. 43 vs. 42 days, respectively p â€‹< â€‹0.001). In multivariable analysis, longer time to surgery (>90 days vs â€‹< â€‹30 days) and Black race vs NHW, were associated with worse survival (HR: 1.56, (95%CI, 1.43-1.70), p â€‹< â€‹0.001 and HR: 1.21, (1.08-1.36), p â€‹= â€‹0.001), respectively. CONCLUSION: Delaying surgery for thyroid cancer is associated with worse survival. However, independent of time to surgery and other confounders, there remains a disparity as black patients have poorer outcomes.

Sex differences and racial/ethnic disparities in the presentation and treatment of medullary thyroid cancer.

BACKGROUND: This study assessed for disparities in the presentation and management of medullary thyroid cancer (MTC). METHODS: Patients with MTC (2010-2020) were identified from the National Cancer Database. Differences in disease presentation and likelihood of guideline-concordant surgical management (total thyroidectomy and resection of ≥1 lymph node) were assessed by sex and race/ethnicity. RESULTS: Of 6154 patients, 68.2% underwent guideline-concordant surgery. Tumors >4 â€‹cm were more likely in men (vs. women: OR 2.47, p â€‹< â€‹0.001) and Hispanic patients (vs. White patients: OR 1.52, p â€‹= â€‹0.001). Non-White patients were more likely to have distant metastases (Black: OR 1.63, p â€‹= â€‹0.002; Hispanic: OR 1.44, p â€‹= â€‹0.038) and experienced longer time to surgery (Black: HR 0.66, p â€‹< â€‹0.001; Hispanic: HR 0.71, p â€‹< â€‹0.001). Black patients were less likely to undergo guideline-concordant surgery (OR 0.70, p â€‹= â€‹0.022). CONCLUSIONS: Male and non-White patients with MTC more frequently present with advanced disease, and Black patients are less likely to undergo guideline-concordant surgery.

The use of thyroid isthmusectomy for management of well differentiated thyroid carcinoma - A systematic review and meta-analysis.

OBJECTIVE: With the growing global incidence of thyroid carcinomas, there is an increasing need for distinct guidelines for isthmus-confined carcinomas. Here, we performed the first systematic review on the topic to date, aiming to provide understanding to isthmusectomy as surgical management for well-differentiated thyroid carcinoma of the isthmus. METHODS: We conducted a systematic review following the PRISMA guidelines, analyzing English-language studies from the past decade that report on thyroid isthmusectomy. Exclusion criteria included isthmusectomy performed alongside full thyroidectomy or partial thyroid lobectomy, lack of data on tumor characteristics or survival outcomes, and non-English publications where a translation was unavailable. Our review identified a total of 227 patients from seven studies. RESULTS: The average 5-year overall survival and disease-free survival rates for patients with isthmus-confined PTC who underwent isthmusectomy were 100 % and 93.1 %, respectively. Similar to that of total thyroidectomy. 3.1 % of patients required completion thyroidectomy. Furthermore, isthmusectomy resulted in fewer surgical complications than total thyroidectomy. CONCLUSIONS: The scarcity of studies providing detailed tumor characteristics and patient outcomes limits our ability to fully evaluate the safety and efficacy of isthmusectomy for isthmus-confined PTC. Additionally, the variable sample sizes and restricted geographic distribution of the included studies calls into questions the generalizability of their findings. Despite these limitations, the data suggest that isthmusectomy may be a viable surgical option for select patients with small, isthmus-confined PTC. In the absence of a randomized controlled trial on the noninferiority of isthmusectomy, significantly more publications are needed before strong conclusions can be drawn.

Routine Use of Preoperative Neck Ultrasound in Primary Hyperparathyroidism Identifies Coexisting Thyroid Disease and Improves Parathyroid Localization.

BACKGROUND: In Jan 2018, we began routinely obtaining neck ultrasound (US) with 123I/99Tc-sestamibi (MIBI) for parathyroid gland localization and to identify thyroid pathology in the setting of primary hyperparathyroidism (1HPT). The aim of this study is to assess if routine neck US is a useful adjunct to 123I/99Tc-MIBI in 1HPT. METHODS: Patients undergoing surgery for 1HPT with both 123I/99Tc-MIBI and US at our institution after implementation of routine US were reviewed. Biopsy and surgical management of thyroid pathology was evaluated. 123I/99Tc-MIBI and US results were compared to intraoperative findings to determine sensitivity and positive predictive value (PPV) for parathyroid localization. RESULTS: From January 2018 to September 2019, there were 423 patients (mean, 61 years) that met inclusion criteria (80% women). Thyroid nodules were found on US in 57%, mean size 1.3 + 0.8 cm. Fine needle aspiration (FNA) was performed in 87 patients with nodules (36%). 35 patients (8.5%) required total or partial thyroidectomy for diagnoses/treatment. Papillary thyroid cancer (PTC) was found in 3.5% of the cohort with micro-PTC 53% and PTC 1-2 cm 40%. A successful parathyroid operation for 1HPT was achieved in 98.6% of patients. Positive predictive value for localization of abnormal parathyroid glands was 97% when US and 123I/99Tc-MIBI had concordant findings. DISCUSSION: Routine use of US in 1HPT commonly identifies nodules that are benign or low-risk PTC. Ultrasound is less sensitive for parathyroid localization but when used with 123I/99Tc-MIBI, concordant imaging has a high PPV.

Insurance type is associated with appropriate use of surgical and adjuvant care for differentiated thyroid carcinoma.

BACKGROUND: We aimed to characterize the association between differentiated thyroid cancer (DTC) patient insurance status and appropriateness of therapy (AOT) regarding extent of thyroidectomy and radioactive iodine (RAI) treatment. METHODS: The National Cancer Database was queried for DTC patients diagnosed between 2010 and 2016. Adjusted odds ratios (AOR) for AOT, as defined by the American Thyroid Association guidelines, and hazard ratios (HR) for overall survival (OS) were calculated. A difference-in-differences (DD) analysis examined the association of Medicaid expansion with outcomes for low-income patients aged <65. RESULTS: A total of 224,500 patients were included. Medicaid and uninsured patients were at increased risk of undergoing inappropriate therapy, including inappropriate lobectomy (Medicaid 1.36, 95% confidence interval [CI]: 1.21-1.54; uninsured 1.30, 95% CI: 1.05-1.60), and under-treatment with RAI (Medicaid 1.20, 95% CI: 1.14-1.26; uninsured 1.44, 95% CI: 1.33-1.55). Inappropriate lobectomy (HR 2.0, 95% CI: 1.7-2.3, P < .001) and under-treatment with RAI (HR 2.3, 95% CI: 2.2-2.5, P < .001) were independently associated with decreased survival, while appropriate surgical resection (HR 0.3, 95% CI: 0.3-0.3, P < .001) was associated with improved odds of survival; the model controlled for all relevant clinico-pathologic variables. No difference in AOT was observed in Medicaid expansion versus non-expansion states with respect to surgery or adjuvant RAI therapy. CONCLUSION: Medicaid and uninsured patients are at significantly increased odds of receiving inappropriate treatment for DTC; both groups are at a survival disadvantage compared with Medicare and those privately insured.

Patient-Reported Outcomes Following Total Thyroidectomy for Graves' Disease.

Background: Graves' disease accounts for ∼80% of all cases of hyperthyroidism and is associated with significant morbidity and decreased quality of life. Understanding the association of total thyroidectomy with patient-reported quality-of-life and thyroid-specific symptoms is critical to shared decision-making and high-quality care. We estimate the change in patient-reported outcomes (PROs) before and after surgery for patients with Graves' disease to inform the expectations of patients and their physicians. Methods: PROs using the MD Anderson Symptom Inventory (MDASI) validated questionnaire were collected prospectively from adult patients with Graves' disease from January 1, 2015, to November 20, 2020, on a longitudinal basis. Survey responses were categorized as before surgery (≤120 days), short term after surgery (<30 days; ST), and long term after surgery (≥30 days; LT). Negative binomial regression was used to estimate the association of select covariates with PROs. Results: Eighty-five patients with Graves' disease were included. The majority were female (83.5%); 47.1% were non-Hispanic white and 35.3% were non-Hispanic black. The median thyrotropin (TSH) value before surgery was 0.05, which increased to 0.82 in ST and 1.57 in LT. In bivariate analysis, the Total Symptom Burden Score, a composite of all patient-reported burden, significantly reduced shortly after surgery (before surgery mean of 56.88 vs. ST 39.60, p < 0.001), demonstrating improvement in PROs. Furthermore, both the Thyroid Symptoms Score, including patient-reported thermoregulation, palpitations, and dysphagia, and the Quality-of-Life Symptom Score improved in ST and LT (thyroid symptoms, before surgery 13.88 vs. ST 8.62 and LT 7.29; quality of life, before surgery 16.16 vs. ST 9.14 and LT 10.04, all p < 0.05). After multivariate adjustment, the patient-reported burden in the Thyroid Symptom Score and the Quality-of-Life Symptom Score exhibited reduction in ST (thyroid symptoms, rate ratio [RR] 0.55, confidence interval [CI]: 0.42-0.72; quality of life, RR 0.57, CI: 0.40-0.81) and LT (thyroid symptoms, RR 0.59, CI: 0.44-0.79; quality of Life, RR 0.43, CI: 0.28-0.65). Conclusions: Quality of life and thyroid-specific symptoms of Graves' patients improved significantly from their baseline before surgery to both shortly after and longer after surgery. This work can be used to guide clinicians and patients with Graves' disease on the expected outcomes following total thyroidectomy.

Radioactive iodine does not improve overall survival for patients with aggressive variants of papillary thyroid carcinoma less than 2 cm.

BACKGROUND: Tall cell and diffuse sclerosing variants of papillary thyroid cancer are associated with aggressive features. Radioactive iodine after total thyroidectomy is poorly studied. METHODS: Patients ≥18 years in the National Cancer Data Base from 2004 to 2016 with classic papillary thyroid cancer, tall cell, or diffuse sclerosing 1 mm to 40 mm were identified. Logistic regression identified factors associated with aggressive features. Overall survival was assessed using Kaplan-Meier method and log-rank tests, after propensity score matching for clinicopathological and treatment variables. RESULTS: A total of 155,940 classic papillary thyroid cancer patients, 4,011 tall cell, and 507 diffuse sclerosing were identified. Tall cell patients represented an increasing proportion of the study population during the analysis period, whereas diffuse sclerosing and classic papillary thyroid cancer patients showed a statistically significant decline. Extrathyroidal extension and nodal involvement were more prevalent among tall cell and diffuse sclerosing patients when compared to those diagnosed with classic papillary thyroid cancer (P < .01). Adjuvant radioactive iodine was less frequently used in patients with classic papillary thyroid cancer when compared to tall cell and diffuse sclerosing patients (42.6% vs 62.4%, 59.0%; P < .001, respectively). Aggressive variants receiving total thyroidectomy versus total thyroidectomy + radioactive iodine propensity score matched across clinicopathologic variables were analyzed. There was no difference in overall survival between the 2 treatment groups for tumors <2 cm (01-1.0 cm, 92.2% vs 84.8%; P = .98); (1.0-2.0 cm, 72.7% vs 88.1%; P = .82). However, overall survival was improved for total thyroidectomy + radioactive iodine propensity score matched patients with tumor sizes 21 to 40 mm versus total thyroidectomy (83.4% vs 70.0%, P = .004). CONCLUSION: For aggressive tumor variants ≤2 cm treated with total thyroidectomy, there is no overall survival advantage provided by the addition of adjuvant radioactive iodine.

Thyroid lobectomy as a cost-effective approach in low-risk papillary thyroid cancer versus active surveillance.

BACKGROUND: An ongoing debate exists over the optimal management of low-risk papillary thyroid cancer. The American Thyroid Association supports the concept of active surveillance to manage low-risk papillary thyroid cancer; however, the cost-effectiveness of active surveillance has not yet been established. We sought to perform a cost-effectiveness analysis comparing active surveillance versus surgical intervention for patients in the United States. METHODS: A Markov decision tree model was developed to compare active surveillance and thyroid lobectomy. Our reference case is a 40-year-old female who was diagnosed with unifocal (<15 mm), low-risk papillary thyroid cancer. Probabilistic outcomes, costs, and health utilities were determined using an extensive literature review. The willingness-to-pay threshold was set at $50,000/quality-adjusted life year gained. Sensitivity analyses were performed to account for uncertainty in the model's variables. RESULTS: Lobectomy provided a final effectiveness of 21.7/quality-adjusted life years, compared with 17.3/quality-adjusted life years for active surveillance. Furthermore, incremental cost effectiveness ratio for lobectomy versus active surveillance was $19,560/quality-adjusted life year (

Implications of radiofrequency ablation in patients undergoing thyroid surgery for benign disease in the United States.

BACKGROUND: Radiofrequency ablation is an alternative strategy for the management of benign thyroid conditions. We analyzed the proportion of patients who underwent thyroid surgery for benign conditions who would be potentially eligible for radiofrequency ablation. METHODS: We identified patients who underwent thyroid surgery from 2015 to 2019 at the study institution for Bethesda II cytopathology or toxic adenoma. Patients were considered potentially eligible for radiofrequency ablation if they had a dominant nodule >2 cm with or without compression symptoms, a dominant nodule <2 cm with compression symptoms, or a toxic adenoma. RESULTS: Of 411 patients in total, 284 (69.1%) would be eligible to consider thyroid radiofrequency ablation. In the radiofrequency ablation-eligible group, 20 (7.0%) experienced voice change after surgery, and 2 (0.7%) were dissatisfied or concerned about their scar. In the radiofrequency ablation-eligible group, 70 patients (24.6%) had malignancy diagnosed by final pathology, and 23 patients (8.1%) had cancers that were equal to or larger than 1 cm in size. CONCLUSION: Many patients who undergo surgery for benign thyroid disease could be considered for radiofrequency ablation as an alternative treatment modality. Given the rate of occult malignancy, optimal evaluation of nondominant nodules before radiofrequency ablation and long-term thyroid surveillance for patients who undergo radiofrequency ablation should be further studied.

Medullary thyroid cancer: What is the optimal management of the lateral neck in a node negative patient at index operation?

BACKGROUND: Medullary thyroid cancer is a neuroendocrine malignancy that can occur sporadically or as the result of genomic rearranged during transfection mutations. Medullary thyroid cancer has a higher rate of metastasis than well-differentiated thyroid cancer. Lateral neck dissection is often performed, and its prophylactic use is controversial. METHODS: Single-center, retrospective review (2000-2017) of patients undergoing primary surgical treatment for medullary thyroid cancer who had negative lateral neck imaging preoperatively. Demographics, genetic associations, clinical, and imaging findings were analyzed. Locoregional recurrence, overall recurrence, and overall survival were examined. RESULTS: A total of 110 patients were identified, of which 18 underwent prophylactic lateral neck dissection and 92 did not. Age, sex distribution, preoperative calcitonin levels, and follow-up were similar among groups. Overall recurrence was 20% for no prophylactic lateral neck dissection and 39% for prophylactic lateral neck dissection (P = .46). Most recurrences were locoregional recurrence, 7.6% for no prophylactic lateral neck dissection versus 22% for prophylactic lateral neck dissection (P = .08), half of it being to the lateral neck in both groups. A total of 7 patients from the no prophylactic lateral neck dissection group required treatment for recurrences versus 4 patients in prophylactic lateral neck dissection group (P = .57). Overall survival at 5 years was similar, 43% the no prophylactic lateral neck dissection group and 31% for prophylactic lateral neck dissection group (P = .52). CONCLUSION: Lateral neck dissection has no effect in decreasing locoregional or overall recurrences in medullary thyroid cancer and has no effect in overall survival when performed prophylactically at index surgical intervention.

Cost analysis of reflexive versus selective molecular testing for indeterminate thyroid nodules.

BACKGROUND: Molecular testing is now commonly used to refine the diagnosis of indeterminate thyroid nodules. The purpose of this study is to compare the costs of a reflexive molecular testing strategy to a selective testing strategy for indeterminate thyroid nodules. METHODS: A Markov model was constructed to estimate the annual cost of diagnosis and treatment of a real-world cohort of patients with cytologically indeterminate thyroid nodules, comparing a reflexive testing strategy to a selective testing strategy. Model variables were abstracted from institutional clinical trial data, literature review, and the Medicare physician fee schedule. RESULTS: The average cost per patient in the reflexive testing strategy was $8,045, compared with $6,090 in the selective testing strategy. In 10,000 Monte Carlo simulations, diagnostic thyroid lobectomy for benign nodules was performed in 2,440 patients in the reflexive testing arm, compared with 3,389 patients in the selective testing arm, and unintentional observation for malignant nodules occurred in 479 patients in the reflexive testing arm, compared with 772 patients in the selective testing arm. The cost of molecular testing had the greatest impact on overall costs, with $1,050 representing the cost below which the reflexive testing strategy was cost saving compared with the selective testing strategy. CONCLUSION: In this cost-modeling study, reflexive molecular testing for indeterminate thyroid nodules enabled patients to avoid unnecessary thyroid lobectomy at an estimated cost of $20,600 per surgery avoided.

Surgical Management of Low-/Intermediate-Risk Node Negative Thyroid Cancer: A Single-Institution Study Using Propensity Matching Analysis to Compare Thyroid Lobectomy and Total Thyroidectomy.

Background: The approach for surgical treatment of patients with low-/intermediate-risk T1T2N0/Nx well-differentiated thyroid cancer (WDTC)-total thyroidectomy (TT) versus thyroid lobectomy (TL)-remains a controversial topic. Conducting a randomized controlled trial (RCT) would be the gold standard to address this issue. However, this is challenging due to excellent survival outcomes, and therefore, high number of patients and long-term follow-up would be required. As an alternative to RCT, we have used propensity score (PS) matching to determine if T1T2N0/Nx patients selected to have TL had equivalent outcomes to a similar group treated with TT. Methods: After institutional review board approval, a database of 6259 patients with WDTC treated with primary surgery at our institution between 1985 and 2016 was analyzed to identify patients with T1T2N0/Nx cancers. Of 3756 patients identified, 943 were managed by TL and 2813 by TT. To control for possible confounders and reduce potential bias, we selected age, sex, histology, 131I therapy, American Thyroid Association risk, and American Joint Committee Cancer stage as our PS matching criteria. Subsequently, 918 TL patients were successfully matched with 918 TT patients. The Pearson χ2 test or Fisher's exact test was used to compare categorical covariates, and Student's t-test was used for comparison of continuous variables between the two groups. Disease-specific survival (DSS), overall survival (OS), and recurrence-free survival (RFS) were calculated using the Kaplan-Meier method and compared using the log-rank test. Results: After PS matching, there were no significant differences between TL and TT patients for OS (10-year OS: 92.2% vs. 91.3%, p = 0.9668), DSS (10-year DSS: 100% vs. 99.1%, p = 0.1967), or RFS (10-year RFS: 99.5% vs. 98.3%, p = 0.079). Conclusions: For low-/intermediate-risk patients with intrathyroidal thyroid cancer <4 cm, patients selected for TL have similar survival outcomes to a comparable group treated by TT.

Association of the Affordable Care Act with access to highest-volume centers for patients with thyroid cancer.

BACKGROUND: Disparities exist in access to high-volume surgeons, who have better outcomes after thyroidectomy. The association of the Affordable Care Act's Medicaid expansion with access to high-volume thyroid cancer surgery centers remains unclear. METHODS: The National Cancer Database was queried for all adult thyroid cancer patients diagnosed from 2010 to 2016. Hospital quartiles (Q1-4) defined by operative volume were generated. Clinicodemographics and adjusted odds ratios for treatment per quartile were analyzed by insurance status. An adjusted difference-in-differences analysis examined the association between implementation of the Affordable Care Act and changes in payer mix by hospital quartile. RESULTS: In total, 241,448 patients were included. Medicaid patients were most commonly treated at Q3-Q4 hospitals (Q3 odds ratios 1.05, P = .020, Q4 1.11, P < .001), whereas uninsured patients were most often treated at Q2-Q4 hospitals (Q2 odds ratios 2.82, Q3 2.34, Q4 2.07, P < .001). After expansion, Medicaid patients had lower odds of surgery at Q3-Q4 compared with Q1 hospitals (odds ratios Q3 0.82, P < .001 Q4 0.85, P = .002) in expansion states, but higher odds of treatment at Q3-Q4 hospitals in nonexpansion states (odds ratios Q3 2.23, Q4 1.86, P < .001). Affordable Care Act implementation was associated with increased proportions of Medicaid patients within each quartile in expansion compared with nonexpansion states (Q1 adjusted difference-in-differences 5.36%, Q2 5.29%, Q3 3.68%, Q4 3.26%, P < .001), and a decrease in uninsured patients treated at Q4 hospitals (adjusted difference-in-differences -1.06%, P = .001). CONCLUSIONS: Medicaid expansion was associated with an increased proportion of Medicaid patients undergoing thyroidectomy for thyroid cancer in all quartiles, with increased Medicaid access to high-volume centers in expansion compared with nonexpansion states.