Pediatric thyroid cancer: An update from the SEER database 2007-2012

Papillary thyroid carcinoma in an 8-year-old Ethiopian child: A case report with literature review

Thyroid nodular disease can present in different forms, such as a solitary nodule, multinodular goiter, nodular goiter caused by autoimmune goiter, and nonpalpable thyroid nodules. Among children, thyroid cancer is the most common type of endocrine cancer. Pediatric thyroid cancer is usually detected as a neck mass without any symptoms, leading to variable stages of progression when diagnosed. Papillary thyroid carcinoma is the most common type of thyroid cancer in children with thyroid nodules. We are presenting a case of an 8-year-old male child who was referred to Jimma Medical Center after he developed swelling on the right side of his neck. On examination, multiple, matted 8 × 6 cm, firm to hard, non-tender right lateral neck masses were found, which moved with swallowing. Thyroid function tests were normal. An ultrasound diagnosis of thyroid carcinoma and a cytologic diagnosis of suspicion for papillary thyroid carcinoma (Bethesda V) was made, and an excisional biopsy was advised. A total thyroidectomy was done. A histopathology diagnosis of Papillary thyroid carcinoma (Classic variant) was made. This is an unusual case of Papillary thyroid carcinoma in an Ethiopian child, with plenty of examples previously recorded in the literature but no such report of its occurrence in our setup to our knowledge. When children under 10 have cervical masses, thyroid cancer should be considered. The evaluation of a palpable thyroid mass typically begins with a blood test to check thyroid function, along with ultrasound and fine-needle aspiration biopsy. Currently, fine-needle aspiration biopsy is the most reliable way to diagnose malignancy and determine the appropriate surgical approach. In most cases, treatment will involve a total thyroidectomy. Lymph node dissection is necessary only if lymph node disease is detected during preoperative evaluation.

Case Series of Surgical Treatment in Pediatric Thyroid Carcinoma in a Single Institution

Introduction

The prevalence of thyroid carcinoma (TC) among pediatric and adolescent populations is infrequent, yet its global occurrence is escalating. Insufficient information pertaining to TC in the pediatric populace of Indonesia presents issues in the identification and management of patients with this condition. The objective of this study is to provide a detailed account of a collection of pediatric TC cases that were recorded at a tertiary care center throughout an extended interval of eight years.

Presentation of Cases

The present study conducted a retrospective data analysis of ten patients who received a diagnosis of TC during the period spanning from 2014 to 2022. The present study focused on analyzing the clinical manifestation, diagnostic measures, treatment modalities, and immediate postoperative consequences of TC. All patients diagnosed with thyroid cancer exhibited the presence of neck lump. Nine patients underwent total thyroidectomy, while one patient underwent isthmolobectomy. The histopathologic evaluation confirmed the diagnosis of thyroid cancer in every individual. There were a significant number of patients, up to 50%, who encountered complications after undergoing surgery. Two patients reported the hoarseness of voice, whereas two other patients experienced the signs of hypocalcemia. Only one patient exhibited both these symptoms simultaneously.

Discussion

The implementation of total thyroidectomy as a surgical intervention in pediatric patients poses a notable challenge. Postoperative monitoring for potential complications following surgery for total thyroidectomy is imperative.

Conclusions

The current study provides evidence that the utilization of total thyroidectomy in combination with lymph node dissection as indicated in patients with lymph node metastases in pediatric patients with thyroid carcinoma leads to a significant reduction in the probability of recurrence of lymph node enlargement. During the performance of surgical procedures, meticulous observation plays a key role in mitigating the risk of postoperative complications, such as hypoparathyroidism, hypocalcemia, and injury to the recurrent laryngeal nerve. Thus, it is imperative to conduct follow-up procedures for post-surgical interventions among pediatric patients diagnosed with TC.

Survival Trends in Pediatric Differentiated Thyroid Cancer: A Middle Eastern Perspective

Pediatric Differentiated Thyroid Cancer (pedDTC) is a rare pediatric malignancy with an increasing incidence over time. To date, there is a paucity of literature specifically addressing pedDTC within the context of Middle Eastern ethnicity. This retrospective study aimed to assess the risk-stratifying factors for overall survival (OS) and event-free survival (EFS) in pediatric DTC patients from Iraq and Jordan. The medical records of 81 patients from two tertiary cancer institutes were retrieved. Kaplan-Meier analysis was employed to investigate OS and EFS, and the Cox proportional hazards model was employed to estimate hazard ratios. All patients underwent surgery and radioactive iodine therapy, with a median age of 14 and an interquartile range of 12-15. Lymph node involvement was observed in 55% of cases, while distant metastases were present in 13.5%. After a median follow-up period of 68 months, the 10-year survival rate was determined to be 94%, while the 10-year EFS rate was 58%. EFS was negatively impacted by cervical lymph node metastases and early age of diagnosis (p ≤ 0.01, each). Therefore, pediatrics with initial cervical lymph node metastases and those diagnosed before puberty tend to experience poorer EFS, which may justify the need for more aggressive management plans.

Practice Patterns in the Operative Management of Pediatric Thyroid Disease Across Surgical Specializations

BACKGROUND

Multiple surgical specializations are involved in the operative management of pediatric thyroid disease, but current practice patterns remain unknown. The objective of this study was to examine current practice patterns in the operative management of pediatric thyroid disease, specifically comparing practices across different surgical specializations including pediatric surgery, pediatric otolaryngology, general surgery, adult otolaryngology, and endocrine-focused general surgery.

METHODS

Children 0-18 years-old undergoing thyroid surgery from 2015 to 2019 were identified using the Healthcare Cost and Utilization Project State Inpatient Databases and State Ambulatory Surgery and Services Databases across 6 states. Surgeon specialization was determined for all included surgeons. Patient and hospital characteristics were compared across surgical specializations. Clinical outcomes including hypocalcemia/hypoparathyroidism, recurrent laryngeal nerve injury, hematoma, and wound infection were assessed.

RESULTS

A total of 1241 pediatric thyroidectomies performed by 363 surgeons were included. Procedures were most frequently performed by pediatric surgeons (34.9%). Only 7.2% of procedures were performed by adult general surgeons. There were statistically significant differences in patient age, sociodemographics, surgical indications, and type of procedure performed between specializations (p < 0.05). Endocrine-focused general surgeons had the highest average annual thyroid procedure volume with 78.2 cases/year, and pediatric surgeons and pediatric otolaryngologists had the lowest volumes with 0.7 and 0.6 cases/year, respectively. Overall complication rates were low.

CONCLUSIONS

Operative management of pediatric thyroid disease was most frequently performed by pediatric surgery. Pediatric specializations are more likely to operate on low-income, minority children with public insurance and patients with Graves' disease. Overall complications were low.

LEVEL OF EVIDENCE

III.

Deciphering pathological behavior of pediatric medullary thyroid cancer from single-cell perspective

Background

Pediatric medullary thyroid cancer (MTC) is one of the rare pediatric endocrine neoplasms. Derived from C cells of thyroid glands, MTC is more aggressive and more prompt to metastasis than other types of pediatric thyroid cancer. The mechanism remains unclear.

Methods

We performed single-cell transcriptome sequencing on the samples of the primary tumor and metastases lymph nodes from one patient diagnosed with MTC, and it is the first single-cell transcriptome sequencing data of pediatric MTC. In addition, whole exome sequencing was performed and peripheral blood was regarded as a normal reference. All cells that passed quality control were merged and analyzed in R to discover the association between tumor cells and their microenvironment as well as tumor pathogenesis.

Results

We first described the landscape of the single-cell atlas of MTC and studied the interaction between the tumor cell and its microenvironment. C cells, identified as tumor cells, and T cells, as the dominant participant in the tumor microenvironment, were particularly discussed in their development and interactions. In addition, the WES signature of tumor cells and their microenvironment were also described. Actively immune interactions were found, indicating B cells, T cells and myeloid cells were all actively participating in immune reaction in MTC. T cells, as the major components of the tumor microenvironment, proliferated in MTC and could be divided into clusters that expressed proliferation, immune effectiveness, and naive markers separately.

Transoral endoscopic thyroidectomy vestibular approach as a novel technique for pediatric populations: Results from a single surgeon

Background

The transoral endoscopic thyroidectomy vestibular approach (TOETVA) is increasingly being adopted worldwide because of its many advantages. However, there are few reports on the effectiveness and safety of TOETVA in children. In this study, we report the results of the application of TOETVA on 27 pediatric patients in Vietnam. To the best of our knowledge, this is also the largest sample size of the TOETVA technique performed by a single surgeon on pediatric patients worldwide. Patients and methods: From June 2020 to February 2022, we performed TOETVA on 27 pediatric patients (≤ 18 years old). The outcomes of the procedure were retrospectively reviewed.

Results

Our study was conducted on 27 pediatric patients, of whom 24 were female (88.9%). The mean age was 16.3 ± 2 (range 10-18). Fifteen patients had benign thyroid nodules with a mean nodule size of 31.6 ± 7.1 (range 20-50mm), and 12 patients had papillary thyroid carcinoma with a mean nodule size of 10.2 ± 5.6 (range 4-19mm). All 27 patients underwent successful TOETVA without any conversion to open surgery. The 15 patients with benign thyroid nodules had lobectomies with a mean operative time of 83.3 ± 10.5 (range 60-105 minutes). Among the 12 patients diagnosed with thyroid cancer, ten had a lobectomy, isthmusectomy, and central neck dissection, with a mean operative time of 89.8 ± 5.7 (range 80-100 minutes). The other two underwent total thyroidectomy with central lymph node dissection with a mean operative time of 132.5 minutes. The mean hospital stay was 4.7 ± 0.9 (range 3-7 days). No patient had permanent complications, such as hypocalcemia, recurrent laryngeal nerve injury, or mental nerve injury. The rates of temporary recurrent laryngeal nerve injury and mental nerve injury were 3.7% and 11.1% respectively.

Conclusions

TOETVA may be a feasible and safe surgical method for children with thyroid disease. However, we recommend that only high-volume thyroid surgeons with experience in TOETVA should perform TOETVA on the pediatric population.

Imaging of pediatric thyroid tumors: A COG Diagnostic Imaging Committee/SPR Oncology Committee White Paper

Pediatric thyroid cancer is rare in children; however, incidence is increasing. Papillary thyroid cancer and follicular thyroid cancer are the most common subtypes, comprising about 90% and 10% of cases, respectively. This paper provides consensus imaging recommendations for evaluation of pediatric patients with thyroid cancer at diagnosis and during follow-up.

Evaluation and management of pediatric thyroid nodules and thyroid cancer at a single institution after adoption of the American Thyroid Association 2015 guidelines

OBJECTIVES

The study purpose is to correlate clinical findings with rates of differentiated thyroid cancer (DTC) in a cohort of children presenting with thyroid nodules at a single institution since the adoption of the 2015 American Thyroid Association (ATA) Guidelines Task Force on Pediatric Thyroid Cancer.

METHODS

Clinical, radiographic, and cytopathologic findings were retrospectively analyzed in a pediatric cohort (≤19 years) identified with ICD-10 codes for thyroid nodules and thyroid cancer from January 2017 until May 2021.

RESULTS

We analyzed 183 patients with thyroid nodules. The mean patient age was 14 years (interquartile range 11-16) with a female (79.2 %) and white Caucasian (78.1 %) predominance. The overall DTC in our pediatric patient cohort was 12.6 % (23 out of 183). Most of the malignant nodules measured from 1-4 cm (65.2 %) with TI-RADS score of ≥4 (69.6 %). Among the fine-needle aspiration results (n=49), the highest frequency of DTC was within the malignant category (16.33 %), followed by suspicious for malignancy (6.12 %), then atypia or follicular lesion of undetermined significance (8.16 %), and lastly follicular lesion or neoplasm and benign with 4.08 % and 2.04 % respectively. Of the forty-four thyroid nodules that underwent surgical intervention, pathology was remarkable for 19 papillary thyroid carcinoma (43.18 %) and 4 follicular thyroid carcinoma (9.09 %).

CONCLUSIONS

Based on the analysis of our pediatric cohort in the southeast region at a single institution, adoption of the 2015 ATA guidelines could lead to an increased accuracy in detecting DTC while reducing the number of patients requiring interventions, such as FNA biopsy and/or surgeries. Further, based on our small cohort, it would be reasonable for thyroid nodules 1 cm or less to be monitored clinically with physical exam and ultrasonography, with further therapeutic or diagnostic intervention considered based on concerning features or parental shared decision making.

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.

Prepubertal Children with Papillary Thyroid Carcinoma Present with More Invasive Disease Than Adolescents and Young Adults

Introduction: Pediatric papillary thyroid carcinomas (PTCs) are more invasive than adult PTCs. No large, contemporary cohort study has been conducted to determine whether younger children are at higher risk for advanced disease at presentation compared to adolescents. We aimed to describe pediatric PTC and contextualize its characteristics with a young adult comparison cohort. Methods: The National Cancer Database was interrogated for pediatric and young adult PTCs diagnosed between 2004 and 2017. Clinical variables were compared between prepubertal (≤10 years old), adolescent (11-18 years old), and young adult (19-39 years old) groups. Multivariable logistic regression modeling for independent predictors of metastases was conducted. A subanalysis of microcarcinomas (size ≤10 mm) was performed. Results: A total of 4860 pediatric (prepubertal n = 274, adolescents n = 4586) and 101,159 young adult patients were included. Prepubertal patients presented with more extensive burden of disease, including significantly larger primary tumors, higher prevalence of nodal and distant metastases, and increased frequency of features such as lymphovascular invasion, and extrathyroidal extension (ETE). Prepubertal age was an independent predictor of positive regional nodes (adjusted odds ratio [AOR] = 1.36 [95% confidence interval {CI} 1.01-1.84], p = 0.04) and distant metastatic disease (AOR = 3.12 [CI 1.96-4.96], p < 0.001). However, there was no difference in survival between groups (p = 0.32). Prepubertal age independently predicted lymph node metastases for microcarcinomas (AOR = 2.19 [CI 1.10-4.36], p = 0.03). Prepubertal (n = 41) versus adolescent (n = 937) patient age was associated with gross ETE (p = 0.004), even with primary tumors ≤1 cm in size. Conclusions: Patients aged <11 years old present with more advanced disease than adolescents, with a higher likelihood of nodal and distant metastatic disease at time of diagnosis, although survival is high. Prepubertal children undergo more extensive treatment, likely reflective of more invasive disease at the outset, even in the setting of a subcentimeter primary tumor.

Thyroid nodules in children and adolescents: Investigation and management

Clinically detectable thyroid nodules are less common in children than adults. However, they are associated with an increased risk of malignancy. Therefore, thorough evaluation of paediatric thyroid nodules is necessary, and an understanding of the features associated with a higher risk of malignancy is important to guide management and referral. Thyroid cancer in children differs significantly from that seen in adults in terms of genetics, presentation, response to treatment and prognosis. Children often present with more advanced disease, but the vast majority have excellent long-term prognosis. Evaluation and management of thyroid nodules and thyroid cancer require a multidisciplinary team approach and involvement of specialists with experience in this field. This review summarises investigative pathways for thyroid nodules in children and outlines current management strategies for paediatric thyroid nodules and cancer.

Clinicopathologic and Prognostic Features of Pediatric Follicular Cell-derived Thyroid Carcinomas: A Retrospective Study of 222 Patients

Pediatric thyroid carcinomas (TCs) are rare and mainly approached based on data extrapolated from adults. We retrospectively reviewed 222 pediatric TCs (patient age less than or equal to 21 y). Lymph node (LN) disease volume at presentation was considered high if the largest positive LN measured ≥1 cm and/or >5 LNs were positive. High-grade follicular cell-derived thyroid carcinoma (HGFCTC) were defined by the presence of marked mitotic count and/or tumor necrosis and considered as high-risk histology along with papillary thyroid carcinomas (PTC) diffuse sclerosing variant (DSV). Disease-free survival (DFS) was analyzed. LN involvement at presentation was significantly associated with male sex, larger tumor size, lymphatic invasion, positive surgical margins, and distant metastases at presentation. Five- and 10-year DFS was 84% and 77%, respectively. Only 1 patient with HGFCTC died of disease. Within PTC variants, PTC-DSV was associated with adverse histopathologic parameters and higher regional disease spread, unlike PTC tall cell variant which did not portend worse behavior. The presence of necrosis conferred worse DFS ( P =0.006), while increased mitotic activity did not. While the entire HGFCTC group did not correlate with outcome ( P =0.071), HGFCTC with necrosis imparted worse DFS ( P =0.006). When restricted to PTC-DSV and HGFCTC with necrosis, high-risk histologic classification emerged as an independent prognostic parameter of DFS ( P =0.020). The excellent prognosis of pediatric TCs differs from that of adult TCs showing similar histologic features. While neither increased mitotic activity nor PTC tall cell variant histology predict adverse outcome, PTC-DSV and tumors with necrosis constitute high-risk histologic variants with an increased risk of protracted disease.

Thyroid cancers in children and adolescents in France: Incidence, survival and clinical management over the 2000-2018 period

INTRODUCTION

Thyroid cancer is the first cause of endocrine malignancy among children. Over the past decades, an increase in the incidence rates (IR) has been observed around the world. Our study aimed to describe epidemiology, therapeutic management and survival rates of children and adolescents with thyroid cancer in France.

METHODS

A population-based study was conducted between 2000 and 2018 in children and adolescents less than 17 years with a diagnostic of thyroid cancer.

RESULTS

A total of 774 thyroid cancers were included: 579 papillary (PTC), 83 follicular (FTC), and 111 medullary carcinomas (MTC). PTC are more frequent in females and in adolescents whereas MTC mainly concerned children, mostly with a familial predisposition. Almost all patients underwent thyroidectomy, completed for most patients with PTC and FTC by radioiodine therapy. Cervical dissection was performed more frequently in patients having PTC and MTC compared to those with FTC. Between 2000 and 2018, thyroid cancers IR in children fluctuated between 1.3 and 3.2 per million, without any significant trend. The median follow-up time was 11.3 years in children, and 5.7 years in adolescents. The 5year-OS was greater than 98.5%.

CONCLUSIONS

Population-based studies are crucial for better understanding and delineation of best management of rare diseases as thyroid cancers in pediatric and adolescent population. Considering the very favorable survival, a stratification should be proposed between cases at low risk and cases at high risk of relapse, in order to consider a strategy of therapeutic de-escalation in the most favorable cases.

Elastographic Evaluation of Thyroid Nodules in Children and Adolescents with Hashimoto’s Thyroiditis and Nodular Goiter with Reference to Cytological and/or Histopathological Diagnosis

There are data indicating the coexistence of papillary thyroid carcinoma and autoimmune thyroiditis (AIT) in children. The aim of the study was elastographic evaluation of thyroid nodules in children and adolescents with AIT and nodular goiter in relation to cytological and/or histopathological diagnosis. We examined 215 children (57 boys and 158 girls) with 261 thyroid nodules (143 non-AIT and 118 AIT). All study participants underwent a conventional ultrasound examination with elastography followed by fine needle aspiration biopsy (FNAB). Abnormal Strain Ratio (SR ≥ 5) was observed in 36 non-AIT nodules and 15 AIT nodules. Papillary thyroid carcinoma was diagnosed in 5 patients (2% of all investigated nodules). SR of malignant thyroid nodules was statistically higher in comparison to SR of benign nodules both in the group of non-AIT (6 ± 4 vs. 3.67 ± 2.62, p = 0.024) and AIT nodules (6.3 ± 0.01 vs. 2.92 ± 1.89, p = 0.047). Comparison of non-AIT and AIT benign nodules revealed that SR was higher in non-AIT nodules (3.67 ± 2.62 vs. 2.92 ± 1.89, p = 0.01). We observed a strong positive correlation (R = 1) between TSH concentration and SR ratio in the group of all malignant thyroid nodules. Autoimmune inflammatory process of the thyroid gland does not limit the use of elastography in the diagnosis of thyroid nodules in children.

Sociodemographic Disparities in the Diagnostic Management of Pediatric Thyroid Nodules

Importance

Thyroid cancer is the most common pediatric endocrine malignant neoplasm. Disparities in the workup of thyroid nodules may be significantly associated with thyroid cancer outcomes.

Objective

To determine the association of sociodemographic factors with the odds of receiving a biopsy, timeliness of the procedure, and risk of nodule malignancy.

Design, Setting, and Participants

This was a retrospective cross-sectional study using insurance claims data from the Optum Clinformatics Data Mart database. The study cohort comprised pediatric patients diagnosed with single thyroid nodules between 2003 and 2020. Data analysis was performed from January 1, 2003, to June 30, 2020.

Main Outcomes and Measures

Multivariable logistic regression models were used to identify demographic variables associated with biopsy and nodule malignant neoplasm. A multivariable linear regression model was used to assess the time between thyroid nodule diagnosis and biopsy.

Results

Of 11 643 children (median [IQR] age at diagnosis or procedure, 15 [12-17] years; 8549 [73.2%] were female and 3126 [26.8%] were male) diagnosed with single thyroid nodules, 2117 (18.2%) received a biopsy. Among the patients who received a biopsy, 304 (14.4%) were found to have a malignant nodule. Greater parental education was associated with a shorter diagnosis-to-biopsy interval (mean difference, -7.24 days; 95% CI, -13.75 to -0.73). Older age at nodule diagnosis (odds ratio [OR], 1.11; 95% CI, 1.09-1.13) and female gender (OR, 1.25; 95% CI, 1.11-1.40) were associated with increased odds of receiving a biopsy, while Black/African American (OR, 0.80; 95% CI, 0.65-0.99) and Hispanic (OR, 0.84; 95% CI, 0.72-0.99) patients had lower odds of receiving a biopsy compared with White patients. Finally, female gender (OR, 1.08; 95% CI, 0.80-1.47) was not associated with lower odds of nodule malignant neoplasm.

Conclusions and Relevance

Findings of this cross-sectional study highlight disparities in the diagnostic management of pediatric thyroid nodules. These results call for future work to ensure equitable access to thyroid care for all children.

Risk factors for lateral lymph node metastasis of papillary thyroid carcinoma in children

INTRODUCTION

Lateral cervical lymph node metastases (LNM) for pediatric patients with papillary thyroid cancer (PTC) is a poor prognostic factor. We aimed to identify risk factors for lateral LNM.

METHODS

This retrospective study had included 48 pediatric patients with papillary thyroid cancer underwent total thyroidectomy and central cervical lymphadenectomy at K hospital from 2016 to 2020.

RESULTS

The number of patients in each T stage was as follows: 24 (50.0%) in stage 1, 9 (18.7%) in Stage 2, 8 (16.7%) in Stage 3, and 7 (14.6%) in Stage 4. Most of the patients had LNM with N1a and N1b rates of 83.3% and 62.5%, respectively. Lung metastases were observed at presentation in three patients (6.3%). Univariate analysis revealed that age (p = 0.021), male (p = 0.011), tumor size > 10 mm (p = 0.002), multifocality (p < 0.001), extrathyroidal extension (p = 0.001) and central LNM (p < 0.001) were factors that increase the risk of metastasis to lateral LNM.

CONCLUSION

Approximately 62.5% of pediatric patients with PTC exhibited lateral LNM at the time of diagnosis. Our study confirmed that multifocality, maximum tumor diameter, extrathyroidal extension and central LNM were independent risk factors for lateral LNM in pediatric PTC.

LEVEL OF EVIDENCE

Level IV.

Progressive diastolic dysfunction in survivors of pediatric differentiated thyroid carcinoma

BACKGROUND

Pediatric differentiated thyroid cancer (DTC) has an excellent prognosis but unknown late effects of treatment. The initial cardiac evaluation showed subclinical diastolic dysfunction in 20% of adult survivors. The objective of this follow-up study was to determine the clinical course of this finding.

METHODS

This multicenter study, conducted between 2018 and 2020, re-evaluated survivors after 5 years. The primary endpoint was echocardiographic diastolic cardiac function (depicted by the mean of the early diastolic septal and early diastolic lateral tissue velocity (e' mean)). Secondary endpoints were other echocardiographic parameters and plasma biomarkers.

RESULTS

Follow-up evaluation was completed in 47 (71.2%) of 66 survivors who had completed their initial evaluation. Of these 47 survivors, 87.2% were women. The median age was 39.8 years (range: 18.8-60.3), and the median follow-up after the initial diagnosis was 23.4 years (range: 10.2-48.8). Between the first and second evaluation, the e' mean significantly decreased by 2.1 cm/s (s.d. 2.3 cm/s, P < 0.001). The median left ventricular ejection fraction did not significantly change (58.0% vs 59.0%, P= NS). In the best explanatory model of e' mean, multivariate linear regression analysis showed that BMI and age were significantly associated with e' mean (β coefficient: -0.169, 95% CI: -0.292; -0.047, P = 0.008 and β coefficient: -0.177, 95% CI: -0.240; -0.113, P < 0.001, respectively).

CONCLUSIONS AND RELEVANCE

In these relatively young survivors of pediatric DTC, diastolic function decreased significantly during 5-year follow-up and is possibly more pronounced than in normal aging. This finding requires further follow-up to assess clinical consequences.

Recent Changes in the Incidence of Thyroid Cancer in Korea between 2005 and 2018: Analysis of Korean National Data

BACKGRUOUND

In this study, we evaluated the recent changes in the standardized, age-specific, stage-specific incidence rates (IRs) of thyroid cancer in Korea and compared them with the incidence data reported by the Surveillance, Epidemiology, and End Results Program.

METHODS

The analysis was conducted using the incidence data (2005 to 2018) from the Statistics Korea and Korea Central Cancer Registry.

RESULTS

The age-standardized IR (SIR) of thyroid cancer increased from 24.09 per 100,000 in 2005 to 74.83 in 2012 (annual percent change [APC], 14.5). From 2012 to 2015, the SIR decreased to 42.52 (APC, -17.9) and then remained stable until 2018 (APC, 2.1). This trend was similar in both men and women. Regarding age-specific IRs, the IRs for ages of 30 years and older showed a trend similar to that of the SIR; however, for ages below 30 years, no significant reduction was observed from the vertex of IR in 2015. Regarding stage-specific IRs, the increase was more prominent in those with regional disease (APC, 17.4) than in those with localized disease until 2012; then, the IR decreased until 2015 (APC, -16.1). The average APC from 2005 to 2018 increased in men, those under the age of 30 years, and those with regional disease.

CONCLUSION

The SIR in Korea peaked in 2012 and decreased until 2015 and then remained stable until 2018. However, in young individuals under the age of 30 years, the IR did not significantly decrease but tended to increase again. In terms of stage-specific IRs, the sharpest increase was seen among those with regional disease.

Prophylactic Central Neck Dissection to Improve Disease-Free Survival in Pediatric Papillary Thyroid Cancer

Background

Pediatric PTC is a rare disease. Although, the prognosis is excellent and the mortality rate is low, the role of prophylactic central neck dissection is still the subject of debate. The aim was to evaluate both the role and safety of prophylactic central neck dissection (CND) in managing pediatric papillary thyroid cancer (PTC), especially in respect of disease-free survival (DFS).

Patients and Methods

In this retrospective study, we collected 54 pediatric cN0 PTC patients (≤ 18 years of age) who were treated from January 2014 to January 2021 at a high-volume thyroid surgery center. Patients were divided into two groups based on the status of prophylactic CND. We analyzed the factors related to the clinicopathological features and recurrence of PTC in children.

Results

Of the 54 cN0 patients, 35 underwent prophylactic CND and 19 patients did not undergo prophylactic CND. The two groups were similar in clinical and pathologic features, such as age, gender, tumor size, multifocal status, and follow-up time. The average DFS was 84.4 ± 2.7 months. Log-rank tests on Kaplan-Meier curves revealed that age, gender, tumor size, multifocality, and extrathyroid extension did not relate to DFS time. Furthermore, DFS time was not affected by the extent of thyroidectomy (p=0.07) or RAI treatment (p=0.21). Prophylactic CND was found to increase DFS time for pediatric patients with cN0 PTC (p = 0.003). There was no statistically significant difference in complications such as transient hypocalcemia (p=0.15) and transient recurrent laryngeal nerve injury (p=0.37) between the prophylactic CND group and the no-prophylactic CND group.

Conclusion

Prophylactic CND was found to be associated with increased DFS and not with increased rates of complications after surgery.

Mutational analysis using next generation sequencing in pediatric thyroid cancer reveals BRAF and fusion oncogenes are common

BACKGROUND

We previously described mutation rates of BRAF^V600E, RAS, RET-PTC and PAX8-PPARγ in pediatric subjects with well-differentiated thyroid cancer (WDTC). We expanded the cohort adding next-generation sequencing (NGS) and assessed genotype-phenotype correlations.

METHODS

Single-center retrospective cohort examining thyroidectomy tissue blocks from consecutive pediatric WDTC patients between 2001 and 2015. Tissues were analyzed at Quest Diagnostics for BRAF, RAS mutations, RET-PTC and PAX8-PPARγ, and additional fusions, using standalone and NGS tests. WDTC included papillary (PTC), follicular (FTC) and follicular-variant PTC (FVPTC).

RESULTS

We genotyped 46 samples (36 females). Mean age at diagnosis was 14.7 years and the cohort comprised of mostly Hispanic (60.9%) and Caucasian (26.1%) patients. Mean follow-up was 3.5 years. Genetic alterations (GA) were noted in 69.6%, with BRAF^V600E (n = 11), and RET-PTC (n = 8) detected only in PTC. GA were detected in 2/7 FTC (1 PAX8-PPARγ, 1 NRAS) and 6/10 FVPTC (3 PAX8-PPARγ, 1 STRN-ALK, 1 BRAF^K601E, 1 NRAS). Patients with BRAF^V600E were predominantly Hispanic (81.8%) and >15 years (81.8%), whereas 87.5% RET-PTC and 50% other-fusions occurred in patients ≤15 years (p = 0.044). Of the 29 PTC patients, 82.8% had GA: BRAF^V600E (37.9%), RET-PTC (27.6%), 17.2% other fusion-oncogenes (2 -ALK, 3 -NTRK). Non-RET fusions had the highest vascular invasion (100%, p = 0.042 vs RET-PTC) and frequent lymphatic invasion (80%). GA were most common in PTC with cervical metastasis.

CONCLUSIONS

BRAF^V600E was the most common single mutation, especially in older and Hispanic adolescents. All fusions combined are more common than BRAF^V600E. NGS reveals a genetic basis in most pediatric WDTC, which may have implications for the role of molecular testing and systemic therapy.

The 2015 American Thyroid Association guidelines and trends in hemithyroidectomy utilization for pediatric thyroid cancer

BACKGROUND

In 2015, the American Thyroid Association (ATA) released its inaugural recommendations for the management of thyroid cancer in children. We aim to evaluate whether there has been a change in hemithyroidectomy utilization for pediatric differentiated thyroid cancer, and the association between those changes and the release of the ATA guidelines.

METHODS

The National Cancer Database was queried and identified 4776 patients ≤18 years old with differentiated thyroid cancer. Causal impact time-series analysis and logistic analysis were utilized to assess factors associated with use of hemithyroidectomy.

RESULTS

Post-2015 hemithyroidectomy rate was greater than predicted based on preguideline trends (predicted: 8.4%, actual: 12.6%, p = 0.001). In logistic analysis of factors associated with hemithyroidectomy use, we find that Papillary histology, tumor size >1 cm, nodal examination, and positive nodes were associated with lower rate of hemithyroidectomy (OR: 0.23, 0.51, 0.62, and 0.18, respectively).

CONCLUSION

There has been a significant increase in hemithyroidectomy utilization for pediatric differentiated thyroid cancer.

High Prevalence of Gene Fusions and Copy Number Alterations in Pediatric Radiation Therapy-Induced Papillary and Follicular Thyroid Carcinomas

Background: Childhood cancer survivors and bone marrow transplant recipients treated with radiation therapy (RT) are at increased risk for subsequent thyroid cancer. However, the genetic landscape of pediatric thyroid cancer, both primary and RT-induced, remains poorly defined, as pediatric papillary thyroid carcinoma (PTC) has been understudied compared with adults and data on pediatric follicular thyroid carcinoma (FTC) are virtually nonexistent. The objective of this study was to characterize and compare the molecular profiles of pediatric RT-induced PTC and FTC cases with primary pediatric thyroid cancers. Methods: A total of 41 differentiated thyroid carcinomas (11 RT cases and 30 primary cases) from 37 patients seen at Phoenix Children's Hospital between January 1, 2010 and December 31, 2019 were evaluated by targeted next-generation sequencing and/or BRAF immunohistochemistry. Results: Eighty-six percent (6/7) of RT-PTC harbored a gene fusion (GF) compared with 56% (14/25) of primary PTC; 14% (1/7) of RT-PTC had a single-nucleotide variant (SNV; specifically, a point mutation in the DICER1 gene) compared with 44% (11/25) of primary PTC (all of the latter had the BRAF^V600E mutation). An exceedingly rare ROS1 fusion was identified in a child with RT-PTC. With respect to FTC, copy number alterations (CNAs) were seen in 75% (3/4) of RT cases compared with 40% (2/5) of primary cases. None of the RT-FTC had SNVs compared with 100% (5/5) of primary FTC. Conclusions: In children, the molecular profile of subsequent RT-induced thyroid cancers appears to differ from primary (sporadic and syndromic) cases, with a high prevalence of GFs in RT-PTC (similar to PTC occurring after the Chernobyl nuclear reactor accident) and CNAs in RT-FTC. A better understanding of the molecular mechanisms underlying these cancers may lead to more accurate diagnosis, prognosis, and treatment, as some of the genomic alterations are potentially targetable.

Pediatric Thyroid Nodules: Ultrasound Characteristics as Indicators of Malignancy

Objective

Pediatric thyroid nodules are uncommon but carry a 25% malignancy risk. Adult patients have well-established ultrasound characteristics that are predictive of malignancy, but these are not clearly defined in pediatric patients. We reviewed a case series of pediatric thyroid nodules.

Study Design

Retrospective chart review.

Setting

Tertiary children’s hospital.

Method

Institutional review board approval was obtained. This case series with chart review includes all pediatric thyroid nodules with ultrasounds from 2006 to 2016 at 2 pediatric tertiary care centers.

Results

An overall 112 pediatric thyroid nodules were analyzed. The mean patient age was 14.3 years; there was a female:male ratio of 4:1; and 94% were Caucasian. Seventeen percent (20/112) of nodules were malignant. In patients with malignant nodules, the average presenting age was 15.5 years, with a female:male ratio of 5.6:1. Seventy percent of malignant nodules had accompanying microcalcifications, 55% had abnormal lymph nodes, and 45% had irregular margins. In the benign nodules, 11% had microcalcifications, 12% had abnormal lymph nodes, and 26% had irregular margins. The presence of microcalcifications (odds ratio, 19.1 [95% CI, 6.0-61.0]; P < .0001), abnormal lymph nodes (odds ratio, 9.0 [95% CI, 3.0-26.6]; P = .0001), and size >3.5 cm (odds ratio, 5.8 [95% CI, 1.5-22.5]; P = .01) was associated with thyroid cancer. Irregular margins were not statistically significant (odds ratio, 2.3 [95% CI, 0.86-6.3]; P = .9).

Conclusions

Our data suggest that abnormal lymph nodes, microcalcifications, and size >3.5 cm could be predictors of malignancy in the pediatric population and influence clinical decision making.

Incidence and prognosis of thyroid cancer in children: based on the SEER database

OBJECTIVE

To update the recognition of the trends in the incidence of childhood thyroid cancer (TC) and its prognosis.

METHODS

A large-scale sample based on long time-line public database was recruited. Join-point regression model was used to analyze the incidence trend of childhood TC. Univariable and multivariable Cox regression model analyses were applied to explore the survival situation and prognostic factors.

RESULTS

The incidence rate of childhood TC increased between 1975 and 2016 from 3.8/million (95% CI 2.6-5.5) to 11.5/million (95% CI 9.2-14.1), AAPC = 2.38% (95% CI 1.98-9.65) and could be divided into two stages of increasing trends. The incidence rate of Trend1 (1975-2005) increased slowly (APC = 1.08%, 95% CI 0.38-1.82) while Trend2 (2005-2016) increased dramatically (APC = 6.77%, 95% CI 4.30-9.28). Annual incidence rate of small size tumor (< 4 cm) and local stage childhood TC increased significantly. The overall cumulative survival rate for childhood TC was high up to 97-99%. Males, black race, MTC type, distant metastasis, tumor size ≥ 4 cm, non-primary cancer were the independent risk factors of childhood TC prognosis.

CONCLUSION

A contribution of overdetection to rising pediatric TC rates might not be able to rule out. For clinical implications, screening TC in children with potential specific risk factors is feasible. Over-treatment to small size and local stage TC in children should be avoided.

Surveillance, Epidemiology, and End Results Database update for pediatric thyroid carcinomas incidence and survival trends 2000-2016

OBJECTIVE

Review the trends in pediatric thyroid carcinomas using the Surveillance, Epidemiology, and End Results (SEER) Database.

METHODS

Institutional review board approval was obtained from Mercy-Bon Secours. The National Cancer Institute's SEER database was used for all cases of pediatric thyroid cancer between the years 2000 and 2016 for patients aged 0-19. Patients were grouped by carcinoma histological subtype, disease specific survival based on treatment modality, and demographic data. Treatment methods were compared using Fifteen-Year Disease Specific Survival Curves.

RESULTS

1175 pediatric patients were identified. The average age-adjusted rate of malignancy was 0.3 per 100,000 patients. Incidence of pediatric thyroid cancer was approximately 1:3.6, male to female. The papillary follicular variant histological subtype was the most common (n = 689, 58.6%), followed by papillary (n = 223, 18.9%), follicular (n = 153, 13.1%), and medullary (n = 110, 9.4%). Overall incidence of thyroid carcinomas increased with age, highest in patients aged 15-19 (69.8%). Incidence of medullary thyroid carcinomas was highest in patients aged 0-9. Patients aged 10-19 treated with surgery alone had the highest disease specific survival fifteen-years past initial diagnoses and treatment in all histologic subtypes (p < 0.05). Patients with metastatic medullary thyroid carcinoma at initial diagnosis who underwent surgery alone showed significantly poorer fifteen-year disease specific survival when compared to other histologic subtypes (p < 0.05).

CONCLUSION

There was improved prognosis in pediatric thyroid carcinomas if diagnosed and treated early. All four major histological subtypes exhibit an increase in overall survival rates, (excluding medullary carcinomas).

Opposite Incidence Trends for Differentiated and Medullary Thyroid Cancer in Young Dutch Patients over a 30-Year Time Span

Simple Summary

Thyroid cancer is a rare disease in childhood; however, its incidence is rising. Thyroid cancer consists of three main types: Papillary thyroid cancer (PTC), follicular thyroid cancer (FTC), and medullary thyroid cancer (MTC). The aim of our retrospective study was to investigate the incidence and survival trends of these three thyroid cancer types in Dutch children, adolescents, and young adults over a 30-year life span. In total, 839 patients aged 0–24 years had been diagnosed with thyroid cancer between 1990 and 2019. The incidence of PTC increased significantly over time, the incidence of FTC showed a stable trend, while the incidence of MTC decreased significantly. Overall, the 10-year survival rates over the last decades were high (>95%) for PTC, FTC, and MTC in young individuals.

Abstract

Thyroid cancer is the most common endocrine malignancy in children. A rising incidence has been reported worldwide. Possible explanations include the increased use of enhanced imaging (leading to incidentalomas) and an increased prevalence of risk factors. We aimed to evaluate the incidence and survival trends of thyroid cancer in Dutch children, adolescents, and young adults (0–24 years) between 1990 and 2019. The age-standardized incidence rates of differentiated thyroid cancer (DTC, including papillary and follicular thyroid cancer (PTC and FTC, respectively)) and medullary thyroid cancer (MTC), the average annual percentage changes (AAPC) in incidence rates, and 10-year overall survival (OS) were calculated based on data obtained from the nationwide cancer registry (Netherlands Cancer Registry). A total of 839 patients aged 0–24 years had been diagnosed with thyroid carcinoma (PTC: 594 (71%), FTC: 128 (15%), MTC: 114 (14%)) between 1990 and 2019. The incidence of PTC increased significantly over time (AAPC +3.6%; 95%CI +2.3 to +4.8), the incidence rate of FTC showed a stable trend ((AAPC −1.1%; 95%CI −3.4 to +1.1), while the incidence of MTC decreased significantly (AAPC: −4.4% (95%CI −7.3 to −1.5). The 10-year OS was 99.5% (1990–1999) and 98.6% (2000–2009) in patients with DTC and 92.4% (1990–1999) and 96.0% (2000–2009) in patients with MTC. In this nationwide study, a rising incidence of PTC and decreasing incidence of MTC were observed. For both groups, in spite of the high proportion of patients with lymph node involvement at diagnosis for DTC and the limited treatment options for MTC, 10-year OS was high.

Treatment outcome with a selective RET tyrosine kinase inhibitor selpercatinib in children with multiple endocrine neoplasia type 2 and advanced medullary thyroid carcinoma

BACKGROUND

Medullary thyroid carcinoma (MTC) in the context of multiple endocrine neoplasia type 2 (MEN2) is caused by mutations in the RET proto-oncogene. Therefore, in children with MEN2 and advanced MTC, the RET tyrosine kinase (TK) pathway is a target for treatment with selpercatinib, a selective RET TK inhibitor.

PATIENTS AND METHODS

A retrospective review of the clinical, genetic, biochemical (calcitonin and carcinoembryonic antigen [CEA]) and imaging data of six medically untreated children with MEN2 and recurrent and or progressive MTC. The main parameters were safety and objective treatment response to selpercatinib.

RESULTS

Six children (three males and three females, aged 3-12 years), four with MEN2B and two MEN2A, are reported. All had initial total thyroidectomy and extensive neck dissections but subsequently developed recurrent and progressive disease. All experienced an improvement in clinical symptoms with a concomitant biochemical response evidenced by significant fall in serum calcitonin and CEA concentrations. The fall in serum calcitonin was evident within 2 weeks of the start of selpercatinib, and responses were ongoing at a median follow-up of 13 months (range, 11-22 months). Four children with measurable radiological disease had good volume reduction. The most common adverse effects were transient but reversible grade 1 or 2 increase in alanine aminotransferase, serum bilirubin and constipation. No child required a dose modification or had to discontinue selpercatinib because of a drug-related adverse event.

CONCLUSION

Selpercatinib has shown excellent therapeutic efficacy with minimal toxicity in children with MEN2 and progressive metastatic RET-mutated MTC.

Diverse Oncogenic Fusions and Distinct Gene Expression Patterns Define the Genomic Landscape of Pediatric Papillary Thyroid Carcinoma

Pediatric papillary thyroid carcinoma (PPTC) is clinically distinct from adult-onset disease. Although there are higher rates of metastasis and recurrence in PPTC, prognosis remains highly favorable. Molecular characterization of PPTC has been lacking. Historically, only 40% to 50% of childhood papillary thyroid carcinoma (PTC) were known to be driven by genomic variants common to adult PTC; oncogenic drivers in the remainder were unknown. This contrasts with approximately 90% of adult PTC driven by a discrete number of variants. In this study, 52 PPTCs underwent candidate gene testing, followed in a subset by whole-exome and transcriptome sequencing. Within these samples, candidate gene testing identified variants in 31 (60%) tumors, while exome and transcriptome sequencing identified oncogenic variants in 19 of 21 (90%) remaining tumors. The latter were enriched for oncogenic fusions, with 11 nonrecurrent fusion transcripts, including two previously undescribed fusions, STRN-RET and TG-PBF. Most fusions were associated with 3' receptor tyrosine kinase (RTK) moieties: RET, MET, ALK, and NTRK3. For advanced (distally metastatic) tumors, a driver variant was described in 91%. Gene expression analysis defined three clusters that demonstrated distinct expression of genes involved in thyroid differentiation and MAPK signaling. Among RET-CCDC6-driven tumors, gene expression in pediatric tumors was distinguishable from that in adults. Collectively, these results show that the genomic landscape of pediatric PTC is different from adult PTC. Moreover, they identify genomic drivers in 98% of PPTCs, predominantly oncogenic fusion transcripts involving RTKs, with a pronounced impact on gene expression. Notably, most advanced tumors were driven by a variant for which targeted systemic therapy exists. SIGNIFICANCE: This study highlights important distinctions between the genomes and transcriptomes of pediatric and adult papillary thyroid carcinoma, with implications for understanding the biology, diagnosis, and treatment of advanced disease in children.

Pediatric Thyroid Cancer: To Whom Do You Send the Referral?

Simple Summary

Pediatric thyroidectomies are performed by pediatric and adult general surgeons as well as pediatric and adult otolaryngologists. Surgeons may be high or low-volume thyroid surgeons. In this review, we discuss the roles of surgical subspecialty, surgeon volume, and institution volume as they relate to pediatric thyroidectomy outcomes. We also present institutional approaches to multidisciplinary treatment of pediatric thyroid cancer.

Abstract

Pediatric thyroid cancer is rare, but increasing in annual incidence. Differentiated thyroid cancer in pediatric patients is treated surgically. Pediatric thyroidectomies are performed by general surgeons, otolaryngologists, general pediatric surgeons, and pediatric otolaryngologists. In a comprehensive literature review, we discuss the evidence supporting the importance of surgeon subspecialty and surgeon volume on outcomes for pediatric thyroid cancer patients. Pediatric general surgeons and pediatric otolaryngologists perform most pediatric thyroidectomies. Certain subpopulations specifically benefit from a combined approach of a pediatric surgeon and a high-volume thyroid surgeon. The correlation between high-volume surgeons and lower complication rates in adult thyroid surgery applies to the pediatric population; however, the definition of high-volume for pediatric thyroidectomies requires further investigation. The development of dedicated pediatric thyroid malignancy centers and multidisciplinary or dual-surgeon approaches are advantageous.

Recombinant human thyroid-stimulating hormone versus thyroid hormone withdrawal preparation for radioiodine ablation in differentiated thyroid cancer in children, adolescents and young adults

OBJECTIVE

Recombinant human TSH (rhTSH) is commonly used to prepare patients for postoperative radioiodine (I-131) ablation after surgery for differentiated thyroid cancer (DTC). In adults, rhTSH is associated with equivalent oncologic efficacy in comparison to thyroid hormone withdrawal (THW), but its use has not been well studied in children. We aimed to measure time to disease progression after rhTSH stimulation vs. THW in paediatric patients under the age of 21 with DTC following total thyroidectomy.

DESIGN

Retrospective cohort study (March 2001-July 2018).

PATIENTS

Sixteen children and adolescents (75% female, median age, 17.4 years) who received rhTSH were compared to 29 historical controls (72% female, median age, 18.5 years) prepared with THW, followed for a median of 2.4 years (range, 0.5-14).

MEASUREMENTS

Stimulated serum TSH concentrations prior to I-131 ablation and time to disease progression, as determined by a component outcome variable encompassing both structural and biochemical disease persistence/recurrence.

RESULTS

No differences were observed in tumour characteristics and I-131 dose (median 2.3 [1.8-2.90] mCi/kg rhTSH) between groups. Patients who received rhTSH achieved a similar median stimulated TSH level (163 [127-184] mU/L), compared to those who underwent THW (136 [94.5-197] mU/L; p = .20). Both groups exhibited similar time to progression (p = .13) and disease persistence/recurrence rates (rhTSH 31% vs. THW 59%, p = .14).

CONCLUSION

In this cohort of children and adolescents with DTC, we observed similar time to disease progression among those who received rhTSH or underwent THW prior to postoperative I-131 ablation.

Increasing incidence and survival of paediatric and adolescent thyroid cancer in Cyprus 1998-2017: A population-based study from the Cyprus Pediatric Oncology Registry

BACKGROUND

Paediatric and adolescent thyroid cancer incidence rates are increasing in many countries. We determined incidence rates, temporal trends and survival from thyroid cancer diagnosed in childhood and adolescence in Cyprus during 1998-2017.

METHODS

Patients aged 0-19 years, diagnosed with thyroid cancer in the Pediatric Oncology Registry of Cyprus were included. Crude incidence rates, age standardized rates, time trends and overall survival were analysed. Annual rates and temporal trends were calculated using Microsoft Excel 2016 and Joinpoint regression analysis.

RESULTS

Eighty-one cases (76.5 % female, 23.5 % male) were identified. The crude rates (per 100,000 persons) were for both sexes 2.00 (95 % CI 1.61, 2.49), females 3.15 (95 % CI 2.45, 4.03) and males 0.92 (95 % CI 0.58, 1.44). The annual percentage changes of crude and standardised rates were 7.5 % (p < 0.05) and 7.6 % (p < 0.05). The annual percentage changes of crude rates were for females 5.1 % (p = 0.1), males 8.4 % (p < 0.05) and 15-19-year-olds 7.6 % (p < 0.05). The female to male rate ratio was 3.42 (95 % CI 2.06, 5.74). Papillary thyroid carcinoma represented 86.4 % of all cases. There was only one case after previous cancer therapy. The rate ratio of 2nd (2008-2017) to 1st (1998-2007) periods for metastatic (regional) stages was 3.76 (95 % CI 1.74, 8.31). Survival until 2018 was 100 %.

CONCLUSION

This population-based study demonstrated that thyroid cancer incidence rates in 0-19-year-olds in Cyprus was among the world's highest. Increasing trends mainly affected males and females aged 15-19 years with papillary thyroid carcinoma, the dominant type. Cases after previous cancer therapy didn't contribute to increasing rates. The increase of metastatic cases suggests a true increase of thyroid cancer rather than overdiagnosis. Although prognosis is excellent with 100 % survival, the rising incidence rate is unexplained, indicating the need to identify causes.

Comparison of Surgical Outcomes between Robotic Transaxillary and Conventional Open Thyroidectomy in Pediatric Thyroid Cancer

Thyroid cancer in children is very uncommon. For pediatric thyroid cancer, robotic surgery has served as a minimally invasive surgical alternative to conventional open surgery. Our study aimed to evaluate the results of robotic versus open surgical treatment for patients with thyroid cancer younger than 20 years of age at the time of diagnosis. This retrospective review included 161 pediatric patients who underwent robotic transaxillary or conventional open thyroidectomy at our institution from 2008 to 2019. Of these patients, 99 comprised the robotic group and 62 the open group. Patient demographics, surgical outcomes, and disease-free survival rates were compared between the two groups. Patients in the open group were more likely to have advanced stage diseases with a larger tumor size and higher tumor-node-metastasis stage than those in the robotic group. Operation time and follow-up period were similar in both groups. Patients in the robotic group had a lower rate of postoperative complications and a shorter length of hospital stay, but they also had a lower average number of retrieved central lymph nodes. However, there were no significant between group differences in recurrence rates and disease-free survival. In the hands of an experienced surgeon, robotic thyroidectomy is a feasible and safe option for pediatric patients.

Trends in Pediatric Thyroid Cancer Incidence, Treatment, and Clinical Course in Korea During 2004-2016: A Nationwide Population-Based Study

Background: The incidence of thyroid cancer has increased worldwide. We investigated nationwide trends in the incidence and treatment course of pediatric thyroid cancer in South Korea. Methods: Using the National Health Information Database, we analyzed 1580 patients (324 males) <20 years of age diagnosed with thyroid cancer during 2004-2016 in South Korea. The annual percentage change (APC) in the age-standardized incidence rate (ASR) was calculated by joinpoint regression analysis. The initial treatment modality was categorized as either surgery only or surgery with radioactive-iodine treatment (surgery+RAIT), and we defined new treatment events as reoperations or additional RAITs among 1464 patients followed up for ≥12 months. Results: During 2004-2016, the mean ASR per 100,000 person-years increased from 0.6 [confidence interval; CI 0.5-0.8] to 0.9 [CI 0.8-1.1], with a mean APC of 4.0% [CI 1.8-6.2]. The ASRs (APCs) among 0-9-, 10-14-, 15-17-, and 18-19-year olds were 0.07 (9.9% [CI 0.08-20.7]), 0.6 (4.6% [CI 0.2-9.2]), 2.2 (3.9 [CI 1.7-6.0]), and 4.2 (3.5% [CI 0.9-6.2]), respectively. The lobectomy and lymph-node-dissection rates increased (from 18.5% to 33.6%, p = 0.0014; and from 29.6% to 84.5%, p < 0.001; respectively), but the RAIT rate decreased (67.9-39.7%, p < 0.001) during the study period. During a median 6.3-year follow-up, two patients died. New treatment events occurred in 56 (10.7%) of patients in the initial surgery-only group (n = 523). In the initial surgery+RAIT group (n = 941), 316 patients received two or more RAITs within 2 years, and 80 (12.8%) of the remaining 625 patients underwent new treatment events. In the surgery+RAIT subgroup, the event-free survival rate was lower in 0-14-year olds than in 18-19-year olds (hazard ratio 2.5 [CI 1.4-4.4]). Conclusions: The pediatric thyroid cancer incidence increased from 2004 to 2012 in South Korea. The lobectomy and lymph-node-dissection rates increased, but the RAIT rate decreased. The higher risk for new treatment events in patients younger than 15 years requiring initial RAIT may be linked to advanced stage at diagnosis, and it needs to be further evaluated.

Trans-oral endoscopic thyroidectomy vestibular approach (TOETVA) for the pediatric population: a multicenter, large case series

INTRODUCTION

A cervical scar has been shown to have an impact on the quality of life of children undergoing thyroid surgery. Transoral endoscopic vestibular thyroidectomy via the vestibular approach (TOETVA) offers the absence of a cutaneous incision, and has not been described to date in the pediatric population.

OBJECTIVE

To describe the first series of TOETVA in a pediatric population.

PATIENTS AND METHODS

A retrospective, multicenter study, including all patients > 18 years old who underwent TOETVA. Data was prospectively collected and included demographics, preoperative ultrasound, cytology and indications for surgery. Intraoperative parameters included length of surgery and complications, with final pathology and postoperative course also reviewed. TOETVA surgical success was defined as completion of surgery via this approach.

RESULTS

Forty-eight children were included. Of these, 43 (89.5%) were girls. The median age was 16 years (range 10-17). The most common indication for surgery was a benign thyroid nodule (n = 26, 54.1%). Eleven patients (22.9%) had papillary thyroid carcinoma on final pathology, of which 90.9% (10/11) were diagnosed pre-operatively based on FNA cytology. Hemithyroidectomy was performed in 36 patients (75%). All surgeries were completed endoscopically. The mean malignant tumor size was 1.4 ± 0.4 cm and all tumors were completely excised with clean margins. No permanent complications were documented. A single patient (2.1%) had transient RLN injury (1.6%, 1/60 nerves at risk). Transient hypocalcemia was documented in 4 of the 12 patients undergoing total thyroidectomy (33.3%). Transient mental nerve injury/chin hypoesthesia was documented in 2 patients (4.2%).

CONCLUSIONS

TOETVA appears to be a feasible and safe approach for thyroidectomy in the pediatric population in carefully selected cases, and may be discussed with patients and parents as an alternative for the trans-cervical approach.

Prognostic analysis of recurrence in children and adolescents with differentiated thyroid cancer

Background:

The standard treatment for pediatric differentiated thyroid carcinoma (DTC) still requires consideration because of a lack of clinical evidence. The purpose of this study was to summarize the clinical experiences and explore the risk factors for post-operative recurrence through a retrospective analysis to develop better clinical strategies for pediatric DTC.

Methods:

This study retrospectively analyzed children and adolescents with DTC who were treated between January 1999 and December 2014 at the Cancer Hospital, Chinese Academy of Medical Sciences. Clinicopathological results and outcomes were collected. A log-rank test of Kaplan-Meier curves and the Cox regression model were used to determine the factors associated with recurrence.

Results:

Data of 150 patients were collected in this study. During the follow-up, there was only one disease-related death. The recurrence rates at 3, 5, and 10 years were 13.6%, 18.7%, and 28.6%, respectively. There was a significant difference in the rate of recurrence according to age (P < 0.001), extrathyroidal extension (P < 0.001), lymph node metastasis (P = 0.023), and invasion of the trachea and esophageal wall (P = 0.004). Cox regression analysis demonstrated that age (P = 0.006) and extrathyroidal extension (P = 0.013) were significant dependent factors of post-operative recurrence.

Conclusions:

The prognosis of DTC in children and adolescents is favorable. A close follow-up is recommended because of the high recurrence rate. A comparatively higher recurrence rate was observed in the younger age group, and new age-based divisions may be needed to conveniently evaluate the possibility of recurrence.

Lymph node metastases in pediatric medullary thyroid carcinoma

BACKGROUND

Unlike medullary thyroid carcinoma in adults, the vast majority of pediatric medullary thyroid carcinoma is hereditary. Pediatric medullary thyroid carcinoma is known to have different genetic alterations driving tumorigenesis, but it is not known if pediatric medullary thyroid carcinoma has different clinicopathologic features. This study aims to identify which pediatric medullary thyroid carcinoma patients might warrant elective neck dissection.

METHODS

We selected all patients ages 0 to 19 diagnosed with clinically evident medullary thyroid carcinoma in the National Cancer Database between 2004 to 2016. Clinicopathologic factors, treatments, and outcomes were analyzed and compared between this cohort and adults (ages ≥20) with medullary thyroid carcinoma.

RESULTS

One hundred twenty-five pediatric medullary thyroid carcinoma (median age: 13) and 5,086 adult medullary thyroid carcinoma (median age: 57) patients were identified. Pediatric patients had smaller tumors (median diameter: 1.2 cm vs 2.0 cm; P < .001), lower rates of nodal metastases (n = 31, 36.9% vs 1,689, 50.4%; P = .02) but double the incidence of multifocal tumors (n = 70, 59.3%, vs 1,412, 29.9%; P < .001) compared with adults. Multifocal tumors conferred a significantly increased risk of nodal metastases in adult medullary thyroid carcinoma (64.4% vs 43.2%; P < .001) but not pediatric medullary thyroid carcinoma (37.7% vs 35.7%; P = .85). Nodal metastases were more frequent among older children (0-5 years: 0.0%, 6-12: 40.7%, 13-19: 41.7%; P = .04). However, rates of occult nodal metastases were similar between older children (6-19 years: n = 12, 21.4%) and adults (557, 25.8% P = .56).

CONCLUSION

Pediatric medullary thyroid carcinoma has lower rates of lymph node metastases compared with adults. The risk of nodal disease was low among the youngest children, but older children ages 6 to 19 were at considerable risk for occult metastases. These findings could guide clinicians in selecting pediatric patients considered for elective lymph node dissection.

Risk of structural persistent disease in pediatric patients with low or intermediate risk differentiated thyroid cancer

PURPOSE

In pediatric patients with differentiated thyroid cancer (DTC), the risk of recurrence is high and the indication for postoperative ¹³¹I administration is still debated. The aim of this study was to assess the outcome in low and intermediate risk pediatric DTC patients.

METHODS

We retrospectively evaluated 45 pediatric patients with low or intermediate risk DTC, treated with surgery and ¹³¹I between 1992 and 2002 and with no detectable antithyroglobulin (Tg) antibodies. Follow-up was performed every 6-12 months with Tg blood level determination and imaging procedures.

RESULTS

During follow-up (64 ± 53 months), 15 events occurred (33% cumulative event rate, with an annual event rate of 5% person years). Five of these patients were submitted to additional surgery and all these 15 patients underwent a second ¹³¹I treatment course. All patients were alive at the end of the follow-up. Structural persistent disease occurred more frequently in patients at intermediate risk (p < 0.01) and in those with Tg values after thyroid hormone withdrawal >10 ng/ml before ¹³¹I therapy (p < 0.01). At multivariate analysis, only a postoperative thyroid stimulating hormone-stimulated Tg level >10 ng/ml was an independent predictor of persistent disease.

CONCLUSIONS

In pediatric patients with DTC, postoperative high stimulated Tg values (>10 ng/ml) should be taken into account for deciding the extent of both initial treatment and follow-up.

Management of Differentiated Thyroid Carcinoma in Pediatric Patients

Differentiated thyroid carcinomas are rare in young children but represent almost 10% of all malignancies diagnosed in older adolescents. Differentiated thyroid carcinoma in children is more likely to demonstrate nodal involvement and is associated with higher recurrence rates than seen in adults. Decisions regarding extent of surgical resection are based on clinical and radiologic features, cytology, and risk assessment. Total thyroidectomy and compartment-based resection of involved lymph node basins form the cornerstone of treatment. The use of molecular genetics to inform treatment strategies and the use of targeted therapies to unresectable progressive disease is evolving.

Consensus statement by the American Association of Clinical Endocrinology (AACE) and the American Head and Neck Society Endocrine Surgery Section (AHNS-ES) on Pediatric Benign and Malignant Thyroid Surgery

OBJECTIVES

To provide a clinical disease state review of recent relevant literature and to generate expert consensus statements regarding the breadth of pediatric thyroid cancer diagnosis and care, with an emphasis on thyroid surgery. To generate expert statements to educate pediatric practitioners on the state-of-the-art practices and the value of surgical experience in the management of this unusual and challenging disease in children.

METHODS

A literature search was conducted and statements were constructed and subjected to a modified Delphi process to measure the consensus of the expert author panel. The wording of statements, voting tabulation, and statistical analysis were overseen by a Delphi expert (J.J.S.).

RESULTS

Twenty-five consensus statements were created and subjected to a modified Delphi analysis to measure the strength of consensus of the expert author panel. All statements reached a level of consensus, and the majority of statements reached the highest level of consensus.

CONCLUSION

Pediatric thyroid cancer has many unique nuances, such as bulky cervical adenopathy on presentation, an increased incidence of diffuse sclerosing variant, and a longer potential lifespan to endure potential complications from treatment. Complications can be a burden to parents and patients alike. We suggest that optimal outcomes and decreased morbidity will come from the use of advanced imaging, diagnostic testing, and neural monitoring of patients treated at high-volume centers by high-volume surgeons.

Case Report: Transoral Endoscopic Thyroidectomy via Vestibular Approach in Pediatric Thyroid Cancer

Background: Transoral endoscopic thyroidectomy via vestibular approach (TOETVA) is a new technique that has become more popular worldwide because of its many advantages. However, this novel approach for thyroid cancer treatment in children is highly challenging, even for high-volume surgeons. In our study, we report our experiences with TOETVA for pediatric patients with thyroid cancer. Patients and Methods: This study included four pediatric patients who underwent TOETVA performed by a single surgeon between June and December 2020. Patient demographics and surgical outcomes including operative time, incidence of complications, and length of hospital stay were evaluated. Results: Four patients successfully underwent TOETVA with no complications. All patients were girls, aged from 13 to 18. Three patients underwent lobectomy and isthmusectomy, plus prophylactic unilateral central neck dissection. One patient had a total thyroidectomy, plus prophylactic bilateral central neck dissection. The mean operative time was 85 min for the lobectomy and 120 min for total thyroidectomy plus central neck dissection. The median hospital stay was 4.1 days. No drains were used. The histological examination showed four cases of malignant disease (papillary thyroid carcinoma). The mean number of harvested lymph nodes was 4.2 (ranged 3 to 8). Conclusion: In the hands of a high-volume surgeon, TOETVA is a novel, feasible, and safe approach for treating selected pediatric patients with thyroid cancer.

Consensus Statement by the American Association of Clinical Endocrinology (AACE) and the American Head and Neck Society Endocrine Surgery Section (AHNS) on Pediatric Benign and Malignant Thyroid Surgery

OBJECTIVES

To provide a clinical disease state review of recent relevant literature and to generate expert consensus statements regarding the breadth of pediatric thyroid cancer diagnosis and care, with an emphasis on thyroid surgery. To generate expert statements to educate pediatric practitioners on the state-of-the-art practices and the value of surgical experience in the management of this unusual and challenging disease in children.

METHODS

A literature search was conducted and statements were constructed and subjected to a modified Delphi process to measure the consensus of the expert author panel. The wording of statements, voting tabulation, and statistical analysis were overseen by a Delphi expert (J.J.S.).

RESULTS

Twenty-five consensus statements were created and subjected to a modified Delphi analysis to measure the strength of consensus of the expert author panel. All statements reached a level of consensus, and the majority of statements reached the highest level of consensus.

CONCLUSION

Pediatric thyroid cancer has many unique nuances, such as bulky cervical adenopathy on presentation, an increased incidence of diffuse sclerosing variant, and a longer potential lifespan to endure potential complications from treatment. Complications can be a burden to parents and patients alike. We suggest that optimal outcomes and decreased morbidity will come from the use of advanced imaging, diagnostic testing, and neural monitoring of patients treated at high-volume centers by high-volume surgeons.

Pediatric Thyroid Cancer: Genetics, Therapeutics and Outcome

An increasing number of children are diagnosed with thyroid cancer. Most patients do not have an identifiable cause; however, tumor predisposition syndromes may be associated with development of both differentiated and medullary thyroid cancer. With an excellent prognosis for most patients, the goal of therapy is to optimize outcome and reduce complications. The increased knowledge of the oncogenic drivers provides opportunities to improve the accuracy of diagnosis, stratify surgery, and select systemic therapy that may be considered for neoadjuvant and adjuvant treatment. Treatment complications can be reduced by referral to regional, high-volume pediatric thyroid centers.

Pediatric differentiated thyroid carcinoma: An update from the APSA Cancer Committee

BACKGROUND

Differentiated thyroid carcinomas (DTCs) are rare in young children but represent almost 10% of all malignancies diagnosed in older adolescents.

METHODS

This article reviews the recent literature describing surgical therapeutic approaches to pediatric DTC, associated complications, and long-term recurrence and survival outcomes.

RESULTS

Similar to adult thyroid cancers, pediatric DTCs are more common in females and are associated with thyroid nodules, family history of thyroid cancer, radiation exposure, iodine deficiency, autoimmune thyroid disease, and genetic syndromes. Management of thyroid cancers in children involves ultrasound imaging, fine needle aspiration, and surgical resection with treatment decisions based on clinical and radiological features, cytology and risk assessment.

CONCLUSIONS

Total thyroidectomy and compartment based resection of clinically involved lymph node basins form the cornerstone of treatment of DTC. There is an evolving literature regarding the use of molecular genetics to inform treatment strategies and the use of targeted therapies to treat iodine refractory and surgically unresectable progressive disease.

TYPE OF STUDY

Summary review.

LEVEL OF EVIDENCE

This is a review article of previously published Level 1-5 articles that includes expert opinion (Level 5).

Long-Term Effects of Radioiodine Treatment on Female Fertility in Survivors of Childhood Differentiated Thyroid Carcinoma

Background: Differentiated thyroid carcinoma (DTC) during childhood is a rare disease. Its excellent survival rate requires a focus on possible long-term adverse effects. This study aimed to evaluate fertility in female survivors of childhood DTC by assessing various reproductive characteristics combined with anti-Müllerian hormone (AMH) levels (a marker of ovarian reserve). Methods: Female survivors of childhood DTC, diagnosed at ≤18 years of age between 1970 and 2013, were included. Survivors were excluded when follow-up time was less than five years or if they developed other malignancies before or after diagnosis of DTC. Survivors filled out a questionnaire regarding reproductive characteristics (e.g., age at menarche and menopause, pregnancies, pregnancy outcomes, need for assisted reproductive therapy). Survivors aged <18 years during evaluation received an altered questionnaire without questions regarding pregnancy and pregnancy outcomes. These data were combined with information from medical records. AMH levels were measured in serum samples and were compared with AMH levels from 420 women not treated for cancer. Results: Fifty-six survivors with a median age of 31.0 (interquartile range, IQR, 25.1-39.6) years were evaluated after a median follow-up of 15.4 (IQR 8.3-24.7) years. The median cumulative dose of ¹³¹I administered was 7.4 (IQR 3.7-13.0) GBq/200.0 (IQR 100.0-350.0) mCi. Twenty-five of the 55 survivors aged 18 years or older during evaluation reported 64 pregnancies, 45 of which resulted in live birth. Of these 55, 10.9% visited a fertility clinic. None of the survivors reported premature menopause. Age at AMH evaluation did not differ between DTC survivors and the comparison group (p = 0.268). Median AMH levels did not differ between DTC survivors and the comparison group [2.0 (IQR 1.0-3.7) μg/L vs. 1.6 (IQR 0.6-3.1) μg/L, respectively, p = 0.244]. The cumulative dose of ¹³¹I was not associated with AMH levels in DTC survivors (r_s = 0.210, p = 0.130). Conclusions: Female survivors of DTC who received ¹³¹I treatment during childhood do not appear to have major abnormalities in reproductive characteristics nor in predictors of ovarian failure.

Recurrent laryngeal nerve monitoring in children using cricothyroid membrane needle electrodes

AIMS

Thyroid pathology is rare in children and the rate of malignancy is higher than in adults. Thyroid surgery in children is therefore particularly at risk of causing recurrent laryngeal nerve (RLN) palsies. The classical technique for monitoring the RLN is not always adapted to children due to the large size of the dedicated endotracheal tubes.

MATERIAL AND METHODS

Double-needle electrodes (NIM 3.0) were placed medially or paramedially through the cricothyroid membrane and carefully kept submucosal just below the level of the vocal folds. Before identification of the RLN, the vagal nerve was dissected on the side of the concerned lobe and stimulated. The thyroid surgery was then performed with the routine identification of the RLN. The response of the RLN is periodically checked using a stimulating probe. The main outcomes were the identification and stimulation of the RLN, quality of the voice in post-operative time.

OBJECTIVE

The main objective of our study is to present a simple and efficient method, available for children of all ages, in order to perform monitoring of the recurrent laryngeal nerves during thyroid surgery.

RESULTS

We present the results of our retrospective series, in a tertiary-care university pediatric hospital. We included nine children, corresponding to 15 nerves. In all cases, the RLN was identified, stimulated and a positive response was obtained via monitoring.

CONCLUSIONS

This technique of monitoring is safe, feasible at any age, even in neonates, and, as the electrode stays in the operation field, its position is easily controlled.

Papillary and Follicular Thyroid Cancer in children and adolescents: Current approach and future directions

An increasing number of children are diagnosed with differentiated thyroid cancer. With an excellent prognosis for the majority of pediatric patients, the goal of therapy is to optimize outcome while reducing complications. Increased knowledge of the somatic, oncogenic driver mutations provides opportunities to improve the accuracy of diagnosis, to stratify surgery, and to treat patients with morbidly invasive or refractory disease. Treatment complications can be reduced by referral to regional, high-volume pediatric thyroid centers.

Pediatric thyroid cancer: Risk factors for central lymph node metastasis in patients with cN0 papillary carcinoma

INTRODUCTION

Prophylactic central neck node dissection (CND) for pediatric patients with papillary thyroid cancer (PTC) is still controversial. We aimed to identify the incidence and the predictive parameters of the central lymph node metastasis (CLN) in pediatric patients with cN0 PTC.

METHODS

This retrospective study had included 32 pediatric patients with cN0 PTC who underwent total thyroidectomy and prophylactic CND from 2015 to 2019.

RESULTS

The proportion of CLN metastasis was 75.0%. Univariate logistic regression demonstrated that CLN metastasis was associated with age (≤15 years; p = 0.028), tumour size > 1 cm (p = 0.008), multifocality (p = 0.028) and external extension (p = 0.041) Multivariate logistic regression revealed that age (≤15 years), multifocality, tumour size (>1 cm) and external extension were independent risk factors of CLN metastasis in pediatric patients.

CONCLUSIONS

In summary, central lymph node metastasis occurred in 75% of cN0 pediatric patient and were more common in larger tumour size (>1 cm), multifocal tumours, extrathyroidal extension, and younger age.

Pediatric thyroidectomies: A surgical subspecialty comparison

OBJECTIVE

This study aims to establish the typical population, safety, and outcomes of pediatric thyroidectomies, specifically identifying surgical complication rates. Furthermore, the study compares management and complication differences between the two specialties that most often manage these patients - Pediatric General Surgery and Otolaryngology.

METHODS

National Surgical Quality Improvement Program - Pediatrics (NSQIP-P) data between the years of 2012 and 2016 was reviewed and analyzed for patient characteristics, perioperative course and outcomes. Sub-group analysis was used to compare groups based on surgeon sub-specialty: Otolaryngology or Pediatric General Surgery.

RESULTS

The study identified 516 cases pediatric patients operated on by Pediatric Otolaryngology (229; 44.4%) and Pediatric General Surgery (287; 55.6%). Overall, rates of surgical and medical adverse events were low (1.2% and 0.7%, respectively). Upon univariate analysis, there were no differences between specialties in surgical adverse events (p = 1.000), medical adverse events (p = 0.196), reoperation (p = 0.505), or readmission (p = 0.262). Indication for surgery differed between specialties, with benign neoplasm more common in the Pediatric Otolaryngology group (48.9% vs. 35.2%), and thyrotoxicosis more common in the Pediatric General Surgery group (43.9% vs. 23.1%) (p < 0.001). Compared to cases done by Otolaryngology, Pediatric General Surgery was independently associated with a shorter operative time (B: -31.583 min [95% CI: -42.802 to -20.364]; p < 0.001).

CONCLUSION

Thyroidectomy in the pediatric population is a safe procedure with no differences in adverse outcomes noted when comparing Pediatric General Surgeons to Pediatric Otolaryngologists. Pediatric General Surgeons were observed to have a significantly shorter operative time.

Imaging and Imaging-Based Management of Pediatric Thyroid Nodules

Thyroid nodules are less frequent in children than adults. Childhood thyroid nodules carry specific features, including a higher risk of malignancy than nodules in adults, rendering them unique in terms of management. Subsequently, they should be considered a distinct clinical entity with specific imaging recommendations. Initial evaluation requires a thorough workup, including clinical examination, and a detailed personal and familial history to determine the presence of possible risk factors. Laboratory and radiologic evaluation play an integral part in the diagnostic algorithm, with ultrasonography (US) being the first diagnostic test in all patients. US elastography has been recently introduced as an incremental method, reducing the subjectivity of the clinical diagnosis of nodule firmness associated with increased malignancy risk. However, fine-needle aspiration biopsy (FNAB) remains the mainstay in the diagnostic work-up of thyroid nodules and is documented to be best method for differentiating benign from malignant thyroid nodules. In addition, thyroid scintigraphy provides functional imaging information, which has a role both in the diagnostic management of thyroid nodules and during follow up in malignancies. Finally, despite providing additional information in certain clinical scenarios, ¹⁸F-fludeoxyglucose Positron Emission Tomography (¹⁸F-FDG-PET), computed tomography (CT), and magnetic resonance imaging (MRI) imaging are not routinely recommended for the evaluation of patients with newly detected thyroid nodules or in all cases of thyroid cancer. The objective of this review is to summarize the concepts in imaging and imaging-based management of nodular thyroid disease in the pediatric population, acknowledging the unique features that this patient group carries and the specific approach it requires.

Risk factors of post-surgery complications in children with thyroid cancer

INTRODUCTION

Thyroid cancer in children is a hot topic because of the large clinical heterogeneity and the risk of severe complications. We aimed to study 1. The frequency, 2. Etiology, and 3. Risk factors of post-surgery complications of thyroid cancer.

MATERIAL AND METHODS

A retrospective analysis including risk factors for post-surgery complications of patients treated for thyroid malignancies in years 2006-2018 was performed.

RESULTS

Over a period of 12 years 22 patients with thyroid malignancy (68% female; 12.6 ± 4.0 years of age, median follow-up 6 years) were identified. Histologically, 12 (55%) patients had papillary carcinoma. Six patients (27.3%) had multiple endocrine neoplasia type 2 (MEN2) syndrome, 3 (13.7%) patients had medullary carcinoma and 1 patient had follicular carcinoma. Neck lymph node metastases were diagnosed in 8 (36.4%), distant metastases in 6 (27.3%), and both locations were involved in 4 (18.2%) patients. Six (27.3%) children had surgical complications: 1 child had unilateral vocal cord paralysis and transient hypoparathyroidism and 5 had transient hypoparathyroidism. The higher risk of surgery complications in forward stepwise logistic regression was associated in with distant metastases (R2 = 0.584, OR 52.63, p = 0.010).

CONCLUSIONS

Postoperative complications were significantly associated with presence of distant metastases. Favorable results were observed in with children with MEN2 syndrome.