Thyroid surgery in children and adolescents

Short-Term Complications After Total Thyroidectomy in Children

INTRODUCTION

Total thyroidectomy for benign disease is becoming more common among children. The purpose of this study was to evaluate 30-day outcomes in children undergoing total thyroidectomy and determine if the short-term outcomes are different in those with a malignant versus benign indication for surgery.

METHODS

This retrospective cohort study used the American College of Surgeons National Surgical Quality Improvement Program-Pediatric (NSQIP-Pediatric) to identify all children who underwent total thyroidectomy from 2015 to 2019. Fisher's exact test was used to compare postoperative outcomes between benign and malignant indications for thyroidectomy.

RESULTS

Among 1595 total thyroidectomy patients, 1091 (68.4%) had a benign indication and 504 (31.6%) had a malignant indication. There were 1234 (77.4%) females, and the median age was 14.9 y (interquartile range [IQR] 12.5, 16.6). Average length of stay (LOS) was similar between cohorts (1.7 d for benign and 1.9 d for malignant, P = 0.30). Parathyroid auto-transplantation was performed in 71 (6.5%) patients in the benign cohort and 43 (8.6%) in the malignant cohort (P = 0.15). The most common complications were readmissions (23 [2.1%] benign and 15 [3.0%] malignant, P = 0.29) and reoperations (7 [0.6%] benign and 5 [1.0%] malignant, P = 0.54). Complication profiles were similar between benign and malignant cohorts (2.8% and 4.6%, respectively [P = 0.10]).

CONCLUSIONS

Children undergoing total thyroidectomy for benign and malignant indications have low rates of 30-d postoperative complications, suggesting that total thyroidectomy is a safe option for children with benign disease. Evaluation of long-term outcomes is needed.

Pediatric intraoperative nerve monitoring during thyroid surgery: A review from the American Head and Neck Society Endocrine Surgery Section and the International Neural Monitoring Study Group

Children are more likely to experience recurrent laryngeal nerve (RLN) injury during thyroid surgery. Intraoperative nerve monitoring (IONM) may assist in nerve identification and surgical decision making. A literature review of pediatric IONM was performed and used to inform a monitoring technique guide and expert opinion statements. Pediatric IONM is achieved using a variety of methods. When age-appropriate endotracheal tubes with integrated surface electrodes are not available, an alternative method should be used. Patient age and surgeon experience with laryngoscopy influence technique selection; four techniques are described in detail. Surgeons must be familiar with the nuances of monitoring technique and interpretation; opinion statements address optimizing this technology in children. Adult IONM guidelines may offer strategies for surgical decision making in children. In some cases, delay of second-sided surgery may reduce bilateral RLN injury risk.

Pediatric Thyroidectomy: NSQIP-P Analysis of Adverse Perioperative Outcomes

Background:

This study identifies risk factors and 30-day adverse outcomes of pediatric patients undergoing thyroidectomy.

Methods:

Retrospective analysis utilizing the American College of Surgeons National Surgical Quality Improvement–Pediatric Database (2015-2016). Study population includes pediatric patients (≤18 years) who underwent hemithyroidectomy (HT), total thyroidectomy (TT), and total thyroidectomy with central neck dissection (TT+ND).

Results:

A total of 720 cases were identified; mean age at time of surgery was 14.1 years, with a female-to-male ratio of 3.4:1. Following hospital discharge, there were 10 related readmissions, with 1 patient requiring reoperation for neck hematoma evacuation. Regression analysis revealed anesthesia time had a significant impact on total length of stay ( P = .0020).

Conclusion:

Contemporary pediatric thyroidectomy has a low incidence of 30-day general surgical postoperative complications. Future research efforts are necessary once thyroidectomy specific variables are incorporated into ACS-NSQIP-P, which will provide further insights into managing this unique patient population.

Total Thyroidectomy versus Bilateral Subtotal Thyroidectomy for Bilateral Multinodular Nontoxic Goiter: A Meta-Analysis

AIM

The aim of this meta-analysis is to assess and validate the feasibility and safety of total thyroidectomy (TT) when compared to bilateral subtotal thyroidectomy (BST) for bilateral multinodular nontoxic goiter (BMNG).

MATERIALS AND METHODS

PubMed, Web of Knowledge, and Ovid's database were searched for studies published in English language between January 1990 and December 2014. A meta-analysis was performed to compare the complications and recurrences of TT versus BST. The search terms used were 'total thyroidectomy', 'bilateral subtotal thyroidectomy', 'multinodular nontoxic goiter' and 'randomized clinical trial'. The reference lists of relevant studies were checked manually to locate any missing studies.

RESULTS

Four trials with a total of 1,078 patients were analyzed. Although the incidence of transient hypoparathyroidism was higher in TT than in BST (OR = 2.59, 95% CI [1.58-4.24], p = 0.0002), TT was associated with a significantly lower incidence of recurrence (OR = 0.04, 95% CI [0.01, 0.17], p < 0.0001). There were no statistically significant differences for the presence of transient/permanent recurrent laryngeal nerve palsy and permanent hypoparathyroidism between the two groups.

CONCLUSION

TT is a feasible and safe procedure for patients with BMNG. Although TT involves a significantly higher risk of postoperative transient hypoparathyroidism, it has a lower recurrence rate than BST.

Papillary Thyroid Carcinoma in Children and Adolescents: Long-Term Follow-Up and Clinical Characteristics

BACKGROUND

The aim of this study was to analyze the clinical features and clinical outcomes of papillary thyroid carcinoma (PTC) in the pediatric and adolescent population treated in our institution.

METHODS

The subjects were 227 PTC patients 20 years of age or under treated initially between 1979 and 2012. Their mean age at diagnosis was 18-year old (range 7-20 years). Patient characteristics and outcomes in the period before 1999 and the period after 2000 were compared. Cause-specific survival (CSS) rates and disease-free survival (DFS) rates were calculated by the Kaplan-Meier method.

RESULTS

Two patients died of their disease and 45 patients had recurrent disease (36 in lymph node, seven in a remnant thyroid, and 11 in the form of distant metastasis). The 10-, 20-, and 30-CSS rates were 99.3, 99.3, and 96.5%, respectively, and the 10-, 20-, and 30-DFS were 83.6, 70.7, and 64.0%, respectively. Gender and preoperative lymph node metastasis were identified as significant factors related to DFS in the multivariate analysis. After the year 2000, there were significantly more patients with a small primary tumor size, significantly more patients without distant metastasis at presentation and significantly more patients without extrathyroidal invasion.

CONCLUSION

The number of patients with advanced cancer has been declining in recent years. Lobectomy with prophylactic unilateral central neck dissection is considered acceptable for patients without the risk factors for recurrence.

Nodular recurrence and hypothyroidism following partial thyroidectomy for benign nodular thyroid disease in children and adolescents

OBJECTIVES

Diagnostic and therapeutic processing of a thyroid nodule in children and adolescents may require lobectomy-isthmusectomy (LI) or nodule-resection (NR). Very few data in the literature report the long-term evolution of the remaining thyroid lobe in a defined pediatric population. In this study, we aimed to answer the following questions: Does a nodule recurrence occur in the remainder lobe? Is a post-operative thyroxine treatment necessary?

MATERIAL AND METHODS

This retrospective study describes 28 patients under 18 who underwent LI (22 cases) or NR (6 cases) from January 2004 to March 2012. Ten of them were lost to follow up, 18 could be assessed (4 NR (22%) and 14 LI (78%) - mean follow-up 45±31 months). All patients benefited of post-operative thyroid ultrasonography, and regular endocrinologic follow-up. The following data were analysed: emergence of new thyroid nodules, evolution of pre-existing nodules, occurrence of post-operative hypothyroidism and requirement for completion thyroidectomy.

RESULTS

The mean age at the time of surgery was 14.3±1.9 years. Two patients (11%) had pre-existing nodules in the remaining thyroid gland, none of which showed an increase in size after surgery. De novo nodules developed in five patients (27.8%). Three patients who underwent LI (21.4%) needed thyroxine treatment for post-operative hypothyroidism. One patient (5.5%) needed completion thyroidectomy.

CONCLUSIONS

In this children and adolescents population, after performing LI or NR, remaining thyroid tissue stays free of nodules in 72.2% of the cases. A post-operative thyroxin treatment is necessary in 21.4% of cases after LI.

Thyroid carcinoma surgery in children and adolescents - 15 years experience surgery of pediatric thyroid carcinoma

OBJECTIVES

The purpose of this study is to evaluate the characteristics of thyroid gland surgery focusing on malignancies at the pediatric age with the main concern on treatment results and complications in extensive primary treatment.

METHODS

The records of all patients 18 years and younger with surgically treated thyroid diseases in the Prague Hospital, Motol, between 1991 and 2006 were retrospectively reviewed.

RESULTS

Thyroid surgery was performed on 148 pediatric patients (including 56 carcinomas). The youngest patient involved in the study was seven years old, the oldest patient 18 years old (mean 13.7 years). Most frequent histological cancer type was PTC (42 cases, 75%). Follicular cancer was diagnosed in five cases (8.9%) and medullar cancer in nine cases (16.1%). A prophylactic thyroidectomy was performed in three cases (5.4%) without clinical signs of thyroid tumor with diagnosed RET gene mutation.

CONCLUSIONS

We consider total thyroidectomy with subsequent radioiodine ablation and TSH suppression as the basic approach in the treatment protocol of pediatric WDTC. The observed 100% recurrence-free and overall survival together with a low incidence of postoperative complications strongly supports the idea of a total thyroidectomy with selective neck dissection in the treatment of metastases of WDTC and MTC.

[Current treatment strategies for papillary thyroid microcarcinoma]

The increase in the incidence of thyroid cancer is accompanied by a mortality rate that is stable or perhaps even slightly decreasing. This phenomenon is due to the increased frequency of papillary microcarcinomas (thyroid tumors with a diameter of less than 1 cm), which is presumably attributable to the improved diagnosis enabled by high resolution ultrasound and fine needle aspiration cytology. The American and European Thyroid Associations have recently published new guidelines for the diagnosis and therapy of differentiated thyroid tumors. These guidelines are aimed at minimizing the diagnostic and therapeutic procedures without reducing their effectiveness. This goal is particularly important for papillary thyroid microcarcinoma patients, who have an excellent prognosis and almost normal life expectancy. This article summarizes the history of thyroid surgery and introduces papillary thyroid microcarcinoma--an important topic in modern thyroid oncology. Current methods for diagnosis, treatment and follow-up care of this disease are discussed.

Treatment strategy of papillary thyroid carcinoma in children and adolescents: clinical significance of the initial nodal manifestation

BACKGROUND

Risk factors and treatment strategy in younger patients with papillary thyroid carcinoma are still controversial.

METHODS

We reviewed 120 consecutive papillary thyroid carcinoma patients younger than 20 years who underwent initial surgery between 1977 and 2004 (14 male and 106 female subjects; mean age, 16.3 years; mean follow-up, 11.6 years). Outcomes were evaluated initially, and risk factors for disease-free survival (DFS) were analyzed statistically. Cox proportional multivariate analysis revealed that initial nodal manifestation (P < .001, hazard ratio 2.97) was the most statistically significant risk factor for DFS. The outcomes were then compared between four subgroups on the basis of the initial nodal manifestation and node dissection: 17 patients in group A (no lymphadenopathy, no or only prophylactic central dissection), 30 patients in group B (no lymphadenopathy, prophylactic modified neck dissection, MND), 46 patients in group C (nonpalpable lymphadenopathy detected by radiological or operative findings, therapeutic MND), and 27 patients in group D (palpable lymphadenopathy, therapeutic MND).

RESULTS

Subtotal/total thyroidectomy and radioactive iodine therapy were performed for 47.1 and 0% in group A, 33.3 and 0% in group B, 43.4 and 10.9% in group C, and 85.1 and 48.1% in group D, respectively. In groups A, B, C, and D, 0%, 3.3%, 28.3%, and 48.1% developed recurrence, respectively (P < .001). DFS Kaplan-Meier curves differed significantly among the four subgroups (P < .0005).

CONCLUSIONS

Initial nodal manifestation is useful to predict DFS in younger papillary thyroid carcinoma patients. Our findings will be beneficial to determine the treatment strategy. Conservative therapy is considered acceptable for patients without risk factors.

Pediatric differentiated thyroid carcinoma in stage I: risk factor analysis for disease free survival

BACKGROUND

To examine the outcomes and risk factors in pediatric differentiated thyroid carcinoma (DTC) patients who were defined as TNM stage I because some patients develop disease recurrence but treatment strategy for such stage I pediatric patients is still controversial.

METHODS

We reviewed 57 consecutive TNM stage I patients (15 years or less) with DTC (46 papillary and 11 follicular) who underwent initial treatment at Ito Hospital between 1962 and 2004 (7 males and 50 females; mean age: 13.1 years; mean follow-up: 17.4 years). Clinicopathological results were evaluated in all patients. Multivariate analysis was performed to reveal the risk factors for disease-free survival (DFS) in these 57 patients.

RESULTS

Extrathyroid extension and clinical lymphadenopathy at diagnosis were found in 7 and 12 patients, respectively. Subtotal/total thyroidectomy was performed in 23 patients, modified neck dissection in 38, and radioactive iodine therapy in 10. Pathological node metastasis was confirmed in 37 patients (64.9%). Fifteen patients (26.3%) exhibited local recurrence and 3 of them also developed metachronous lung metastasis. Ten of these 15 achieved disease-free after further treatments and no patients died of disease. In multivariate analysis, male gender (p = 0.017), advanced tumor (T3, 4a) stage (p = 0.029), and clinical lymphadenopathy (p = 0.006) were risk factors for DFS in stage I pediatric patients.

CONCLUSION

Male gender, tumor stage, and lymphadenopathy are risk factors for DFS in stage I pediatric DTC patients. Aggressive treatment (total thyroidectomy, node dissection, and RI therapy) is considered appropriate for patients with risk factors, whereas conservative or stepwise approach may be acceptable for other patients.

Total thyroidectomy for benign disease in the pediatric patient--feasible and safe

PURPOSE

Total thyroidectomy (TT) is a safe and efficacious treatment of malignant thyroid disease in children. The role of TT in benign thyroid disease is less well-defined. The goal of this study was to compare the safety of TT performed for benign and malignant disease.

METHODS

The medical records of 31 patients undergoing TT from January 2000 to June 2007 at a single center were reviewed. The benign cohort totaled 15 patients consisting of 12 with Graves' disease, 2 with hyperthyroidism, and 1 with large and symptomatic multinodular goiter. The malignant cohort totaled 16 patients consisting of 9 with malignant disease, 4 with a nodule and history of cancer or radiation exposure, and 3 with RET proto-oncogene mutations.

RESULTS

The most common complication was transient hypocalcemia observed in 7 (46%) of 15 patients with benign disease and 9 (56%) of 16 patients with malignancy (P = .72). Permanent hypocalcemia, defined as need for calcium supplement 6 months postprocedure, was observed in 1 patient with benign disease (6.67%) and 1 patient with malignancy (6.25%; P = 1.0). A single parathyroid gland was reimplanted in 2 patients with malignancy and 2 patients with benign disease (P = 1.0). One case of keloid scar was noted, and no cases of recurrent laryngeal nerve palsy, nerve paralysis, tracheal injury, tracheostomy, or wound infection were encountered in either cohort. There were no cases of relapse hyperthyroidism in the benign cohort.

CONCLUSIONS

Similar rates of postoperative complications can be expected with TT for benign thyroid disease as compared to TT for malignant disease. Total thyroidectomy is a safe treatment option for benign thyroid disease in children.

Report of a hürthle cell neoplasm in a peripubertal girl

Thyroid nodules are rare in children compared to adults. Although most thyroid nodules are benign, the risk of malignancy is greater in pediatric patients. Papillary and follicular cell tumors account for the majority of thyroid neoplasms; Hürthle cell tumors account for less than 5%. Despite being uncommon, malignant Hürthle cell tumors are potentially more aggressive than papillary and follicular cell tumors. Therefore, distinguishing between types of thyroid neoplasms in a timely fashion has implications for prognosis and therapy. We describe a 12-year-old peripubertal girl who presented with a large right-sided thyroid nodule that was subsequently diagnosed as a Hürthle cell adenoma. To our knowledge, she represents the youngest patient with a Hürthle cell neoplasm.