# Cost‐Effectiveness Analysis of the Milan System for Reporting Salivary Gland Cytopathology in Fine‐Needle Aspiration Cytology of Salivary Gland Lesions

## TL;DR

Using a specific system for analyzing salivary gland samples, this study shows that a less invasive test can save money compared to immediate surgery.

## Contribution

The study demonstrates the cost-effectiveness of FNAC under the Milan System for salivary gland lesions compared to upfront surgery.

## Key findings

- FNAC followed by surgery, if needed, reduced costs by over 30% compared to upfront surgery.
- Cost savings ranged from $5606 to $13,096 in the U.S. and 2465€ to 5954€ in Germany.
- FNAC is more cost-efficient when performed in high-output centers with expert cytopathologists.

## Abstract

Salivary gland lesions (SGL) are a rare and heterogeneous group of benign and malignant masses. Fine‐needle aspiration cytology (FNAC), guided by the Milan System for Reporting Salivary Gland Cytopathology (MSRSGC), offers a minimally invasive method for early differentiation of SGL. The purpose of this study was to evaluate the cost‐effectiveness of FNAC in diagnosing major SGL within the MSRSGC framework.

Three decision tree models were created based on probabilities from real‐world and literature data. Real‐world data was derived from the previously published largest single‐center study evaluating FNAC performance of SGL to date. Costs were determined from German and American fee catalogs. Multiple Monte Carlo simulations were run to assess the cost‐effectiveness of performing FNAC within the MSRSGC framework under different conditions for both health care systems.

Using decision analysis, FNAC followed by surgery, if indicated, was less costly than upfront surgery. The cost reduction through FNAC was over 30% for all models. Cost reduction per case through FNAC followed by surgery, if indicated, compared to upfront surgery ranged between $5606 and $13,096 in the US model (average costs for upfront surgery: $17,472) and between 2465€ and 5337€ in the German model (average costs for upfront surgery: 8018€). When enhancing the German model with real world data, the cost reduction ranged between 2478€ and 5954€ (average costs for upfront surgery: 7988€).

In this model based on MSRSGC estimates and real‐world data, FNAC followed by surgery, if indicated, proved to be a more cost‐efficient approach to diagnosing SGL than upfront surgery. Thus, patients and healthcare systems benefit from high‐output centers that guarantee expert cytopathological diagnosis.

This study evaluated the cost‐effectiveness of fine‐needle aspiration cytology (FNAC), guided by the Milan System, for diagnosing salivary gland lesions. Decision tree models using real‐world and literature data showed that FNAC followed by surgery, when indicated, reduced costs by 30% or more in both U.S. and German healthcare models compared to upfront surgery. Overall, FNAC proved to be a more cost‐efficient strategy, highlighting the value of expert cytopathology in high‐volume centers.