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Endocrine Care: Kevin Cheung, Sanziana A. Roman, Tracy S. Wang, Hugh D. Walker, and Julie Ann Sosa Calcitonin Measurement in the Evaluation of Thyroid Nodules in the United States: A Cost-Effectiveness and Decision Analysis J Clin Endocrinol Metab 2008; 93: 2173-2180 [Abstract] [Full text] [PDF]

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Julie Ann Sosa, Kevin Cheung , Tracy S. Wang, Sanziana A. Roman   (9 September 2008)

Cost effectiveness of calcitonin for thyroid nodules

Yair Liel   (5 August 2008)

Response to Letter 9 September 2008
Julie Ann Sosa, MA, MD Yale University School of Medicine, Kevin Cheung , Tracy S. Wang, Sanziana A. Roman Send letter to journal: Re: Response to Letter julie.sosa{at}yale.edu Julie Ann Sosa, et al.	We thank Dr. Liel for his interest in our paper. In response to his question, our analysis does account for the cases of medullary thyroid cancer (MTC) that would be diagnosed by fine needle aspiration (FNA), as per the American Thyroid Association guidelines. Dr. Liel’s next point that “most of the cases of MTC [are] diagnosed by FNA” is true, but more complicated than it seems. The inherent advantage of serum calcitonin screening is that it is exquisitely sensitive to detecting MTC. Pacini et al. (1) found that FNA had a sensitivity of 37% for MTC; Costante et al. (2) demonstrated an FNA sensitivity of 47% for MTC. As Pacini et al. (1) notes, FNA cytology in unsuspected cases of MTC is often confused with other thyroid cancers, and typical cytological features may be missed without special staining techniques. Technical considerations of FNA may further limit detection. In the study by de la Serna Saravia et al. (3), FNA sensitivity for MTC is reported at 94%. This may be an overestimate, however, as the authors focus only on the sensitivity of cytological diagnosis of a total of 21 cases, reviewed by three pathologists of varying expertise, and omitting inadequate aspirates. They also only consider cases of histologically proven thyroid tumors; they do not report the outcome of the cases not undergoing surgery and histologic examination. We performed sensitivity analyses and found the cost-effectiveness of calcitonin screening to be robust. References 1. Pacini F, Fontanelli M, Fugazzola L, Elisei R, Romei C, Di Coscio G, Miccoli P, Pinchera A 1994 Routine measurement of serum calcitonin in nodular thyroid diseases allow the preoperative diagnosis of unsuspected sporadic medullary thyroid carcinoma. J Clin Endocrinol Metab 78:826-829 2. Costante G, Meringolo D, Durante C, Bianch D, Nocera M, Tumino S, Crocetti U, Attard M, Maranghi M, Torlontano M, Filetti S 2007 Predictive value of serum calcitonin levels for preoperative diagnosis of medullary thyroid carcinoma in a cohort of 5817 consecutive patients with thyroid nodules. J Clin Endocrinol Metab 92:450-455 3. de la Serna Saravia C, Cuellar F, Saravio Day E, Harach HR 2006 Accuracy of aspiration cytology in thyroid cancer: a study in 1 institution. Acta Cytol 50:384-387
Cost effectiveness of calcitonin for thyroid nodules 5 August 2008
Yair Liel, MD Soroka University Medical Center, Beer-Sheva, Israel Send letter to journal: Re: Cost effectiveness of calcitonin for thyroid nodules liel{at}bgu.ac.il Yair Liel	I read with interest the report by Cheung et al. on the cost-effectiveness of calcitonin measurement in the evaluation of thyroid nodules (1). The authors conclude that calcitonin measurement added as an initial step in thyroid nodule evaluation, consistent with the ATA guideline, appears to be cost-effective, i.e., similar to other accepted screening procedures. However, according to the ATA guideline, FNA of the nodule is a mandatory step following TSH measurement and a diagnostic ultrasound, and FNA has a comparable, usually high, diagnostic accuracy for medullary carcinoma as for papillary thyroid carcinoma (2, 3). It is not clear from the report whether the analysis by Cheung et al. accounted for the fact that most of the cases of medullary carcinoma would, anyway, be diagnosed by FNA, which would leave a very small number of patients with false-negative FNA for medullary carcinoma who would specifically and uniquely gain benefit from calcitonin measurements, and probably rendering its routine measurement cost-ineffective. References 1. Cheung K, Roman SA, Wang TS, Walker HD, Sosa JA. 2008 Calcitonin measurement in the evaluation of thyroid nodules in the United States: a cost-effectiveness and decision analysis. J Clin Endocrinol Metab 93:2173-2180 2. Radetic M, Kralj Z, Padovan I. 1984 Reliability of aspiration biopsy in thyroid nodes: study of 2190 operated patients. Tumori 70:271-276 3. Serna de la Saravia C, Cuellar F, Saravio Day E, Harach HR. 2006 Accuracy of aspiration cytology in thyroid cancer: a study in 1 institution. Acta Cytol 50:384-387