318 chapter 4 No difference in the surgical complication rate was observed between both groups. Still, following the reduction in diagnostic surgeries, the rate of new levothyroxine suppletion-dependent hypothyroidism due to partial thyroidectomy procedures was only 6% (5/86) in the [18F]FDG-PET/ CT-driven group as compared to 17% (7/41) in the diagnostic surgery group (p=0.07, OR 0.3 [95% CI, 0.1-1.1]). Other surgical complications infrequently occurred (Table 8). EQ-5D-5L questionnaires were completed by 69 of 91 (76%) patients in the [18F]FDG-PET/CT-driven and 29 of 41 (71%) patients in the diagnostic surgery group (p=0.54). Based on the EQ-5D-5L domain scores at all four measurements and the QALYs estimated from both the EQ-5D-5L and the VAS, perceived HRQoL during the first year after the [18F]FDG-PET/CT scan was similar in both groups (Table 9, Figure 9). Adjusted for the stratifying variables and malignancy/borderline rate, a mean 0.793 (95% CI, 0.753-0.833) QALYs were estimated in the [18F]FDG-PET/CT-driven group, as compared to 0.725 (0.651-0.799) QALYs in the diagnostic surgery group (p=0.11). The adjusted mean societal costs during the first year were significantly lower in the [18F]FDG-PET/CT-driven group than the diagnostic surgery group: €14,800 (95% CI, +€12,600-+€17,000) as compared to €21,700 (+€16,800-+€26,600) per patient, respectively, with an adjusted mean difference of -€6,900 (-€12,100--€1,600, p=0.01) (Table 10). Incidental [18F]FDG-PET/CT findings with diagnostic or therapeutic consequences were reported for 22 of 132 (17%) [18F]FDG-PET/CT scans (Table 11). These included 21 [18F]FDG-positive thyroid incidentalomas in 19 (14%) patients, for which 13 additional FNAC procedures were performed: cytology was nondiagnostic (Bethesda I) in three, benign (Bethesda II) in six, AUS/FLUS in three and FN/SFN in two nodules. Eleven of 21 (52%) incidentalomas were surgically resected. Two ipsilateral incidentalomas were malignant (9.5%, 2/21): in one patient, the incidentaloma was part of the multifocal poorly differentiated carcinoma; in the other, the incidentaloma was a 6 mm follicular variant of PTC (FVPTC). Seven ipsilateral incidentalomas were removed through the scheduled hemithyroidectomy, of which two procedures were extended with a nodulectomy of the incidentaloma located in the isthmus. In four patients, their initially scheduled hemithyroidectomy was extended to a total thyroidectomy to include a contralateral incidentaloma; all were histopathologically benign: one follicular adenoma and three hyperplastic nodules. These total thyroidectomy procedures in 4 of 132 (3%) of patients are considered overtreatment due to the [18F]FDG-PET/CT. Altogether, in three of 22 (14%) patients the diagnostic and/or therapeutic consequences of the incidental [18F]FDG-PET/CT findings were justified and disease was detected: besides the two thyroid malignancies, this included one patient who was diagnosed with potential diabetes mellitus based on an increased fasting plasma glucose prior to the [18F]FDG-PET/CT scan. In four (17%) patients, major therapeutic consequences were considered unbeneficial overtreatment. Although compliant with current guidelines, total thyroidectomy was performed instead of diagnostic hemithyroidectomy because Bethesda III, Bethesda IV, Bethesda VI, and Bethesda II cytology with an NRAS point
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