Increased trend of thyroid cancer in childhood over the last 30 years in EU countries: a call for the pediatric surgeon

Incidence and Temporal Patterns of Differentiated Thyroid Carcinoma in Children and Adolescents in Germany: A Pooled Analysis Based on Data from the German Malignant Endocrine Tumor Registry and the German Childhood Cancer Registry

Introduction: The increasing incidence of differentiated thyroid carcinoma (DTC) in children and adolescents has become a growing concern. This study provides the first extensive assessment of incidence patterns and temporal trends of pediatric DTC in Germany, using the best available data from the German Malignant Endocrine Tumor (MET) Registry and the German Childhood Cancer Registry (GCCR) covering a period of 25 years. Patients and Methods: We conducted a register-based incidence and time series analysis, identifying all children and adolescents diagnosed with DTC at ages 0-17 years between 1997 and 2021 in Germany, as recorded in the German MET Registry and/or the GCCR. Age-specific and age-standardized incidence rates (ASR) over time, average annual percentage changes (AAPC), and cross-tabulations were used to evaluate incidence and temporal patterns. Results: We identified 469 DTC cases, including 85.7% papillary thyroid cancer and 9.4% follicular thyroid cancer. The average ASR for the period 1997-2021 was 1.16 per million, with higher rates in females compared with males (1.64 vs. 0.72 per million, respectively). Incidence rates increased with increasing age. The overall ASR increased from 0.84 per million in 1997-2001 to 1.48 per million in 2017-2021, with an AAPC of 3.46% [confidence interval or CI: 2.12-4.83]. The increase was most pronounced in adolescents aged 15-17 years (AAPC: 6.79% [CI: 4.43-9.19]). The proportion of incidentalomas rose from 5% in 1997-2001 to 26% in 2017-2021, yet we observed no marked shift in tumor size between symptomatic and incidental cases. Conclusions: Our study revealed a significant increase in pediatric DTC incidence in Germany, most pronounced among adolescents. The observation of an increasing incidence mirrors global trends and presents a complex public health challenge. While improved detection likely contributes to this trend, the stable tumor size distribution suggests that other factors are also in play. The rising detection of incidentalomas suggests enhanced diagnostic practices unrelated to symptoms of thyroid neoplasia. These findings highlight the need to carefully evaluate diagnostic and screening practices in pediatric populations.

Clinicopathological Findings of 220 Pediatric, Adolescent, and Young Adult Patients with Thyroid Cancer in Fukushima Medical University Hospital

Background: Thyroid ultrasound examinations (TUEs), conducted as part of the Fukushima Health Management Survey (FHMS), were initiated to monitor the health status of residents after the Fukushima Daiichi Nuclear Power Plant accident owing to concerns regarding the increased incidence of thyroid cancer among children, as observed after the Chernobyl Nuclear Power Plant accident. This study reported the clinicopathological characteristics of patients with thyroid cancer diagnosed through the FHMS and treated at the Fukushima Medical University Hospital. Methods: Data regarding the clinicopathological characteristics of patients with thyroid cancer were collected and evaluated in this descriptive study. Results: Among the 263 patients diagnosed with thyroid cancer as of September 2021, 220 patients with cytologically diagnosed thyroid cancer were treated as referrals from the FHMS. The median (interquartile range) age at the time of diagnosis was 18.6 (16.2-20.3) years. The median maximum tumor diameter was 13.0 (10.4-18.0) mm. To reduce surgical invasiveness, 199 patients (90.1%) underwent unilateral lobectomy. Pathological findings were suggestive of papillary thyroid carcinomas (PTC) in 216 (98.2%) patients; among them, 205 patients had PTC of the classical type. In addition, 216 (98.2%) patients had stage I disease. Cancer cell extension in the sternothyroid muscle or perithyroidal soft tissues and microscopic lymphovascular invasion were observed in 112 (50.9%) and 123 (55.9%) patients, respectively. No differences were observed between the two age groups (<18.6 years and ≥18.6 years) in terms of the clinical or pathological characteristics of thyroid cancer: risk classification (p = 0.69) and American Thyroid Association pediatric risk level (p = 0.24). Compared with those from previous reports, few surgical complications were observed. Conclusions: Patients with thyroid cancer diagnosed with TUEs underwent safe and minimally invasive operations, and careful postoperative follow-up was provided. The pathological findings of the detected thyroid cancers indicated that the majority were classical papillary carcinomas, and approximately half of the patients had extrathyroidal or lymphovascular invasion. No differences were observed between the two age groups in terms of the clinical or pathological characteristics of thyroid cancer.

Recent insights into trends of thyroid cancer incidence in Lithuanian population exposed to Chernobyl fallout early in life

In the last three decades, an increase in thyroid cancer incidence has been observed worldwide, as well as in Lithuania. Although the rise was linked to overdiagnosis, the role of lifestyle and environmental factors, including exposure to ionizing radiation, cannot be excluded. In our retrospective study, we aimed to assess the association between the average age-specific thyroid dose due to the radioactive iodine uptake during childhood and adolescence from the Chernobyl fallout in Lithuania, and the trends of incidence of thyroid cancer from 1991 to 2015 in different regions. Averaged age-dependent thyroid doses were estimated for every municipality based on radioiodine activity in milk, reconstructed from available 131I activity measurements in the grass. Thyroid cancer incidence rates were calculated for the entire population and for two age at the time of exposure groups: 0-19 years and 0-9 years. Thyroid cancer relative risk (RR) was estimated for three municipality-specific thyroid dose (for 0-year-old babies) categories: less than 100 mGy (reference group), 100-199 mGy, and ≥200 mGy. Over the study period (1991-2015), a total of 5664 cases of thyroid cancer were registered in the entire Lithuanian population; 817 cases in the age group from 0 to 19 years at the time of the Chernobyl accident, and 266 cases in the age group from 0 to 9 years. Age-standardized thyroid cancer incidence rates have notably increased since 2000, peaked in 2009 (especially in females), and then slightly decreased and stabilized. The estimated average municipality-specific age-dependent thyroid doses ranged from 270 mGy in western Lithuania to 1.5 mGy in central and northern Lithuania. For the age group of 0-19 years at the time of the accident, in the period 1991-1995, the thyroid cancer relative risk was significantly increased (RR 3.91; 95 % CI: 1.27-10.29, p=0.01) in the highest dose category, compared to the lowest (although based on a small number of cases). For the age group 0-9 years at the time of the accident, a tendency of increased RR in the highest dose category appeared in the most recent period, 2011-2015. Our observations need to be confirmed by further following trends of thyroid cancer incidence in the cohort of 0-19-year-old Lithuanians at the time of the Chernobyl accident.

Cryopreserved Thyroid Tissue Autotransplant in Pediatric Age Patients: A Feasibility Study and Literature Review

BACKGROUND AND AIMS

This paper aims to study an alternative solution to hormonal replacement therapy in specific groups of patients who underwent thyroidectomy during childhood or adulthood. After cryopreservation, thyroid autotransplantation could be an alternative solution which would allow us to use the ability of the thyroid tissue of producing hormones according to the physiological needs of the body.

MATERIALS AND METHODS

A feasibility study about the effects of the most modern cryopreservation techniques on the structural and functional integrity of the follicular cells of the thyroid tissue has been carried out. Patients who could benefit from the treatment have been found for both autotransplant techniques. Additionally, a literature review has been conducted.

RESULTS

The histological analysis has shown that cryopreservation does not alter the original architecture, and the culture examination that cell viability is successfully preserved. Moreover, both thyroid autotransplantation studies on animals and those on humans that were found in the literature have shown good results regarding the viability and functionality of the transplant.

CONCLUSIONS

The viability of cryopreserved thyroid tissue found in this study is encouraging. Further studies to evaluate the levels of FT3, FT4 and thyroglobulin in thyroid tissue after cryopreservation are needed to verify that the secretory properties of the thyrocytes have been maintained intact. Furthermore, autotransplanted cases found in the literature do not have a long-term follow-up.

The Prognostic Power of Preablation Stimulated Thyroglobulin in Children With Differentiated Thyroid Cancer

OBJECTIVE

To analyze prognostic factors in children with differentiated thyroid carcinoma (DTC) who have been treated in a single center in the last 27 years.

METHODS

We studied 126 children (≤18 years old) who have been treated with near-total thyroidectomy followed by radioiodine therapy and thyroid hormone replacement. Follow-up of the patients was done 2, 6, and 12 months after treatment and then by yearly evaluation. Response to treatment was defined according to the American Thyroid Association guidelines.

RESULTS

Papillary thyroid cancer was the main pathology (93.7%), and 52.4% of the patients had lymph node metastasis at presentation, which was extensive (>5) in 30% of the patients. Distant metastasis was seen in 8.8%. The mean initial dose of I-131 was 74 ± 42.2 MBq/kg. The median follow-up was 59 months and the median time to achieve an excellent response was 29 months. The preablation stimulated thyroglobulin (psTg) level was 202.4 ± 301.8 ng/mL in patients with first-year incomplete response compared with 11.2 ± 17.5 ng/mL in others (P =.001). Furthermore, using logistic regression, the psTg level was found to be the only significant predictor of distant metastasis, and psTg ≥ 13.75 ng/mL was the most powerful predictor of first-year incomplete response. Moreover, distant metastasis was more common in boys than in girls, and it took longer time for boys to achieve an excellent response.

CONCLUSION

The psTg level was the only significant predictor of distant metastases in children with DTC, and psTg ≥ 13.75 ng/mL was the most powerful predictor of first-year incomplete response.

Impact of lateral cervical lymph node metastasis on lung metastasis in pediatric thyroid cancer: A correlation study

BACKGROUND

Thyroid cancer (TC) frequently manifests with lung metastases in the pediatric population, occurring at a significant rate of 30 %. This study aims to evaluate the impact of regional patterns of cervical lymph node metastases on lung metastases in pediatric TC.

METHODS

Retrospective analysis was conducted on data from pediatric TC patients spanning the years 2000 to 2018. We compared the rates of lymph node metastasis (LNR), the number of lymph node metastases, and the number of dissected lymph nodes in the central and lateral cervical regions between patients with and without lung metastases. Statistical methods were employed to adjust for confounders during hypothesis testing.

RESULTS

A total of 227 pediatric patients, with a median age of 15.12 ± 2.84 years, were included in the study. Of these, 202 (89 %) exhibited LN metastasis, with 40(17.62 %) patients presenting with lung metastasis. Patients with lung metastases were found to be younger (13.40 ± 3.11 vs. 15.50 ± 2.64, p < 0.001), had larger primary tumor diameters (3.49 ± 1.98 vs. 2.31 ± 1.45, p < 0.001), and exhibited a higher number of lymph node metastases (23.40 ± 10.75 vs. 14.65 ± 13.16, p < 0.001). Notably, in patients with LN metastases, the presence of >12 lateral cervical lymph node metastases emerged as a significant risk factor for lung metastases. Among children with metachronous lung metastases, the median time to detection of lung metastases was 43 (12-132) months, and they appeared to receive a greater proportion of radioactive iodine (RAI) treatment compared to those with synchronous lung metastases.

CONCLUSION

Lateral cervical lymph node metastasis independently predicts the likelihood of lung metastases in pediatric TC. Furthermore, our findings emphasize the importance of thorough examination of the lungs during follow-up, particularly when the number of metastatic lateral cervical lymph nodes exceeds 12.

Global incidence and prevalence of differentiated thyroid cancer in childhood: systematic review and meta-analysis

Objective

Differentiated thyroid cancer (DTC) is rare in childhood and adolescence although it represents the most frequent endocrine malignancy in this population. DTC includes both papillary thyroid carcinoma (PTC) and follicular thyroid carcinoma (FTC). Most pediatric DTCs are PTCs, while FTCs are rare. To date, no systematic reviews on the global epidemiology of pediatric and adolescent DTC have been published. This systematic review and meta-analysis aims to estimate the overall incidence and prevalence of DTCs in patients aged 0-19 years.

Methods

The systematic research was conducted from January 2000 to December 2021 through MEDLINE via PubMed, Cochrane Library, and Embase databases. Two separate meta-analyses were performed for PTC and FTC.

Results

After the selection phase, a total of 15 studies (3,332 screened) met the inclusion criteria and are reported in the present systematic review. Five studies were conducted in Europe, five in North America, two in South America, one in Asia, one reported data for 49 countries and territories across the five continents, and one from both the USA and Africa. Most of the studies (n = 14) reported data obtained from national registries, and only one provided information collected from hospital medical records. Beyond the actual trend over time, our study reported a pooled global incidence rate (IR) of PTC and FTC in the pediatric age of 0.46 (95% CI: 0.33-0.59) and 0.07 (95% CI: 0.02-0.12) per 100,000 person-years, respectively. The highest IRs were recorded among Caucasian girls, and the lowest in black or other races/ethnicities.

Conclusion

Our data confirm that DTC in the pediatric population is a rare condition. The pooled IRs of the studies included in this meta-analysis are ~0.5 for PTC, which is the most common histological type when both genders and all age groups are considered. The implementation of a prospective international registry on pediatric DTC, as part of the wider European Registries for Rare Endocrine Conditions, has been recently proposed. In addition to providing relevant information on the clinical behavior of this rare disease, standardization of data collection will be pivotal to fill current gaps and allow an accurate estimation of the real incidence and risk factors of DTC.

Risk of thyroid neoplasms in patients with 22q11.2 deletion and DiGeorge-like syndromes: an insight for follow-up

Introduction

The chromosome 22q11.2 deletion syndrome comprises phenotypically similar diseases characterized by abnormal development of the third and fourth branchial arches, resulting in variable combinations of congenital heart defects, dysmorphisms, hypocalcemia, palatal dysfunction, developmental or neuropsychiatric disorders, and impairment of the immune system due to thymic dysfunction. Other genetic syndromes, often called DiGeorge-like, share clinical and immunological features with 22q11.2 deletion syndrome. This syndrome has been rarely associated with malignancies, mainly hematological but also hepatic, renal, and cerebral. Rarely, malignancies in the head and neck region have been described, although no aggregate of data on the development of thyroid neoplasms in patients with this clinical phenotype has been conducted so far.

Materials and methods

To characterize this possible association, a multicenter survey was made. Thus, we present a case series of five pediatric patients with 22q11.2 deletion syndrome or DiGeorge-like syndrome who were occasionally found with confirmed or highly suspected neoplasms of the thyroid gland during their follow-up. In three cases, malignancies were histologically confirmed, but their outcome was good due to an early recognition of suspicious nodules and precocious surgery.

Conclusions

This study underlines for clinicians the higher risk of neoplasms in the head and neck district for patients affected by these syndromes. It also emphasizes the importance of a prolonged clinical and ultrasound follow-up for patients with this clinical and immunological phenotype.

Performance of ACR TI-RADS and the Bethesda System in Predicting Risk of Malignancy in Thyroid Nodules at a Large Children's Hospital and a Comprehensive Review of the Pediatric Literature

While thyroid nodules are less common in children than in adults, they are more frequently malignant. However, pediatric data are scarce regarding the performance characteristics of imaging and cytopathology classification systems validated to predict the risk of malignancy (ROM) in adults and select those patients who require fine-needle aspiration (FNA) and possibly surgical resection. We retrospectively reviewed the electronic medical records of all patients 18 years of age or younger who underwent thyroid FNA at our institution from 1 July 2015 to 31 May 2022. Based on surgical follow-up from 74 of the 208 FNA cases, we determined the ROM for the American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS) ultrasound risk stratification system and The Bethesda System for Reporting Thyroid Cytopathology and added our results to those of pediatric cohorts from other institutions already published in the literature. We found the following ROMs for 1458 cases using ACR TI-RADS (TR): TR1. Benign: 2.2%, TR2. Not Suspicious: 9.3%, TR3. Mildly Suspicious: 16.6%, TR4. Moderately Suspicious: 27.0%, and TR5. Highly Suspicious 76.5%; and for 5911 cases using the Bethesda system: Bethesda I. Unsatisfactory: 16.8%, Bethesda II. Benign: 7.2%, Bethesda III: Atypia of Undetermined Significance: 29.6%, Bethesda IV. Follicular Neoplasm: 42.3%, Bethesda V. Suspicious for Malignancy: 90.8%, and Bethesda VI. Malignant: 98.8%. We conclude that ACR TI-RADS levels imply higher ROMs for the pediatric population than the corresponding suggested ROMs for adults, and, in order to avoid missing malignancies, we should consider modifying or altogether abandoning size cutoffs for recommending FNA in children and adolescents whose thyroid glands are smaller than those of adults. The Bethesda categories also imply higher ROMs for pediatric patients compared to adults.

Clinical Value of Ultrasonography and Serum Markers in Preoperative N Staging of Thyroid Cancer

We aimed to determine factors influencing lymph node metastasis (LNM) and develop a more effective method to assess preoperative N staging. Overall, data of 2130 patients who underwent thyroidectomy for thyroid cancer between 2018 and 2021 were retrospectively analysed. Patients were divided into groups according to pN0, pN1a, and pN1b stages. Pathology was used to analyse the correlation between preoperative serum marker indicators and LNM. Receiver operating characteristic curves were used to compare the diagnostic value of ultrasound (US) examination alone, serum thyroglobulin, age, and combined method for LNM. A significant moderate agreement was observed between preoperative US and postoperative pathology for N staging. Between the pN0 and pN1 (pN1a + pN1b) groups, the differences in free triiodothyronine, anti-thyroid peroxidase antibody, and serum thyroglobulin levels were statistically significant. Among the indicators, serum thyroglobulin was an independent predictor of LNM. The area under the receiver operating characteristic curve was 0.610 for serum thyroglobulin level for predicting LNM, 0.689 for US alone, and 0.742 for the combined method. Both preoperative US and serum thyroglobulin level provide a specific value when evaluating the N staging of thyroid cancer, and the combined method is more valuable in the diagnosis of LNM than US alone.

Correlation between Lindane Use and the Incidence of Thyroid Cancer in the United States: An Ecological Study

The increasing rate of thyroid cancer may be attributable to endocrine disruptive chemicals. Lindane is a persistent organochlorine pesticide with endocrine disruptive properties that has been classified as carcinogenic to humans. The aim of this ecological study was to evaluate potential correlation between lindane exposure and thyroid cancer incidence in the United States (US). Data on statewide age-adjusted thyroid cancer incidence rate (per 100,000 people) was obtained from the Centers for Disease Control and Prevention for all US states for 2019. Lindane use estimates per cropland (kg/acres cropland) were then overlaid on the map of age-adjusted thyroid cancer incidence rate using ArcGIS. The trend of lindane use in the US between 1992 and 2007 was calculated using the Mann Kendall correlation test. The correlation between statewide lindane use and age-adjusted thyroid cancer incidence rates was calculated using Spearman correlation. Lindane use in the US decreased significantly between 1992 and 2007 (T = -0.617; p < 0.001). There was no statistically significant correlation between lindane use in 1992 and thyroid cancer incidence rate for any of the years between 1999 and 2019. Our results suggest that restrictions clearly seem to be effective in reducing lindane use, however, more research is needed for individual pesticides and thyroid cancer.