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Ann Thorac Surg 2008;86:934-940. doi:10.1016/j.athoracsur.2008.05.002
© 2008 The Society of Thoracic Surgeons
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Original Articles: General Thoracic

Radiotracer-Guided Thoracoscopic Resection is a Cost-Effective Technique for the Evaluation of Subcentimeter Pulmonary Nodules

Eric L. Grogan, MD, MPHa,*, George J. Stukenborg, PhD, MAb, Alykhan S. Nagji, MDa, Winsor Simmons, RNa, Benjamin D. Kozower, MDa, David R. Jones, MDa, Thomas M. Daniel, MDa

a Department of Surgery, Division of Thoracic and Cardiovascular Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
b Department of Public Health Sciences, Biostatistics and Epidemiology, University of Virginia School of Medicine, Charlottesville, Virginia

Accepted for publication May 5, 2008.

* Address correspondence to Dr Grogan, Thoracic and Cardiovascular Surgery, Heart & Vascular Center, PO Box 800679, University Virginia Health System, Charlottesville, VA 22908-0679 (Email: elg9q{at}virginia.edu).

Presented at the Forty-fourth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28–30, 2008.

Background: Excisional biopsy of small subcentimeter pulmonary nodules can be difficult using standard thoracoscopic techniques and may require thoracotomy. Radiotracer-guided thoracoscopic resection (RGTR) was developed to facilitate resection of intraparenchymal subcentimeter pulmonary nodules. Decision analysis, used to model cost and effectiveness, is useful to compare treatment options. We hypothesize that RGTR strategy is more cost-effective compared with thoracotomy for subcentimeter pulmonary nodules.

Methods: The cost-effectiveness of RGTR versus thoracotomy for evaluating highly suspicious subcentimeter pulmonary nodules was examined with a decision analysis model (Fig 1). A 40-patient institutional cohort who underwent RGTR was used to estimate probabilities and costs of the two treatment options within the model. Effectiveness was estimated using 5-year, stage-specific cancer survival and population survival curves. The Society of Thoracic Surgeons General Thoracic Database was queried obtaining mortality estimates for thoracotomy and thoracoscopic wedge resections. These were used to adjust the 5-year survival estimates of patients with benign disease. Sensitivity analyses determined model robustness and the thresholds at which the most cost-effective strategy changed.


Figure 1
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  		Fig 1. Decision analysis model. Decision tree showing the two treatment choices for evaluating a highly suspicious solitary pulmonary nodule (SPN) in which traditional thoracoscopy is not possible because of the location of the nodule. The clinician has two strategies (fltns = decision node); one is to perform a radiotracer-guided thoracoscopic resection (RGTR) or a traditional thoracotomy. The patient may or may not have a successful radiotracer-guided thoracoscopic resection procedure that relates to the probability of success ({circ} = the occurrence of chance events-chance node). Probability of 5-year survival is based on the disease found and the costs of the strategy ((lefttriangle) = terminal node). Estimated probabilities and costs are listed in Table 1.

 
Results: Radiotracer-guided thoracoscopic resection was 95% successful with no mortality. The average cost-to-effectiveness ratio of RGTR strategy was $27,887 versus $32,271 for thoracotomy. Sensitivity analyses demonstrated that the thoracotomy strategy was more cost-effective if the estimated cost of RGTR increased by 33% or the estimated cost-effectiveness of thoracotomy decreased by 14% or more. Radiotracer-guided thoracoscopic resection was more cost-effective as long as the probability of success was greater than 44%.

Conclusions: Decision analysis is a useful tool to evaluate treatment options for thoracic surgeons, and RGTR is a more cost-effective strategy than thoracotomy for subcentimeter pulmonary nodules.






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