Differentiated thyroid cancer in children

Nodular Thyroid Disease in Children and Adolescents

Thyroid nodules in children are extremely uncommon. Most thyroid nodules, both benign and malignant, present as asymptomatic neck masses. A thyroid nodule in a child is significant because of the risk of malignancy. A review of medical records at our institution demonstrated 71 patients 20 years of age and younger with surgically managed thyroid nodules, of which 45 were benign and 26 were malignant. Our diagnostic workup, including serum thyroid studies, radiologic evaluation, and fine-needle aspiration, is discussed. Because of the possibility of malignancy, we recommend that all solitary thyroid nodules be excised in children unless fine-needle aspiration definitively determines a benign histology. The extent and type of surgical management is controversial and is still subject to much debate. Partial thyroidectomy appears adequate for benign disease, but even though there is no statistical difference in survival, we recommend total thyroidectomy for the management of malignant disease.

Nuclear Medicine in Pediatric and Adolescent Tumors

Nuclear medicine has an important role in the management of many cancers in pediatric age group with multiple imaging modalities and radiopharmaceuticals targeting various biological uptake mechanisms. 18-Flourodeoxyglucose is the radiotracer of choice especially in patients with sarcoma and lymphoma. (18)FDG-PET, for sarcoma and lymphomas, is proved to be superior to conventional imaging in staging and therapy response. Although studies are limited in pediatric population, (18)FDG-PET/CT has found its way through international guidelines. Limitations and strengths of PET imaging must be noticed before adapting PET imaging in clinical protocols. Established new response criteria using multiple parameters derived from (18)FDG-PET would increase the accuracy and repeatability of response evaluation. Current data suggest that I-123 metaiodobenzylguanidine (MIBG) remains the tracer of choice in the evaluation of neuroblastoma (NB) because of its high sensitivity, specificity, diagnostic accuracy, and prognostic value. It is valuable in determining the response to therapy, surveillance for disease recurrence, and in selecting patients for I-131 therapy. SPECT/CT improves the diagnostic accuracy and the interpretation confidence of MIBG scans. (18)FDG-PET/CT is an important complementary to MIBG imaging despite its lack of specificity to NB. It is valuable in cases of negative or inconclusive MIBG scans and when MIBG findings underestimate the disease status as determined from clinical and radiological findings. F-18 DOPA is promising tracer that reflects catecholamine metabolism and is both sensitive and specific. F-18 DOPA scintigraphy provides the advantages of PET/CT imaging with early and short imaging times, high spatial resolution, inherent morphologic correlation with CT, and quantitation. Regulatory and production issues currently limit the tracer's availability. PET/CT with Ga-68 DOTA appears to be useful in NB imaging and may have a unique role in selecting patients for peptide receptor radionuclide therapy with somatostatin analogues. C-11 hydroxyephedrine PET/CT is a specific PET tracer for NB, but the C-11 label that requires an on-site cyclotron production and the high physiologic uptake in the liver and kidneys limit its use. I-124 MIBG is useful for I-131 MIBG pretherapeutic dosimetry planning. Its use for diagnostic imaging as well as the use of F-18 labeled MIBG analogues is currently experimental. PET/MR imaging is emerging and is likely to become an important tool in the evaluation. It provides metabolic and superior morphological data in one imaging session, expediting the diagnosis and lowering the radiation exposure. Radioactive iodines not only detect residual tissue and metastatic disease but also are used in the treatment of differentiated thyroid cancer. However, these are not well documented in pediatric age group like adult patients. Use of radioactivity in pediatric population is very important and strictly controlled because of the possibility of secondary malignities; therefore, management of oncological cases requires detailed literature knowledge. This article aims to review the literature on the use of radionuclide imaging and therapy in pediatric population with thyroid cancer, sarcomas, lymphoma, and NB.

Thyroid Cancer in Children: Management and Outcome Experience of a Referral Center

OBJECTIVE: To shed light on the discrepancy between the advanced stage at presentation and high recurrence rate of well-differentiated thyroid cancer in children and the overall good survival.

DESIGN AND METHODS: The files of 75 children with well-differentiated thyroid cancer treated from 1954 to 2001 in a major tertiary-care hospital were reviewed for disease course, management, and outcome.

RESULTS: Sixty patients (80%) had positive neck metastases with involvement of central compartment lymph nodes in all, lateral neck nodes in 36, and distant metastases in 4. Sixty-seven patients underwent total thyroidectomy with adjuvant radioiodine treatment and 8 underwent hemithyroidectomy; all had concomitant neck treatment. The rate of local (5%) and neck (9%) recurrence was similar to the total rate reported in adults. Total thyroidectomy led to a significantly lower recurrence rate (7.5%) than hemithyroidectomy (38%; P < 0.005). Type of neck dissection did not affect recurrence or appearance of distant metastases. All deaths (n = 2) were due to distant metastases, whereas 30% of adult deaths are due to local or neck disease.

CONCLUSIONS: The treatment of choice for well-differentiated thyroid cancer in young patients is total thyroidectomy. Neither regional disease at presentation nor recurrences affect survival.

Evaluation and management of the pediatric thyroid nodule

Thyroid nodules are commonly diagnosed in adults. Although rare in children, the risk for thyroid cancer is much higher in the pediatric population compared with adults. Presenting as either a solitary nodule or a multinodular goiter, thyroid nodular disease in children requires a thorough workup that includes a detailed clinical examination comprised of prior history of thyroid disease in the patient or in their family, history of radiation exposure, careful palpation of the thyroid and lymph nodes, blood tests, ultrasonography, and cytological assessment. Thyroid surgery is the gold-standard treatment for pediatric thyroid nodules; nonetheless, the extent of surgery remains controversial. Because surgery is not without risk, the decision matrix necessitates focus on the benefits of surgery for the child contingent upon all the preoperative exams. New diagnostic technology such as molecular testing with fine needle aspiration biopsy may help distinguish between benign and malignant lesions while potentially decreasing surgery for benign disease. The objective of this review is to summarize new concepts in clinical disease management of nodular thyroid disease in the pediatric population, including patient history, medical examination, and diagnosis workup.

Diagnostic utility of fine-needle aspiration cytology in pediatric differentiated thyroid cancer

BACKGROUND

Pediatric patients present with thyroid nodules less often than adults, but the rate of malignancy is much higher. This study was designed to determine the ability of fine-needle aspiration cytology (FNA) to diagnose accurately and facilitate management of thyroid neoplasms in pediatric patients.

METHODS

A retrospective study revealed 110 patients <19 years old who had undergone thyroid surgery and FNA biopsy at two academic institutions over the last 28 years. FNA sensitivity for diagnosing papillary thyroid cancer (PC) and follicular neoplasm (FN) was investigated.

RESULTS

Of 110 patients who presented for surgery, 27 had PC and 33 had a FN: 4 follicular carcinomas (FCs) and 29 follicular adenomas (FAs). Among the PCs patients, the FNA results were as follows: 1 (4%) nondiagnostic, 6 (22%) atypical, 2 (7%) benign, and 18 (67%) malignant lesions. The sensitivity of a malignant FNA was 90% for diagnosing a PC. Sensitivity of an atypical FNA was 75% for FCs and 69% for FAs, giving an overall FN sensitivity of 70%. Of the atypical FNA readings, 60% had confirmed histological atypical features, and 19% were malignant. In 95% of the malignant FNA reports, final histology confirmed PC, resulting in a positive predictive value of 95%.

CONCLUSIONS

FNA biopsy can reliably diagnose malignancy in pediatric thyroid patients and should be used as a standard technique to indicate surgical treatment. Atypical or suspicious FNA results do not predict cancer effectively, confirming the current accepted practice for adults that diagnostic excision is required to exclude malignancy in pediatric patients.

Diffuse sclerosing variant is a major subtype of papillary thyroid carcinoma in the young

BACKGROUND

Pediatric thyroid cancer differs from adult thyroid cancer in presentation and outcome. Pediatric thyroid cancer has a higher recurrence rate and greater percentage of lymph node and pulmonary metastasis. The clinicopathologic characteristics of pediatric thyroid cancer according to the histologic subtype have not been reported, however. In this study, we determined the histological subtypes of pediatric thyroid cancer and analyzed other clinicopathologic characteristics.

METHODS

All patients with thyroid cancer who were admitted to Severance Hospital, Seoul, South Korea, were retrospectively reviewed; their age was <20 years at diagnosis, and they were seen between January 1995 and August 2008.

RESULTS

Sixty-eight patients were identified. The histologic types of thyroid carcinoma were papillary thyroid carcinoma (PTC) in 57 (83.8%), follicular carcinoma in 8 (11.8%), and poorly differentiated carcinoma in 3 (4.4%). There were 28 (41.2%) cases of diffuse sclerosing variant of papillary carcinoma (DSVPC), 26 (38.2%) of conventional PTC, 2 (2.9%) of follicular PTC, and 1 (1.5%) cribriform-morular PTC. In patients with PTC, there was a higher incidence of bilateral thyroid involvement (p = 0.003), extrathyroidal extension (p = 0.009), and lymph node involvement (p = 0.018), and lower recurrence-free survival (p = 0.032) in DSVPC than in non-DSVPC. Univariate regression analysis revealed that extrathyroidal extension (p = 0.025) and tumor size (p = 0.001) were positively associated with a shorter time to recurrence.

CONCLUSION

DSVPC is a major subtype of PTC in the young.

Secondary thyroid papillary carcinoma in osteosarcoma patients: report of two cases

We report two cases of papillary thyroid carcinoma occurring after the successful treatment of osteosarcoma. One of the patients was administered with several alkylating agents and topoisomerase II inhibitor as part of the primary treatment of osteosarcoma. The onset of thyroid carcinoma occurred after 5 and 12 yr after cessation of the osteosarcoma therapy. All the patients involved in this study are alive and free of their malignancies. There have been eight case reports of these two malignancies occurring in the same patient. Thyroid carcinoma rarely occurs in patients with osteosarcoma; however, vigilant surveillance and long-term follow-up should be emphasized for all survivors.

Differentiated Pediatric Thyroid Cancer: Correlates With Adult Disease, Controversies in Treatment

The biologic behavior of differentiated thyroid cancer can differ between adults and children, especially in those children younger than 10 years of age. Unlike adults, young children typically present with advanced disease at diagnosis. Despite this, children respond rapidly to therapy and have an excellent prognosis that is significantly better than that of their adult counterparts with advanced disease. In contradistinction to adults, children with thyroid cancer also have higher local and distant disease recurrences with progression-free survival of only 70% at 5 years, mandating life-long surveillance. Although thyroid cancer is the most common carcinoma in children, overall incidence is low, a factor that has prevented performance of a controlled, randomized, prospective study to determine the most efficacious treatment regimen in this age group. So, although extensively investigated, treatment of pediatric patients with differentiated thyroid cancer remains controversial. This article reviews the current controversies in the treatment of pediatric differentiated thyroid cancer, focusing on issues of optimal initial and subsequent therapy as well as that of long-term follow-up. Our approach to treatment is presented. In so doing, similarities and differences between adults and children with differentiated thyroid cancer as regards unique considerations in epidemiology, diagnosis, staging, treatment, therapy-related late effects, and disease surveillance are presented. The expanding use of and appropriate roles for thyrogen and fluorine-18-fluorodeoxyglucose positron emission tomography in disease evaluation and surveillance will be addressed.

Thyroid carcinoma presenting in childhood or after treatment of childhood malignancies: An institutional experience and review of the literature

BACKGROUND/PURPOSE

Thyroid carcinomas can occur as a primary malignancy (PTM) or secondary after another malignancy (STM). Information about the presentations and outcomes of patients with STM are limited. The authors sought to compare the clinical characteristics, course, and outcomes of patients with primary or secondary thyroid malignancies.

METHODS

The authors reviewed the medical records of 8 children with PTM and 17 children with STM referred to St Jude Children's Research Hospital between February 1962 and February 2002 for evaluation and treatment of malignant thyroid carcinoma.

RESULTS

The 8 children who had primary thyroid carcinoma had it diagnosed at a median age of 12.5 years (range, 7.3 to 16.3 years). Seven patients had papillary carcinoma, and 1 patient had follicular carcinoma. Three of the 8 (37.5%) had metastatic disease involving regional lymph nodes; 2 patients (25.0%) had lung metastases. Six patients required radioactive iodine (I 131) ablation for residual or metastatic disease after surgical resection. All 8 patients remain alive a median of 22.6 years after diagnosis (range, 0.7 to 30.5 years); 1 continues to receive radioactive iodine (I 131) ablation for persistent disease. Seventeen patients had thyroid carcinoma as a second malignant neoplasm after treatment for acute lymphoblastic leukemia (n = 6), Hodgkin's disease (n = 5), central nervous system tumor (n = 2), Wilms' tumor (n = 1), retinoblastoma (n = 1), non-Hodgkin's lymphoma (n = 1), or neuroblastoma (n = 1). Patients with secondary thyroid carcinoma presented at a median age of 21.5 years (range, 15.3 to 42.6 years), a median of 16.2 years (range, 0.9 to 29.2 years) after diagnosis of the primary cancer. Twelve of the 17 patients (70.6%) had received radiation to the thyroid gland during therapy for the primary cancer. Four patients (23.5%) had metastatic disease involving regional lymph nodes. Six patients (35.3%) required I(131) ablation for residual or metastatic disease after thyroidectomy. At the time of this report, all 17 patients are alive and in continue to be free of disease.

CONCLUSIONS

Pediatric thyroid carcinoma is uncommon and responds well to current therapy. Given the limited period of follow-up of our cohort of secondary malignant thyroid tumors that arise after childhood cancer, these lesions appear to have similar presentations and outcomes when compared with primary carcinomas and can therefore be managed in the same manner.

Childhood and adolescent thyroid carcinoma

OBJECTIVES

This analysis was performed to evaluate the influence of clinical and treatment factors on local tumor control, control of distant metastasis, survival, and complications in children and adolescents with thyroid carcinoma.

METHODS

The records of 56 children and adolescents with papillary and follicular carcinoma of the thyroid were reviewed. They ranged in age from 4 to 20 years. There were 43 females and 13 males. At diagnosis, 15 (27%) patients had disease confined to the thyroid, 34 (60%) had additional lymph node metastasis to the neck or upper mediastinum, and 7 (13%) also had lung metastasis. Treatment consisted of a total thyroidectomy in 48 patients, a subtotal thyroidectomy in 4 patients, and a lobectomy in 4 patients. All 56 patients received postoperative thyroid hormone suppressive therapy. (131)I was administered to 82% (46 of 56) of patients after their initial surgery.

RESULTS

The overall survival rate was 98% with a follow-up of 0.6-30.7 years (with a median follow-up of 11.0 years). The one death that occurred in this patient population was the result of a congenital heart defect and was unrelated to thyroid carcinoma. The 10-year progression-free survival rate was 61%. Nineteen patients (34%) experienced a recurrence of their thyroid carcinoma. The time to first recurrence of disease ranged from 8 months to 14.8 years (mean, 5.3 years). None of those with disease confined to the thyroid developed recurrent disease. The recurrence rate was 50% (17 of 34) in patients with lymph node metastasis and 29% (2 of 7) in patients with lung metastasis (P = 0.02). Tumor characteristics were evaluated for time to first recurrence utilizing the logistic likelihood ratio test to predict disease recurrence. Thyroid capsule invasion (P = 0.02), soft tissue invasion (P = 0.03), positive margins (P = 0.006), and tumor location at diagnosis (thyroid only vs. thyroid and lymph nodes vs. thyroid, lymph nodes, and lung metastasis, P = 0.02) were significant for developing recurrent disease. Patients younger than 15 years old at diagnosis were more likely to have more extensive tumor at diagnosis than patients who were 15 years and older (thyroid only vs. thyroid and lymph nodes vs. thyroid, lymph nodes, and lung metastasis, P = 0.02).

CONCLUSION

Carcinoma of the thyroid in children and adolescents has little risk of mortality but a high risk of recurrence. Younger patients present with a more advanced stage of disease and are more likely to have disease recurrence. Total thyroidectomy and lymph node dissection, followed by postoperative (131)I therapy, thyroid hormone replacement (suppressive) administration, and diligent surveillance are warranted.

Differentiated thyroid cancer in children and adolescents

In this retrospective study we analyzed cancer characteristics and outcome in a consecutive series of 48 young patients (< or =20 yr of age) with a differentiated thyroid cancer (DTC), observed during the period 1977-1998. In none of them was thyroid cancer related to ionizing radiation. The median age was 18.1 yr, range 7-20, and the female/male ratio was 2.5/1. Papillary thyroid cancer (PTC) occurred in 83% and follicular thyroid cancer (FTC) in 17% of cases. All patients underwent total or near total thyroidectomy plus pre- and/or paratracheal lymphnode dissection. Surgery complication rate was low (4% permanent hypoparathyroidism; no permanent lesion of recurrent laryngeal nerve). Extrathyroid disease was present in 52% of patients with PTC and in 50% of patients with FTC, while nodal metastases were present in 62.5% of patients with PTC and in 12.5% of patients with FTC. Lung metastases occurred in 10 patients with PTC (25%) and in none with FTC. Twenty-one patients required radioiodine treatment for metastatic disease: 11 patients for relapsing lymph-node metastases, 4 patients for lung metastases, 6 patients for both lymph-node and lung metastases. After a mean follow-up of 85+/-12 months all patients followed regularly (no.=47) were alive; 37 patients (79%) were free of disease and 10 (21%) had residual disease. Our results indicate that non-radiation-related DTC occurring in young patients often presents at an advanced stage. For this reason, although the prognosis is usually good in these patients, we believe that total or near total thyroidectomy with lymphadenectomy is always the required initial surgical treatment.

Thyroid cancer in children: report of three cases and a review of the Japanese literature

We experienced three cases of thyroid cancer in children less than 15 years of age between 1982 and 1995. We herein present these three cases with a review of 141 reported cases of childhood thyroid cancer in Japan. Our patients were 6, 13, and 14 years old. The patients, all girls, were diagnosed as having thyroid cancer based on diagnostic imaging. One of them was also diagnosed by a fine-needle aspiration biopsy (FNAB). One of them underwent subtotal thyroidectomy, and the other two underwent lobectomy. Modified neck dissections were performed on all three. Pathologically, the tumors were all papillary carcinomas. Multiple lymph node metastases were present in all patients. However, the postoperative courses have been good, and there have been no signs of recurrence, 10, 8, and 2 years after their respective operations. In 144 reported cases of childhood thyroid cancer in Japan including ours, the youngest patient was a 2-year-old boy, and the female to male ratio was 2.1:1. FNAB was performed in 25 cases, and 23 (92%) of the tumors were diagnosed as malignant. Histologically, 76% were papillary carcinoma and 20% follicular carcinoma. At operation, lymph node metastases were found in 80% of the cases, and lung metastases in 17%. For treatment, 88% of the patients received a more extensive operation than a lobectomy. Of the 144 patients, 8 died.

Differentiated thyroid cancer: clinical characteristics, treatment, and outcome in patients under 21 years of age who present with distant metastases. A report from the Surgical Discipline Committee of the Children's Cancer Group

BACKGROUND/PURPOSE

Young patients with differentiated thyroid cancer typically present with regional lymph node involvement (60% to 80%), and 10% to 20% have distant metastases. This study characterizes the clinical presentation, treatment, and outcome in patients with differentiated thyroid cancer who were less than 21 years of age at diagnosis and who presented with distant parenchymal metastases.

METHODS

A retrospective, multi-institutional data base that included 327 patients in this age group with differentiated thyroid carcinoma was searched for patients who presented with distant metastases, and 83 cases (25%) were found. The median time to first disease progression was 2.4 years (range, 0.1 to 12.4 years) and the overall median follow-up was 10.9 years (range, 1.0 to 42.1 years).

RESULTS

The median age at diagnosis was 14.6 years (range, 6.6 to 20.8 years); 69% were girls and 92% were white. In 12%, there was a history of prior head and neck irradiation, and 10% of these patients had a family history of carcinoma. Preoperative needle biopsies were performed in 25%. Regional lymph nodes were positive in 90%, and extrathyroidal extension occurred in 48%. The site of distant metastases included the lungs in all patients. Total thyroidectomy, subtotal thyroidectomy, lobectomy, and nodule excision was done in 66%, 24%, 3%, and 8% of patients, respectively. There was no residual cervical disease after surgery in 75%, whereas 14% had microscopic and 11% had gross residual. Histopathologic subtypes included papillary-follicular (48%), papillary (42%), and follicular (10%). The median tumor size was 3.0 cm (range, 0.4 to 11.0 cm). In this group, 100% of patients received adjuvant iodine 131I therapy, and the overall survival rate at 10 years was 100%. The progression-free survival rate was 76% at 5 years and 66% at 10 years from diagnosis.

CONCLUSIONS

A significant number of young patients with thyroid cancer present with distant metastases and will require radioiodine therapy. This should be considered when planning the surgical approach because total or subtotal thyroidectomy facilitates 131I imaging and treatment. Although about one third of these patients will experience relapse or disease progression, the overall mortality rate is low.

Gender, clinical findings, and serum thyrotropin measurements in the prediction of thyroid neoplasia in 1005 patients presenting with thyroid enlargement and investigated by fine-needle aspiration cytology

One thousand five euthyroid patients (870 females and 135 males, mean age 47 years), who presented with thyroid enlargement were evaluated by fine-needle aspiration cytology (FNAC) of the thyroid as the first-line investigation. The final cytological or histological diagnosis was determined after surgery (n = 312) or clinical follow-up for a minimum period of 2 years (range 2-14 years, mean 6.7 years). Goiter type was assessed clinically and was classified as diffuse in 147, multinodular in 247, or solitary nodule in 611. The overall sensitivity and specificity of the procedure in the detection of thyroid neoplasia was 88% and 89%, respectively. Males who presented with thyroid enlargement had significantly higher rates of malignancy (p = 0.007) and neoplasia (benign + malignant) (p = 0.002) than females, as did subjects with solitary nodule compared with diffuse or multinodular goiters (malignancy p = 0.001, neoplasia p < 0.001). Subjects with normal thyrotropin (TSH) (>0.4 mU/L) at presentation had a nonsignificantly increased risk of thyroid neoplasia (p = 0.07) and malignancy, in contrast to those with low TSH (<0.4 mU/L). We confirmed FNAC of the thyroid to be an accurate test in the detection of thyroid neoplasia. Gender and goiter type at presentation both contribute significantly to the prediction of the diagnosis of thyroid neoplasia.

Pediatric hemorrhagic thyroid nodule: a case report

Hemorrhagic thyroid nodules are rare in the pediatric age group. They present as rapidly enlarging neck masses. Diagnostic modalities available are laboratory evaluation, ultrasound, radionuclide imaging, and fine needle aspiration. Depending on the pattern of growth of the lesion, one may observe or proceed with surgery. A rapidly enlarging thyroid mass raises the suspicion of malignancy, and hemorrhagic nodules, though rare, must be considered in the differential diagnosis.

DNA ploidy in papillary carcinoma of the thyroid gland in children and adolescents

OBJECTIVE

To evaluate DNA ploidy in papillary thyroid carcinoma in children in correlation to the clinical course of the disease.

METHODS

Flow cytometric DNA ploidy measurements were performed on formalin-fixed, paraffin-embedded tumor specimens from 14 children and 14 adult patients with papillary carcinoma of the thyroid gland. Analysis of DNA content was performed blind to patient's age and clinical presentation.

RESULTS

Seven patients presented with cervical metastasis, one patient had distal metastasis and four patients had local invasion. All patients underwent total thyroidectomy. Seven children underwent bilateral modified neck dissection. Twenty-five tumors expressed diploid DNA content. No statistically significant difference in DNA content was observed between the tumors from child and adult patients. No correlation was found between DNA content and aggressive presentation in the pediatric group.

CONCLUSION

Our primary results indicate that diploid DNA content is common in papillary thyroid carcinoma in children and aggressive clinical presentation is not associated with DNA aneuploidy. Larger prospective studies and long-term clinical follow-up is warranted to document the clinical significance of these observations.

Carcinoma of the thyroid in children: a 25-year experience

Over the past 25 years, 23 children with carcinoma of the thyroid have been treated at the Christie Hospital, Manchester. Twenty-one cases were well-differentiated carcinoma, and two were medullary carcinoma. They were all treated by resection, 14 with total thyroidectomy and 9 with lobectomy or subtotal thyroidectomy. Sixteen children also had surgery for nodal disease. Two children presented with lung metastases. Sixteen children received post-operative radiotherapy (4 external beam, 12 131I). Median follow-up of 67 months (range 7-233), was the same for the 21 well-differentiated carcinomas and the whole group including the two medullary carcinomas. All 21 children with well-differentiated carcinomas are alive with no evidence of progressive disease. Two relapsed after total thyroidectomy, but both were salvaged, one with external beam radiotherapy, one with 131I. One child with medullary carcinoma died with progressive disease after 43 months, the other is alive, but with slowly progressive disease 145 months after diagnosis. Ten of 14 children experienced post-operative hypocalcaemia following total thyroidectomy, in 7 cases it persisted long-term. 131I and external beam radiotherapy were both well tolerated. The long-term results of treatment of well-differentiated carcinoma of the thyroid are excellent, but there remains disagreement over the extent of treatment required. Some authors believe the condition is multifocal and requires total thyroidectomy, others argue that lobectomy or subtotal thyroidectomy avoids the possible post-operative complications of total thyroidectomy and gives equal long-term cure rates. We agree with the latter view. Although a small series cannot be conclusive, we feel that our results are consistent with this. We also believe, that for children, radiotherapy can be reserved for relapse only, as long as regular follow-up is available.

Total thyroidectomy in the treatment of thyroid carcinoma in childhood

Between 1974 and 1993 ten girls and six boys aged 6-16 years underwent total thyroidectomy, with therapeutic selective neck dissection in six patients. All were treated after operation with radioactive iodine (131I) for ablation of thyroid tissue remnants. Papillary carcinoma occurred in ten patients, follicular carcinoma in two and medullary thyroid lesions in four. The patients were followed for a median of 11.5 (range 1-20) years with regular determinations of serum thyroglobulin levels and 131I whole-body scanning when indicated. Only one patient had a slight increase in thyroglobulin levels without evidence of disease on further screening. In children with medullary lesions the serum levels of basal and pentagastrin-stimulated calcitonin remained normal. Currently all patients are alive and without disease. Hypocalcaemia lasting for more than 1 year was observed in one patient. Recurrent nerves were not injured accidentally, but because of tumour invasion two of 32 recurrent nerves had to be sacrificed. This surgical approach is safe and well tolerated in children.

Papillary thyroid cancer with pulmonary metastases beginning in childhood: clinical course over three decades

We present a case of childhood papillary thyroid cancer with persistent but stable pulmonary metastases for over three decades in order to highlight the natural history and clinical features of this unusual disease entity. A nine-year-old girl had thyroidectomy and cervical lymph node dissection followed by neck irradiation for invasive papillary thyroid cancer. Diffuse pulmonary metastases were present at the time of diagnosis and were treated with radioactive iodine 10 and 30 years later; both the chest radiographs and the patient remained stable throughout. This case illustrates the potential indolence of thyroid cancer when it presents during childhood.

Pediatric thyroid cancer after the Chernobyl disaster. Pathomorphologic study of 84 cases (1991-1992) from the Republic of Belarus

BACKGROUND

During the initial period after the Chernobyl accident, large amounts of radioactive iodine were released in fallout, resulting in serious exposure to the thyroid gland in the residents of areas around the nuclear power station. Beginning in 1990, a definite increase in the incidence of thyroid cancer was noted in children of the Republic of Belarus.

METHODS

Morphologic and clinical features of 84 cases of post-Chernobyl thyroid carcinoma in Belarussian children from 5 to 14 years of age are reported. The latent period for tumor development was 4-6 years, with a mean of 5.8 years.

RESULTS

Papillary carcinoma was found in 83 patients and medullary carcinoma in one. Besides typical papillary carcinoma (14%), solid (34%), follicular (33%), mixed (10%), and diffuse sclerosing (9%) variants were observed. The follow-up period ranged from 8 months to 2.5 years. One patient died, local recurrence developed in 2, and cervical lymph node metastases developed in 10. To date, the incidence of local recurrence or metastatic disease after surgery was significantly higher in patients 5-8 years of age and in residents of areas nearest to the Chernobyl station.

CONCLUSIONS

Post-Chernobyl pediatric thyroid carcinoma is characterized by a short latency, a higher proportion of tumors arising in young children, and an almost equal sex ratio. Microscopically, these tumors were usually aggressive, often demonstrating intraglandular tumor dissemination (92%), thyroid capsular and adjacent soft tissue invasion (89%), and cervical lymph node metastases (88%). Papillary carcinoma was diagnosed in 99% of cases, with an unusually high frequency of solid growth patterns. Morphologic changes in nonneoplastic thyroid tissue were present in 90% of the glands, and the most specific findings were vascular changes and perifollicular fibrosis.

Pulmonary metastases in children and young adults with differentiated thyroid cancer

BACKGROUND

The prognostic significance and optimal care of children with differentiated thyroid cancer and pulmonary metastases are not well established.

METHODS

Of 209 patients younger than 25 years of age who were treated at University of Texas M. D. Anderson Cancer Center between 1960 and 1990 and for whom there was sufficient information, 19 (9%) had pulmonary metastases at presentation.

RESULTS

All of these patients had regional lymphadenopathy at the time of diagnosis. All but two had intense, diffuse radioiodine uptake in the lungs; there were two false-negative scans immediately after surgical procedure caused by competing thyroid residual. The chest radiograph (CXR) was normal in 8 of 17 (42%) patients with abnormal radioiodine scans. After therapy with radioiodine (100-499 mCi), CXR appeared normal in 7 of 9 patients with initial abnormal radiographs (within 6-75 months). Radioiodine uptake by the lungs normalized in 3 of 8 patients with initially normal radiographs, and in 3 of 9 patients with initially abnormal radiographs. There have been no deaths in these 19 patients.

CONCLUSION

Pulmonary metastases are not uncommon in children and young adults with differentiated thyroid cancer, especially those who have regional lymphadenopathy. The lung metastases almost always concentrate radioiodine diffusely and may be associated with a normal CXR in almost half of the patients. Pulmonary metastases may be overlooked unless near total thyroidectomy is followed by total body radioiodine scan (TBS) in all children and young adults who have regional lymphadenopathy of the neck.

Pathomorphological findings in thyroid cancers of children from the Republic of Belarus: a study of 86 cases occurring between 1986 ('post-Chernobyl') and 1991

Recently, an impressive increase in malignant thyroid tumours has been observed among children less than 15 years of age living in the Republic of Belarus at the time of the nuclear accident of Chernobyl in 1986. More than half of these patients lived in the region of Gomel, nearest to Chernobyl. Because of the very short time interval between the accident and the tumour occurrence an independent review of the available histopathological material was done. Out of 101 cases diagnosed as thyroid cancers, we reviewed slides of 93 cases and agreed the diagnosis of malignancy in 92.5%. Of these tumours 96.5% were papillary carcinomas, 61.5% were moderately or poorly differentiated. Extrathyroidal extension was observed in 60.5%, regional lymph node metastases in 74% and distant metastases in 7%. One of the patients died from lung metastases. Our results confirm that the neoplasms increasingly diagnosed between 1986 and 1991 among children of this region are thyroid carcinomas. In addition, we correlate several histopathological findings with sex and age of the patients and other parameters, and compare the results with data from other studies.

Nuclear DNA measurements on thyroid carcinoma in young patients

Nuclear DNA measurements were performed on thyroid carcinomas from 36 patients aged 20 years or less. Histologic material from the tumors were stained according to the Feulgen technique and measured with slide cytophotometry. Thirty-two of the 36 tumors were of papillary type, 3 were medullary carcinoma and 1 was a follicular carcinoma. Of the 32 papillary carcinomas, 6 tumors (19%) were aneuploid and 26 (81%) were diploid, including 2 cases with lung metastases at diagnosis. Of the 3 medullary carcinomas, 2 were diploid and 1 aneuploid. The only follicular carcinoma was aneuploid. The patients were followed between 10 and 35 years, and 34 were alive at the end of the study. Two patients died, both had medullary carcinomas. One patient, with a diploid tumor, died during surgery. The other patient, with an aneuploid tumor, died 5 years after diagnosis of metastatic disease. Six patients had recurrences, all within 7 years. All the primary tumors and the corresponding recurrences showed a diploid DNA content. The results show that the majority of thyroid carcinomas in young patients exhibit diploid DNA profiles which is in agreement with the overall good prognosis in this patient category. However, since also patients with aneuploid tumors exhibited a similar good prognosis it seems that DNA measurements do not contribute additional prognostic information in young patients.

Malignant tumors of the head and neck in children: a twenty-year review

This 20-year (1965-1985) retrospective review identified 241 children under the age of 19 years who presented with a malignancy of the head and neck. Hodgkin's disease and other malignant lymphomas predominated, accounting for 59% of the total number of cases. Soft tissue sarcomas, specifically rhabdomyosarcoma, were the next most common lesions (17.5%). Thyroid carcinomas (10%), neuroblastomas (5%), nasopharyngeal carcinomas (5%), salivary gland malignancies (2.5%), and malignant teratomas (1%) accounted for the remaining cases. The neck was the primary site of presentation, followed by the naso-oropharynx, orbit, face and scalp, salivary glands, and aural region, in descending order of frequency. Advances in the diagnosis, staging and treatment of children with malignant tumors of the head and neck have occurred since the last comprehensive survey of such lesions was published in 1973. Otolaryngologists must be aware of these advances in order to remain active members of a multi-discipline team responsible for the care of these children.