Differentiated thyroid cancer: an update

The incidence of differentiated thyroid cancer (DTC) is increasing. There remains controversy regarding several aspects of its management, including the need for prophylactic central compartment neck dissection and use of recombinant human thyroid stimulating hormone (rhTSH) for ¹³¹I radioactive iodine remnant ablation in patients with low-risk disease.

Central compartment neck dissection entails removal of the prelaryngeal, pretracheal, and paratracheal lymph nodes. Description of the dissection should include the indication (prophylactic vs. therapeutic) and extent of dissection (unilateral vs. bilateral). After 3.7 years, patients who underwent rhTSH-assisted ablation appeared to have similar rates of ablation as patients who underwent thyroid hormone withdrawal using criteria of negative whole body scans (84% of euthyroid and 94% of hypothyroid patients) and stimulated thyroglobulin less than 2 ng/ml (95%, euthyroid; 96%, hypothyroid). In the United States, rhTSH would cost $15,994 per patient, with an incremental societal cost of $1365 per patient and incremental cost-effectiveness ratio of $52,554/quality-adjusted-life-year.

The use of rhTSH in patients with low-risk DTC undergoing thyroid remnant ablation appears to have similar efficacy in remnant ablation and tumoricidal effects and is associated with improved patient quality of life. Cost-effectiveness appears to be above the conventional threshold for cost-effectiveness, but is dependent on cost of rhTSH, patient utility, days off work, and rates of remnant ablation.