Health-related quality of life following FDG-PET/CT for cytological indeterminate thyroid nodules

Abstract

Objective: This study assessed the health-related quality of life (HRQoL) in patients undergoing 2-[18F]fluoro-2-deoxy-D-glucose (FDG)-PET/CT for an indeterminate (Bethesda III/IV) thyroid nodule. FDG-PET/CT accurately rules out malignancy and prevents 40% of futile diagnostic surgeries in these nodules.

Design: Secondary analyses of HRQoL data from a randomised controlled multicentre trial (NCT02208544) in 126 patients from 15 hospitals in the Netherlands were done.

Methods: Longitudinal HRQoL assessment was performed using the EuroQol 5-dimension 5-level (EQ-5D-5L), the RAND 36-item Health Survey v2.0 (RAND-36), and the Thyroid Patient-Reported Outcome (ThyPRO) questionnaire on baseline, 3, 6, and 12 months, relative to the date of the FDG-PET/CT scan.

Results: Patients who were randomised to active surveillance following an FDG-negative nodule instead of diagnostic surgery reported stable HRQoL scores throughout the year. Univariate analysis indicated better HRQoL for patients undergoing surveillance than surgical patients with benign histopathology on multiple physical and psychosocial domains. Univariate within-group analysis suggested both temporary and continued HRQoL deteriorations in patients with benign histopathology over time. Multivariate within-group analysis demonstrated no significant longitudinal HRQoL changes in patients undergoing active surveillance. In contrast, in patients with benign histopathology, worse HRQoL was observed with regard to ThyPRO cognitive impairment (P = 0.01) and cosmetic complaints (P = 0.02), whereas goitre symptoms (P < 0.001) and anxiety (P = 0.04) improved over time. In patients with malignant histopathology, anxiety also decreased (P = 0.05).

Conclusions: The reassurance of a negative FDG-PET/CT resulted in sustained HRQoL throughout the first year of active surveillance. Diagnostic surgery for a nodule with benign histopathology resulted in more cognitive impairment and physical problems including cosmetic complaints, but improved goitre symptoms and anxiety. Anxiety was also reduced in patients with malignant histopathology.

Keywords: Bethesda; FDG-PET/CT; diagnostic thyroid surgery; health-related quality of life; indeterminate cytology; thyroid nodule.

Figure 1

Study flowchart of the first year, visualizing the study procedures, observed treatment, treatment outcomes, and excluded patients. *One patient had a TSC and POHT. †One patient underwent RAI after initial TT for malignancy; two patients underwent cTT for malignancy but no RAI. cTT, completing total thyroidectomy; F/u, follow-up; HT, hemithyroidectomy, including isthmus resection (n = 3) and hemithyroidectomy plus nodulectomy (n = 2); POHT, postoperative levothyroxine-dependent hypothyroidism after partial thyroidectomy procedure; PSC, permanent surgical complication, including recurrent nerve paralysis (n = 3); RAI, adjuvant radioiodine therapy; TT, total thyroidectomy; TSC, transient surgical complication, including haematoma with re-exploration surgery, wound infection, seroma, and transient hypoparathyroidism.

Figure 2

Within-group changes in mean ThyPRO scores over time. For the ThyPRO, scores range from 0 (best score) to 100 (worst score). The P value indicates the statistically significant within-group differences between two assessments over time, using a paired samples t-test. Full data, including mean differences and other P values, are presented in Supplementary Table 3. *Indicates clinically relevant difference using the MIC values established by Nordqvist et al. (31). MIC, minimally important change; ThyPRO, Thyroid Patient-Reported Outcome.