The role of imaging in Graves’ disease: A cost-effectiveness analysis
Abstract
According to many guidelines, scintigraphy remains the first suggested diagnostic procedure in hyperthyroid patients in spite of the widespread availability of ultrasounds. The aim of this study was to evaluate the cost-effectiveness of sonography versus scintigraphy in the management of Graves's disease, and to assess ultrasound features suggesting cancer in detecting thyroid nodules. Among 1470 hyperthyroid patients evaluated in our department from 2002 to 2005, 426 (29%) had Graves' disease: echographic and scintigraphic features were not suggestive of GD in 20/426 (4.8%) and 11/426 (2.6%) patients, respectively (p=0.763), even if one of the two procedures was almost always diagnostic. Ultrasound identified 68/426 (16%) patients with a concomitant solid lesion, while scintigraphy detected only 9/426 (2.1%) "cold" nodules (p<0.001). Thyroid cancer was diagnosed in 30/68 (47.7%) patients. Malignancy presented at ultrasound investigation blurred margins (26.7% versus 15.8%), microcalcifications (33.3% versus 28.9%) and an anteroposterior and transverse diameter ratio>or=1 (73.3% versus 71.1%); more frequently than benign nodules, but this was not statistically significant. The total cost to obtain a diagnosis by ultrasound was euro14645.34 (euro13312.5 for echography+euro1332.84 for scintigraphy in the 29 patients "negative" at echographic evaluation for GD) versus euro19922.71 by scintigraphy (euro19578.96 for scan+euro343.75 for ultrasounds in the 11 patients "negative" at scintigraphy). Our data show no difference in terms of diagnosis between sonography and scintigraphy. Indeed, scintigraphy was less sensitive in detecting nodules (often of malignant nature) than ultrasound, and, moreover, with a consequent increase of the direct cost of nodule management when scintigraphy is the first line procedure. In conclusion, according to our results, we suggest that ultrasounds with color-Doppler evaluation should be performed as first step in all hyperthyroid patients, and that scintigraphic examination should be limited only to the uncommon cases, where physician's observation, laboratory assays and/or ultrasounds are not diagnostic.
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The use of thyroid ultrasonography in all patients with GD has been shown to identify more nodules and cancer than does palpation and 123I scintigraphy.
“The use of thyroid ultrasonography in all patients with GD has been shown to identify more nodules and cancer than does palpation and 123 I scintigraphy.”
From 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis (2016) · cites this paper as [223]
Most cancers identified by thyroid ultrasonography in patients with GD are papillary microcarcinomas with minimal clinical impact.
“However, since most of these cancers are papillary microcarcinomas with minimal clinical impact, further study is required before routine ultrasound (which may lead to surgery) can be recommended (223,224).”
From 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis (2016) · cites this paper as [223]
Cites
THE SPECTRUM OF THYROID DISEASE IN A COMMUNITY: THE WHICKHAM SURVEY
Tunbridge, W. M. G., Evered, D. C., Hall, R., Appleton, D. R., BREWIS, M., CLARK, F., Evans, J. G., Young, E. T., Bird, T., & Smith, P. (1977) · Clinical Endocrinology · doi:10.1111/j.1365-2265.1977.tb01340.x · Cited by 2,665 · see citing works
Hegedűs, L. D. (2004) · New England Journal of Medicine · doi:10.1056/nejmcp031436 · Cited by 1,498 · see citing works
Baskin, H. J., Cobin, R. H., Duick, D. S., Gharib, H., Guttler, R. B., Kaplan, M. M., Segal, R. L., Garber, J. R., Hamilton Jr, C. R., Handelsman, Y., et al. (2002) · Endocrine Practice · doi:10.4158/1934-2403-8.6.457 · Cited by 673 · see citing works
Solitary thyroid nodule. Comparison between palpation and ultrasonography
Tan, G. H. (1995) · Archives of Internal Medicine · doi:10.1001/archinte.155.22.2418 · Cited by 225 · see citing works
Thyroid palpation versus high-resolution thyroid ultrasonography in the detection of nodules.
Wiest, P. W., Hartshorne, M. F., Inskip, P. D., Crooks, L. A., Vela, B. S., Telepak, R. J., Williamson, M. R., Blumhardt, R., Bauman, J., & Tekkel, M. (1998) · Journal of Ultrasound in Medicine · doi:10.7863/jum.1998.17.8.487 · Cited by 223 · see citing works
Thyroid nodule shape suggests malignancy
Cappelli, C., Castellano, M., Pirola, I., et al. (2006) · European Journal of Endocrinology · doi:10.1530/eje.1.02177 · Cited by 210 · see citing works
Self-citationThe continuing importance of thyroid scintigraphy in the era of high-resolution ultrasound
Meller, J., & Becker, W. (2002) · European Journal of Nuclear Medicine and Molecular Imaging · doi:10.1007/s00259-002-0811-8 · Cited by 158 · see citing works
Outcome of Differentiated Thyroid Cancer in Graves’ Patients1
Pellegriti, G., Belfiore, A., Giuffrida, D., Lupo, L., & Vigneri, R. (1998) · The Journal of Clinical Endocrinology & Metabolism · doi:10.1210/jcem.83.8.4997 · Cited by 150 · see citing works
Graves' disease, thyroid nodules and thyroid cancer
Belfiore, A., Russo, D., Vigneri, R., & Filetti, S. (2001) · Clinical Endocrinology · doi:10.1046/j.1365-2265.2001.01415.x · Cited by 146 · see citing works
Torlontano, M., Crocetti, U., Augello, G., D’Aloiso, L., Bonfitto, N., Varraso, A., Dicembrino, F., Modoni, S., Frusciante, V., Giorgio, A. D., et al. (2006) · The Journal of Clinical Endocrinology & Metabolism · doi:10.1210/jc.2005-1185 · Cited by 137 · see citing works
Thyroid carcinoma in thyrotoxic patients treated by surgery
Pacini, F., Elisei, R., Coscio, G. C. D., et al. (1988) · Journal of Endocrinological Investigation · doi:10.1007/bf03350115 · Cited by 129 · see citing works
Cappelli, C., Pirola, I., Cumetti, D., Micheletti, L., Tironi, A., Gandossi, E., MARTINO, E. D., Cherubini, L., Agosti, B., Castellano, M., et al. (2005) · Clinical Endocrinology · doi:10.1111/j.1365-2265.2005.02406.x · Cited by 120 · see citing works
Self-citationThyroid Nodules in Graves' Disease: Classification, Characterization, and Response to Treatment
Carnell, N. E., & VALENTE, W. A. (1998) · Thyroid · doi:10.1089/thy.1998.8.571 · Cited by 108 · see citing works
Neumann, F. (2009) · Experimental and Clinical Endocrinology & Diabetes · doi:10.1055/s-0029-1211261 · Cited by 87 · see citing works
Thyroid Nodules in Graves' Disease: Classification, Characterization, and Response to Treatment
Carnell, N. E., & VALENTE, W. A. (1998) · Thyroid · doi:10.1089/thy.1998.8.647 · Cited by 83 · see citing works
Benign Thyroid Disease: What Is the Role of Nuclear Medicine?
Sarkar, S. D. (2006) · Seminars in Nuclear Medicine · doi:10.1053/j.semnuclmed.2006.03.006 · Cited by 74 · see citing works
The Spectrum and Significance of Autoantibodies Reacting with the Thyrotropin Receptor
Zakarija, M., & McKenzie, J. M. (1987) · Endocrinology and Metabolism Clinics of North America · doi:10.1016/s0889-8529(18)30483-3 · Cited by 74 · see citing works
Outcome of Differentiated Thyroid Cancer in Graves' Patients
Pellegriti, G. (1998) · The Journal of Clinical Endocrinology & Metabolism · doi:10.1210/jc.83.8.2805 · Cited by 73 · see citing works
Vitti, P., Rago, T., Mancusi, F., Pallini, S., Tonacchera, M., Santini, F., Chiovato, L., Marcocci, C., & Pinchera, A. (1992) · European Journal of Endocrinology · doi:10.1530/acta.0.1260128 · Cited by 72 · see citing works
Cappelli, C., Braga, M., MARTINO, E. D., et al. (2006) · Surgery Today · doi:10.1007/s00595-005-3115-3 · Cited by 68 · see citing works
Self-citationMeasurement of Thyroid Blood Flow Area Is Useful for Diagnosing the Cause of Thyrotoxicosis
Kurita, S., Sakurai, M., Kita, Y., Ota, T., Ando, H., Kaneko, S., & Takamura, T. (2005) · Thyroid · doi:10.1089/thy.2005.15.1249 · Cited by 56 · see citing works
Grey scale thyroid ultrasonography in the evaluation of patients with Graves' disease
Vitti, P. (2000) · European Journal of Endocrinology · doi:10.1530/eje.0.1420022 · Cited by 46 · see citing works
Boi, F., Loy, M., Piga, M. A., Serra, A., Atzeni, F., & Mariotti, S. (2000) · European Journal of Endocrinology · doi:10.1530/eje.0.1430339 · Cited by 33 · see citing works
Saleh, A., Cohnen, M., Fürst, G., et al. (2002) · Experimental and Clinical Endocrinology & Diabetes · doi:10.1055/s-2002-19992 · Cited by 32 · see citing works
Kaplan, M. M., & Utiger, R. D. (1978) · Clinics in Endocrinology and Metabolism · doi:10.1016/s0300-595x(78)80037-1 · Cited by 31 · see citing works
Power Doppler sonography in the diagnosis of Graves’ disease
Arslan, H., Unal, O., Algün, E., et al. (2000) · European Journal of Ultrasound · doi:10.1016/s0929-8266(99)00079-8 · Cited by 30 · see citing works
Stocker, D. J., Foster, S. S., Solomon, B. L., et al. (2002) · Thyroid · doi:10.1089/10507250252949432 · Cited by 27 · see citing works
Baldini, M., Orsatti, A., Bonfanti, M. T., Castagnone, D., & CANTALAMESSA, L. (2005) · Journal of Clinical Ultrasound · doi:10.1002/jcu.20157 · Cited by 20 · see citing works
Dasgupta, S., & Savage, M. W. (2005) · International Journal of Clinical Practice · doi:10.1111/j.1742-1241.2005.00545.x · Cited by 12 · see citing works
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Ross, D. S., Burch, H. B., Cooper, D. S., Greenlee, M. C., Laurberg, P., Maia, A. L., Rivkees, S. A., Samuels, M., Sosa, J. A., Stan, M. N., et al. (2016) · Thyroid® · doi:10.1089/thy.2016.0229 · Cited by 2,938 · see citing works
“However, since most of these cancers are papillary microcarcinomas with minimal clinical impact, further study is required before routine ultrasound (which may lead to surgery) can be recommended (223,224).”
BackgroundBahn, R. S., Burch, H. B., Cooper, D. S., Garber, J. R., Greenlee, M. C., Klein, I., Laurberg, P., McDougall, I. R., Montori, V. M., Rivkees, S. A., et al. (2011) · Endocrine Practice · doi:10.4158/ep.17.3.456 · Cited by 1,098 · see citing works
The American Thyroid Association and American Association of Clinical Endocrinologists Taskforce on Hyperthyroidism and Other Causes of Thyrotoxicosis, Bahn, R. S., Burch, H. B., Cooper, D. S., Garber, J. R., Greenlee, M. C., Klein, I., Laurberg, P., McDougall, I. R., Montori, V. M., et al. (2011) · Thyroid · doi:10.1089/thy.2010.0417 · Cited by 898 · see citing works
De Leo, S., Lee, S. Y., & Braverman, L. E. (2016) · The Lancet · doi:10.1016/s0140-6736(16)00278-6 · Cited by 883 · see citing works
Kahaly, G. J., Bartalena, L., & Hegedüs, L. (2011) · Thyroid® · doi:10.1089/thy.2011.2106.ed3 · Cited by 80 · see citing works
- Authors
- Cappelli, C., Pirola, I., De Martino, E., Agosti, B., Delbarba, A., Castellano, M., & Rosei, E. A.
- Affiliations
- University of Brescia (IT)
- Corresponding author
- Cappelli, C.
- Venue
- European Journal of Radiology
- Publisher
- Elsevier BV
- Published
- 2008-01
- Volume
- 65
- Issue
- 1
- Pages
- 99-103
- ISSN
- 0720-048X (ISSN-L)
- OpenAlex
- W2140801903
- Cited by
- 65
- References
- 29
- Citations by year
- 2026: 1 · 2025: 1 · 2024: 1 · 2023: 2 · 2022: 3 · 2021: 5 · 2020: 5 · 2019: 5 · 2018: 2 · 2017: 2 · 2016: 5 · 2015: 4 · 2014: 2 · 2013: 4 · 2012: 4
- FWCI
- 2.69
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- European Journal of Radiology (publishedVersion)
- PubMed (publishedVersion)
- Institutional Research Information System (Università degli Studi di Brescia) (submittedVersion)
- Topics
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Thyroid Cancer Diagnosis and Treatment
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Thyroid Disorders and Treatments
- Health Sciences › Medicine › Surgery › Thyroid and Parathyroid Surgery
- Keywords
- Graves' disease, thyroid ultrasound, thyroid scintigraphy, cost-effectiveness, hyperthyroidism, thyroid nodules, thyroid cancer detection, cold thyroid nodules, color Doppler ultrasound, diagnostic accuracy, diagnostic imaging selection, microcalcifications
- MeSH terms
- Female, Graves Disease, Humans, Male, Middle Aged, Predictive Value of Tests, Sensitivity and Specificity, Tomography, Emission-Computed, Chi-Square Distribution, Ultrasonography, Doppler, Color
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