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

Ultrasound, laboratory and histopathological insights in diagnosing papillary thyroid carcinoma in a paediatric population: a single centre follow-up study between 2000-2022

Background

Papillary thyroid carcinoma (PTC) often coincides with autoimmune thyroiditis (AIT); whether this association is incidental or causal remains debated.

Objective

To evaluate the ultrasonographic, laboratory, and histopathological features of PTC in paediatric patients with and without AIT and its relationship to puberty.

Design

A retrospective cohort study.

Patients and methods

A retrospective analysis of medical records of 90 patients (69; 76.7% females). The mean age at PTC diagnosis was 13.8 years [range 6-18]. All patients were evaluated ultrasonographically before thyroid surgery. Thyroid nodules were categorised using the European Thyroid Imaging Reporting and Data System (EU-TIRADS PL), and cytopathology was assessed using Bethesda criteria. Neck ultrasound results and thyroid and autoimmune status were correlated with histopathological PTC assessment.

Results

The coexistence of PTC and AIT was found in 48.9% (44/90) of patients. The percentage of AIT was increasing with age; AIT was present only in 1/3 of prepubertal, close to 50% in pubertal, and over 60% in adolescent patients. The youngest patients (aged <10 years old) presented more often with goitre and lymphadenopathy and less often with AIT than adolescents (15-18 years of age). There were no differences in TPOAb, TgAb, and TSH levels between the age subgroups. Presurgical TgAb levels were higher than those of TPOAb in the youngest patients. Histopathological analysis revealed that the solid subtype was observed more often in prepubertal children and diffuse sclerosing in children below 14 years of age, whereas the classic subtype dominated in late pubertal. Univariate and multivariate analyses revealed that lymph nodes metastases (LNM) were associated with PTC diameter and fT4 level, whereas extrathyroidal extension with age and angioinvasion with PTC diameter and age. The correlations between age and fibrosis, and the presence of psammoma bodies in malignant tissues were close to significant. We did not observe an association between TSH levels and the presence of autoimmunity and PTC variables.

Conclusions

In paediatric patients the natural course of PTC may be less aggressive in adolescent patients than in younger children (especially < 10 years of age). We suggest that pre-operative evaluation of paediatric patients with thyroid nodules could include apart from assessment of thyroid hormones, evaluation of TPOAb, TgAb, and TRAb together with comprehensive neck ultrasonography.

Paediatric differentiated thyroid carcinoma: a UK National Clinical Practice Consensus Guideline

This guideline is written as a reference document for clinicians presented with the challenge of managing paediatric patients with differentiated thyroid carcinoma up to the age of 19 years. Care of paediatric patients with differentiated thyroid carcinoma differs in key aspects from that of adults, and there have been several recent developments in the care pathways for this condition; this guideline has sought to identify and attend to these areas. It addresses the presentation, clinical assessment, diagnosis, management (both surgical and medical), genetic counselling, follow-up and prognosis of affected patients. The guideline development group formed of a multi-disciplinary panel of sub-speciality experts carried out a systematic primary literature review and Delphi Consensus exercise. The guideline was developed in accordance with The Appraisal of Guidelines Research and Evaluation Instrument II criteria, with input from stakeholders including charities and patient groups. Based on scientific evidence and expert opinion, 58 recommendations have been collected to produce a clear, pragmatic set of management guidelines. It is intended as an evidence base for future optimal management and to improve the quality of clinical care of paediatric patients with differentiated thyroid carcinoma.

Outcome and complications after surgery for thyroid carcinoma in pediatric age—an evaluation of practice

Objectives

To discuss management protocol, surgical complications, and outcomes of thyroid carcinoma in children.

Methods

We performed a retrospective analysis including all pediatric patients with thyroid carcinoma who were managed at our institution between January 2011 and January 2021. Data were analyzed regarding demographics, clinical features, operative details, postoperative complications, and survival data.

Results

Thirty-two patients were identified; 26 females (81.25%) and 6 males (18.75%). The median age at operation was 14 years (range: 5–18). Twenty-six (81.25%) patients presented with palpable thyroid swelling. Median tumor size was 3 cm (range: 1–7). Metastatic workup did not detect any pulmonary metastases. Total thyroidectomy was performed in 25 patients (78%), and 16 of them underwent additional bilateral neck dissection (16 had central nodal dissection, and 7 had both central and lateral nodal dissection). Seven patients (22%) underwent hemithyroidectomy, and only one of them had a completion thyroidectomy after 2 weeks. Conservative resection was adopted in six children with similar criteria (tumor size < 1.5 cm in one lobe, no extrathyroid extension, differentiated thyroid carcinoma, no detected lymph nodes). Postoperative complications occurred in eight patients (all had total thyroidectomy) with an overall incidence of 25%. Seven patients had transient morbidities that were managed conservatively (chylous leak n = 1, hypoparathyroidism n = 3, and nerve palsy n = 3). At a median follow-up time of 54 months, four patients had relapsed (all underwent total thyroidectomy). The 5-year OS and EFS were 100% and 87.5%, respectively.

Conclusion

Operative resection for pediatric thyroid carcinoma can be performed with average short-term complications and achieving excellent outcomes. Total thyroidectomy remains the standard procedure of choice in the majority of those patients. However, conservative surgery can be successfully adopted in a well-selected group of children with favorable long-term results as per our findings.

Clinical Heterogeneity of Differentiated Thyroid Cancer between Children Less than 10 Years of Age and Those Older than 10 Years: A Retrospective Study of 70 Cases

OBJECTIVES

The objectives of this study were to explore the clinical heterogeneity of differentiated thyroid cancer (DTC) between prepubertal children and adolescents and guide clinical treatment.

METHODS

A retrospective study included patients with DTC aged ≤19 years in Beijing Children's Hospital from June 2014 to June 2019. All patients were enrolled and divided into 2 subgroups based on the threshold age of 10 years, namely the childhood group (CG) (≤10 years old); and the adolescent group (AG) (between 10 and 19 years old). The χ² test and Fisher's exact test were used to estimate the effect of risk factors in the 2 age groups. Multivariate binary logistic regression models were conducted to assess the recurrent risk factors.

RESULTS

Seventy cases of DTC were included with an average age of 9.94 ± 2.88 years, including 35 in CG and 35 in AG. The most common clinical manifestation was a painless mass in the neck, accounting for 77.1% (54/70) of patients. Compared with the AG, the CG was more likely to have lymph node metastasis (p = 0.022) and distant metastasis (p = 0.041). The CG was more likely to have extrathyroidal extension (p = 0.012) and had a significantly higher recurrence rate than the AG (p = 0.040). Age was an independent variable predictive of recurrence (p = 0.0347).

CONCLUSION

Regional invasiveness, cervical lymph node metastasis, and distant metastasis of DTC were more likely to occur in children ≤10 years old. Meanwhile, children ≤10 years old with DTC were more likely to have recurrence than adolescent's postsurgical treatment. Thus, children younger than 10 years of age with DTC should be treated more aggressively.

Clinical Assessment of Pediatric Patients with Differentiated Thyroid Carcinoma: A 30-Year Experience at a Single Institution

Background

Thyroidectomy is the typical treatment for pediatric thyroid carcinoma; total thyroidectomy is commonly performed. We aimed to report our experience at a single tertiary institution and to evaluate the risk factors for recurrence, especially based on surgical extent, in pediatric patients with differentiated thyroid carcinoma (DTC).

Methods

A data of 94 pediatric patients who underwent thyroid surgery for DTC from January 1982 to December 2012 at Yonsei University Hospital (Seoul, Korea) were reviewed. The clinicopathologic features and surgical outcomes were retrospectively analyzed through complete chart reviews.

Results

The mean age was 16.6 ± 3.0 (range, 5–19) years. Fourteen patients had recurrence. Tumor size >2 cm (hazard ratio [HR], 14.241; p = 0.011) and positive lymph nodes (HR, 1.056; p = 0.039) were significant risk factors for disease-free survival (DFS) in multivariate analysis. In Kaplan–Meier analysis, a statistically significant difference was noted in the DFS according to tumor size 2 cm (p < 0.001). However, the DFS was not significantly different between the bilateral total thyroidectomy (BTT) and less than BTT groups (p = 0.215).

Conclusions

BTT remains the treatment of choice in pediatric patients with DTC. Lobectomy may be considered for patients with limited disease, including those with tumor size <2 cm, no suspicious lymph nodes, intrathyroidal lesion, and no multifocal disease.

Thyroid surgery in 103 children in a single institution from 2000-2014

BACKGROUND

Data on thyroid surgery in children are scarce.

OBJECTIVE

Analyze outcome data on thyroid surgery in a pediatric population.

DESIGN

Medical record review.

SETTING

Tertiary health care institution.

PATIENTS AND METHODS

We collected demographic and clinical data on patients 18 years or younger who had thyroid surgery in the period 2000 to 2014. Descriptive data are presented.

MAIN OUTCOME MEASURES

Indications for thyroidectomy, thyroid pathology, complications, length of stay, and radioactive iodine treatment and recurrences.

SAMPLE SIZE

103.

RESULTS

Of 103 patients who underwent 112 thyroidectomy procedures, 80 (78%) were females and the mean age at operation was 13.2 years. and 17 (16%) were associated with multiple endocrine neoplasia type 2. There was no history of radiation exposure. Eighty-one patients (78%) had fine needle aspiration (FNA) which correlated with the final histopathology in 94% of cases. Sixty-six patients (64%) had malignant cancer (61 papillary), 44 (74.6%) of 59 patients who had neck dissection had lymph node metastasis and 7 (11%) had distant metastases to the lung. Procedures included total thyroidectomy (50%), hemithyroidectomy (17%), completion (31%), and subtotal thyroidectomy (2%). Twenty-three patients (22%) developed hypocalcemia (3 permanent) and 6 (5.8%) had unilateral recurrent laryngeal nerve injury (3 permanent). Patients were followed up for a mean duration of 71.7 months (median 60 months). Of 66 patients with thyroid cancer, 43 (65%) received radioactive iodine, and 10 (15%) had recurrence.

CONCLUSION

Malignancy is the commonest indication for thyroid surgery in children and FNA is highly diagnostic. Hypocalcemia and recurrent laryngeal nerve injury are significant complications. The recurrence rate in thyroid cancer is 15%.

LIMITATIONS

Retrospective.

CONFLICT OF INTEREST

None.

Pre-operative ultrasound guided wire localization for recurrent or persistent thyroid disease: A series of four cases

INTRODUCTION

Successful pediatric revision thyroid surgery depends primarily on effective localization of recurrent or persistent lesions. Secondary to fibrosis and scarring, blind regional dissection can fail to retrieve the tissues of concern. Conventionally, high resolution CT or ultrasound of the neck has been used to map lesions within the thyroid bed. The success rate of excising recurrent lesions using these mapping techniques is at best 80%. We present a small series of patients in which hook wire localization was used to help localize and excise recurrent and/or persistent neck disease during secondary operations.

METHODS

The wire-localization technique was utilized for a prospective case series of four pediatric patients with history of previous thyroidectomy and recurrent or persistent malignant thyroid disease.

RESULTS

All four patients had recurrence or persistence of their disease process in the central or lateral neck. Patients successfully underwent preoperative hook wire localization of their persistent or recurrent neck lesions with successful subsequent neck dissection. Each case involved a single wire localization for a unique mass, equally a total of 4 lesions accessed by the technique over the four cases. The ultrasound-guided wire-localization technique assisted in the localization and excision of non-palpable lesions. No complications were seen in our small series as a result of this technique.

CONCLUSION

Hook wire localization may be a useful tool to help the surgeon more efficiently localize and excise recurrent or persistent disease in a scarred/previously operated field.

Pediatric differentiated thyroid carcinoma: trends in practice and outcomes over 40 years at a single tertiary care institution

BACKGROUND

This study aims to analyze changes in characteristics, practice and outcomes of pediatric differentiated thyroid cancer (DTC) at our tertiary care institution.

METHODS

Patients <21 years of age diagnosed between 1973 and 2013 were identified. Clinicopathological data, treatment and outcomes were obtained by a retrospective review.

RESULTS

Thirteen males and 68 females were divided into Group A (n=35, diagnosed before July 1993) and Group B (n=46, diagnosed after July 1993). Group B was more likely to undergo neck ultrasound (US) (70% vs. 23%, p<0.0001) and fine-needle aspiration (FNA) biopsy (80% vs. 26%, p<0.0001). Patients in Group B more often underwent total thyroidectomy as a definitive surgical treatment (87% vs. 69%, p=0.04). There was no difference in radioactive iodine use. Recurrence-free survival was similar.

CONCLUSIONS

Increased use of US and FNA has affected initial surgical management in the latter part of the study, possibly due to extension of adult DTC guidelines. The effects of the new pediatric DTC guidelines need further study.

Paediatric follicular thyroid carcinoma - indolent cancer with low prevalence of RAS mutations and absence of PAX8-PPARG fusion in a Japanese population

AIMS

Paediatric follicular thyroid carcinomas are uncommon, and their clinicopathological features and molecular profiles are still unknown. In the present study, we aimed to investigate the clinicopathological aspects of a large series of follicular thyroid carcinomas (FTCs) in paediatric patients and to analyse the point mutations in codons 12, 13 and 61 of NRAS, HRAS and KRAS genes and the rearrangements of PAX8-PPARG.

METHODS AND RESULTS

A total of 41 paediatric FTCs less than 21 years of age were enrolled into the present study. We used direct sequencing and reverse transcription-polymerase chain reaction (RT-PCR) to detect RAS mutations and PAX8-PPARG fusions, respectively. The paediatric FTCs were 6:1 in a female to male ratio, with a mean tumour size of 52.7 mm. Distant metastasis was found in one case at the time of presentation. During a median follow-up time of 69 months, two cases had lung metastasis and all patients were alive. Histologically, all cases were minimally invasive FTCs and varied in growth patterns: microfollicular (39%), follicular (14.6%), solid/trabecular (6%), oncocytic (4.9%) and mixed patterns (26.8%). The mean Ki67 index was 5.7% and it was not statistically different among the growth patterns. NRAS mutations were found in five cases (12.2%) and associated significantly with small tumour size (P = 0.014). PAX8-PPARG fusion was not detected in our series.

CONCLUSION

Paediatric FTCs are indolent in clinical course in spite of their large tumour size and have a distinct genetic background. RAS mutations and PAX8-PPARG fusions may not play major roles in the tumorigenesis of paediatric FTCs.

Perioperative determinants of transient hypocalcemia after pediatric total thyroidectomy

PURPOSE

We seek to identify risk factors associated with hypocalcemia after pediatric total thyroidectomy.

METHODS

We retrospectively reviewed patients younger than 21years undergoing total thyroidectomy between January 2002 and January 2016. We defined hypocalcemia as any serum calcium <8mg/dl or ionized calcium <1.0mmol/L. Perioperative risk factors were identified through multivariate logistic regression.

RESULTS

Ninety-one children underwent total thyroidectomy. The average age was 13.7±4.4years, and 77% were female. Transient hypocalcemia was diagnosed in 34% (n=31) of patients. There was one case of permanent hypoparathyroidism. Predictors of transient hypocalcemia included age (OR 0.87, 95% CI 0.8-0.97, p=0.01), lymphadenectomy (OR 6.6, 95% CI 1.7-31.6, p=0.01), and hyperthyroidism (OR 13.3, 95% CI 1.3-1849, p=0.03). Patients with malignancy undergoing central (OR 7.1, 95% CI 1.5-33.4, p=0.01) or central plus lateral lymphadenectomy (OR 6.33, 95% CI 1.0-40.1, p=0.05) had significantly increased risk for transient hypocalcemia. Malignancy, MEN2A/B, goiter, preoperative calcium supplementation, incidental parathyroid removal, and postoperative PTH <15pg/ml were not associated with transient hypocalcemia.

CONCLUSIONS

Younger age, hyperthyroidism, and concomitant lymphadenectomy during total thyroidectomy increase risk of developing transient hypocalcemia. Malignant cases with central or central plus lateral lymphadenectomy are also at increased risk. Aggressive perioperative management of hypocalcemia should be initiated in patients with these risk factors.

LEVEL OF EVIDENCE

2b.

Surgical management of papillary thyroid carcinoma in childhood and adolescence: an Italian multicenter study on 250 patients

PURPOSE

The extent of surgery for pediatric papillary thyroid carcinoma is debatable. The aim of this study was to evaluate the feasibility of offering pediatric patients a tailored surgical approach based on certain clinical features.

METHODS

A national multicenter retrospective review of 250 pediatric patients treated for papillary thyroid carcinoma in a 14-year period was performed. Outcomes of interest included tumor-related features, type of surgery, surgical morbidity, disease-free and overall survival rates. Recurrence was thoroughly analyzed with particular focus on how it correlated with certain patient- and tumor-related features.

RESULTS

The majority of patients (58.8 %) had tumors >2 cm in size. Nodal involvement occurred in 115/250 (46 %) patients and distant metastasis in 4 % (10/250). Total thyroidectomy and lobectomy were performed in 90.4 % (226/250) and 9.6 % (24/250) of patients, respectively. The overall rate of surgical complications was 20.8 % (52/250). These included transient and permanent hypoparathyroidism (13.6 and 4.4 %, respectively), and vocal fold palsy (2.8 %). All surgical complications occurred exclusively in the total thyroidectomy group. The rate of recurrent disease was 12 % (30/250) with the vast majority of recurrences (96.6 %) occurring in the total thyroidectomy group. The risk of recurrence correlated significantly with certain tumor-related features (size > 2 cm, multifocality, extrathyroidal invasion, nodal positivity, and distant metastasis). However, it did not correlate with the patient's age or sex. Overall survival was 100 %.

CONCLUSION

Pediatric patients are likely to benefit from a tailored surgical strategy. Uniformly offering patients total thyroidectomy seems to be an overly radical approach.

Review of clinical and pathological features of 93 cases of well-differentiated thyroid carcinoma in pediatric age at the Lisbon Centre of the Portuguese Institute of Oncology between 1964 and 2006

INTRODUCTION

Thyroid carcinoma is the most common endocrine malignancy. In childhood, thyroid carcinoma usually behaves aggressively and relapses frequently. Nevertheless, it has a favorable prognosis. Our aim is to present our experience with pediatric well-differentiated thyroid carcinoma (WDTC) treated at the Portuguese Institute of Oncology in Lisbon (L-PIO), between 1964 and 2006.

METHODS

Review of clinical files of WDTC in≤18-year-old patients selected from the databases of the Endocrinology Service of L-PIO and the South Portugal Regional Cancer Registry (SPCR).

RESULTS

93 cases of WDTC were found. Of these, 70 (75.3%) were girls. The median age was 15 years old (range 5-18) with a median follow-up time of 15.1 years (range 0.2-47.8). The most common histological diagnosis was papillary carcinoma of the classical variant (n=60, 64.5%). Initial staging showed locoregional dissemination in 27 (29.0%) patients and distant metastasis in 16 (17.2%) patients. Median age was lower in patients with distant disease than in patients with locoregional disease or with disease confined to the thyroid (P=0.007). After the initial treatment, 44 (47.3%) patients were in remission and 46 (49.5%) had persistent disease (lost follow-up in 3). Of the disease-free patients after initial treatment, 11 (25.0%) relapsed later. At the last observation, most patients (n=63, 67.7%) showed no evidence of disease.

CONCLUSION

Our study demonstrates that children with distant metastatic disease are younger than children with a less aggressive disease. However, in both groups the response to treatment is favorable and the prognosis is usually excellent.

Postoperative Complications After Prophylactic Thyroidectomy for Very Young Patients With Multiple Endocrine Neoplasia Type 2: Retrospective Cohort Analysis

The aim of this study was to investigate whether younger age at surgery is associated with the increased incidence of postoperative complications after prophylactic thyroidectomy in pediatric patients with multiple endocrine neoplasia (MEN) 2. The shift toward earlier thyroidectomy has resulted in significantly less medullary thyroid carcinoma (MTC)-related morbidity and mortality. However, very young pediatric patients might have a higher morbidity rate compared with older patients. Hardly any literature exists on complications in the very young. A retrospective single-center analysis was performed on the outcomes of MEN2 patients undergoing a prophylactic total thyroidectomy at the age of 17 or younger. Forty-one MEN2A and 3 MEN2B patients with thyroidectomy after January 1993 and at least 6 months of follow-up were included, subdivided in 9 patients younger than 3 years, 15 patients 3 to 6 years, and 20 patients older than 6 years. Postoperative hypocalcemia and other complications were registered. Twelve (27%) patients developed transient hypocalcemia and 9 (20%) patients suffered from permanent hypocalcemia, with a nonsignificant trend toward higher incidence with decreasing age. Three (7%) patients had other complications, of whom 2 were younger than 3 years. For patients younger than 3 years, the average length of stay (LOS) was 6.7 days, versus 1.7 and 3.5 days, respectively, for the older patient groups (P < 0.05). Patients with complications had a longer LOS compared with patients without (5.0 vs 2.0, P < 0.01). None of the patients had clinical signs of recurrent MTC after a mean follow-up of 10.5 years. Prophylactic thyroidectomy in very young children is associated with a higher rate of complications, causing a significant increased LOS. Irrespective age of surgery, MTC did not recur in any patient. In planning optimal timing of surgery, clinicians should take the risk of complications into account. We advise not to perform total thyroidectomy before the age of 3 for patients defined high risk by the American Thyroid Association guideline.