The value of frozen section examinations in determining the extent of thyroid surgery in patients with indeterminate fine-needle aspiration cytology

Objectives: To determine the usefulness of intraoperative frozen section (FS) examinations in establishing the diagnosis of thyroid cancer in patients undergoing thyroidectomy for nodules with indeterminate cytological features and to determine the cost-effectiveness of FS examinations in this situation. Design: Retrospective medical record review. The results of fine-needle aspiration biopsies (FNABs), FS examinations, and final pathologic examinations are compared. A cost-effectiveness analysis of routine FS examinations compared with the cost of additional surgical procedures is performed. Setting: A private surgical practice in a medical school-affiliated teaching hospital. Patients: The records of all 480 patients undergoing thyroidectomy between January 1, 1998, and September 30, 2000, were reviewed. All 199 patients with a dominant thyroid nodule and FNAB results either highly suggestive of papillary cancer or indeterminate were studied. Results: Of the patients with FNAB results highly suggestive of papillary cancer, 95% had cancer according to the final pathologic examination results. The diagnosis of cancer was made by FS examination results in 67% of these patients. Of the remaining 178 patients whose FNAB result was indeterminate, 64 (36%) had thyroid cancer. Malignancy was diagnosed by FS examination results in 30 (47%) of these patients. If FS examinations had not been performed, these 30 patients would have required a second operation to complete a total thyroidectomy. The cost savings of routine FS examinations in patients with indeterminate FNAB results is $1298 per patient. Conclusions: The routine performance of FS examinations in patients with thyroid nodules with indeterminate cytological features is a cost-effective way of avoiding a second surgical procedure if a total thyroidectomy is indicated. In patients with FNAB results highly suggestive of papillary cancer, FS examinations are not useful. In these patients, the definitive operation can be based on the results of the FNAB.