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American Head & Neck Society
Translational Research Meeting

April 21-22, 2015

AHNS Annual Meeting
April 22-23, 2015 during the
Combined Otolaryngology Spring Meetings


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Cost Effectiveness Of Intraoperative Pathology In The Management Of Indeterminate Thyroid Nodules

Presentation: S018
Topic: Endocrine Surgery
Type: COSM
Date: Thursday, April 23, 2015
Session: 8:00 AM - 9:00 AM Scientific Session #4
Authors: Christopher Vuong, MD, Daniel Kwon, MD, Alfred Simental, MD, Cherine Kim, Sonia Mohan, MD, Pedro Andrade Filho, MD, Mia Perez, MD, Steve Lee, MD, PhD
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Institution(s): Loma Linda University Medical Center
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Intro: Fine-needle aspiration (FNA) is a widely used method to determine the preoperative malignancy potential of thyroid nodules using the Bethesda Thyroid Scale (BTS).  Rapid frozen section (RFS) can also be used in attempt to identify the presence of thyroid malignancy. FNA has proven to be sensitive for identifying papillary carcinoma. However, Follicular Lesions (FL), Atypia of Undetermined Significance (AUS) or Follicular Lesion of Undetermined Significance (FLUS), which are classified as BTS III/IV, present more of a challenge in identifying or excluding malignancy. Preoperative or intraoperative identification of malignancy may prevent reoperation in patients with lesions requiring total thyroidectomy.  RFS may be useful in determining malignancy in AUS, FLUS, and FL, and help avoid re-operation. Our objective is to determine the efficacy of RFS in detecting thyroid malignancy and to use a cost-analysis model to compare routine frozen section versus a secondary operation in patients who have indeterminate FNA that are discovered to have malignancy on final pathology.

Methods: A retrospective chart review was conducted at the Loma Linda University Medical Center (LLUMC) between January 2009 and June 2013 on 1114 patients who were identified with preoperative FNA for thyroid lesions and subsequently underwent intraoperative RFS during thyroidectomy. Patients with a cytologic diagnosis of AUS, FLUS or FL on FNA had their pathology results evaluated to correlate the intraoperative RFS and final pathology report.  Specifically, the impact of RFS on surgical management and avoidance of additional surgery was determined. Cost analysis was performed comparing estimated costs at our institution for intraoperative pathology consultation versus second thyroid surgery.

Results: Of the 1114 patients initially identified, 314 patients had FNA showing AUS or FLUS with 32 of these patients harboring malignancy.  RFS identified malignancy in 13 of 32 patients resulting in total thyroidectomy, avoiding a second surgical event. RFS was unable to detect malignancy in 19 patients who eventually had malignancy seen on final pathology. Of these false negatives, 7 were micropapillary carcinoma and these patients elected for observation. However, 12 patients eventually required a second surgery. There were no false positives for RFS pathology indicating malignancy. In our series, for every 24 patients with AUS or FLUS, RFS allowed one patient to avoid a second surgery.  Accounting for the additional cost of intraoperative RFS analysis contrasted with avoiding re-operation, routine use of RFS in AUS or FLUS at our institution resulted in approximate savings of $14 per surgery in this population.

Conclusion: Rapid frozen section detected malignancy in 4% of patients with BTS III/IV FNA, preventing a second surgical procedure in these patients. This practice appears to be essentially cost-neutral when used to avoid re-operation for completion thyroidectomy. Considering the additional socioeconomic effects and social burdens of each surgical event, intraoperative rapid frozen section analysis appears to be a useful tool in patients with indeterminate FNA pathology. 

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