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Nasser T, Altirkistani BA, Bougis SM, Abu Ghasham AH, Nafadi IB. Outcomes of Differentiated Thyroid Cancer in Children and Adolescents at King Abdulaziz Medical City, Jeddah. Cureus 2024; 16:e65992. [PMID: 39100815 PMCID: PMC11295254 DOI: 10.7759/cureus.65992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2024] [Indexed: 08/06/2024] Open
Abstract
Objective Differentiated thyroid cancer (DTC) is rare in the pediatric population, with most data from the Western world. We aimed to describe the clinical presentation, treatment intervention, histopathological characteristics, complications, follow-up, and response to treatment in 17 patients with DTC at or below the age of 20 years. Interventions This was a retrospective cohort study at King Abdulaziz Medical City, Jeddah, Saudi Arabia. We included patients aged younger than 20 years with DTC. Total or near-total thyroidectomy was performed in 82% of the patients, central and/or lateral neck dissection in 35% of cases, and radioactive iodine (RAI) ablation in 76% of cases. Results The study included 17 patients (14 females), with a median age of 16 years at the time of diagnosis. Thyroid nodules were the main complaint in 88% of the patients. Thyroid ultrasonography was the main method for the initial evaluation. Papillary cancer was the most common type of tumor, and lymph node spread was found in 82% of the patients. Moreover, 40% of the patients exhibited excellent responses to therapy, with 35% showing indeterminate results. Only 23.5% of the patients developed hypocalcemia postoperatively. Conclusions Classical papillary thyroid carcinoma was the predominant histopathological type, and most patients showed excellent responses to therapy, followed by indeterminate in most of the cases. The most common presentation was a neck nodule, signifying the role of thorough physical neck examinations. Finally, recurrence occurred in a minority of patients. However, none of these patients died.
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Affiliation(s)
- Tariq Nasser
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, SAU
- Department of Medicine/Endocrinology, King Abdullah International Medical Research Center, Jeddah, SAU
- Department of Medicine/Endocrinology, King Abdulaziz Medical City, Jeddah, SAU
| | - Bsaim Abdulsalam Altirkistani
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, SAU
- Department of Medicine/Endocrinology, King Abdullah International Medical Research Center, Jeddah, SAU
| | - Suaad Muhammad Bougis
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, SAU
- Department of Medicine/Endocrinology, King Abdullah International Medical Research Center, Jeddah, SAU
| | - Asma Hassan Abu Ghasham
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, SAU
- Department of Medicine/Endocrinology, King Abdullah International Medical Research Center, Jeddah, SAU
| | - Ibrahim Basem Nafadi
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, SAU
- Department of Medicine/Endocrinology, King Abdullah International Medical Research Center, Jeddah, SAU
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Banks L, Kelly NA, Onwuka A, Althubaiti A, Damilano C, Hoffman RP, Aldrink JH, Jatana KR, Walz P. Does preoperative calcium and 1, 25 OH vitamin D supplementation impact postoperative hypocalcemia and length of stay following pediatric thyroidectomy? Int J Pediatr Otorhinolaryngol 2024; 178:111895. [PMID: 38422761 DOI: 10.1016/j.ijporl.2024.111895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 01/24/2024] [Accepted: 02/10/2024] [Indexed: 03/02/2024]
Abstract
OBJECTIVE To investigate whether perioperative calcium and 1,25 OH vitamin D supplementation (PCDS) influences the rates of postoperative hypocalcemia and length of stay (LOS) following pediatric thyroidectomy. STUDY DESIGN Retrospective Cohort Review. SETTING Tertiary children's hospital. METHODS 94 patients who underwent completion or total thyroidectomy with or without concomitant neck dissection from 2010 to 2020 at a single institution were included. Patients with pre-existing hypocalcemia or preoperative vitamin D insufficiency were excluded. Rates of postoperative hypocalcemia and LOS were compared for patients receiving PCDS to those receiving no supplementation. RESULTS Thirty percent of patients with PCDS had documented postoperative hypocalcemia compared to 64% of patients without PCDS (p = 0.01). Patients with PCDS had a median LOS of 30 h compared to 36 h (p = 0.002). Multivariable analyses confirmed that patients with PCDS had lower odds of postoperative hypocalcemia (OR: 0.32, CI: 0.11, 0.89) and shorter LOS by 17 h (SE: 8, p = 0.04) after adjustment for confounders. CONCLUSION PCDS is associated with significantly lower risk of hypocalcemia and shorter LOS. Standardizing preoperative care for pediatric patients undergoing thyroidectomy may decrease variability and improve outcomes following surgery.
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Affiliation(s)
- Laura Banks
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Natalie A Kelly
- Ohio University Heritage College of Osteopathic Medicine, Dublin, OH, USA
| | | | - Abdulrahman Althubaiti
- Department of Otolaryngology - Head and Neck Surgery, College of Medicine, University of Jeddah, Jeddah, Saudi Arabia
| | - Cecilia Damilano
- Divison of Endocrinology, Department of Pediatrics, Nationwide Children's Hosp., Columbus, OH, USA
| | - Robert P Hoffman
- Divison of Endocrinology, Department of Pediatrics, Nationwide Children's Hosp., Columbus, OH, USA
| | - Jennifer H Aldrink
- Division of Pediatric Surgery, Department of Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Kris R Jatana
- Department of Pediatric Otolaryngology, Head and Neck Surgery, Nationwide Children's Hosp., Columbus, OH, USA; Department of Otolaryngology-Head & Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Patrick Walz
- Department of Pediatric Otolaryngology, Head and Neck Surgery, Nationwide Children's Hosp., Columbus, OH, USA; Department of Otolaryngology-Head & Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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Song C, Luo JY, Pang YY, He RQ, Li XJ, Chen G, Zhao CY, Qu N, Chen YM, Yang L, Li BQ, Shi L. Historical context, process, and development trends of pediatric thyroid cancer research: a bibliometric analysis. Front Oncol 2024; 14:1340872. [PMID: 38463235 PMCID: PMC10921230 DOI: 10.3389/fonc.2024.1340872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 01/24/2024] [Indexed: 03/12/2024] Open
Abstract
Objective At present, the structure of knowledge in the field of childhood thyroid cancer is not clear enough, and scholars lack a sufficient understanding of the developing trends in this field, which has led to a shortage of forward-looking outputs. The purpose of this research is to help scholars construct a complete knowledge framework and identify current challenges, opportunities, and development trends. Methods We searched the literature in the Web of Science Core Collection database on August 7, 2023 and extracted key information from the top 100 most cited articles, such as the countries, institutions, authors, themes, and keywords. We used bibliometric tools such as bibliometrix, VOSviewer, and CiteSpace for a visualization analysis and Excel for statistical descriptions. Results The top 100 most cited articles fluctuated over time, and the research was concentrated in European countries, the United States, and Japan, among which scientific research institutions and scholars from the United States made outstanding contributions. Keyword analysis revealed that research has shifted from simple treatment methods for pediatric thyroid cancer (total thyroidectomy) and inducing factors (the Chernobyl power station accident) to the clinical applications of genetic mutations (such as the BRAF and RET genes) and larger-scale genetic changes (mutation studies of the DICER1 gene). The thematic strategy analysis showed an increasing trend towards the popularity of fusion oncogenes, while the popularity of research on traditional treatments and diagnostics has gradually declined. Conclusion Extensive research has been conducted on the basic problems of pediatric thyroid cancer, and there has been significant outputs in the follow-up and cohort analysis of conventional diagnostic and treatment methods. However, these methods still have certain limitations. Therefore, scholars should focus on exploring fusion genes, the clinical applications of molecular targets, and novel treatment methods. This study provides a strong reference for scholars in this field.
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Affiliation(s)
- Chang Song
- Department of Pathology, Second Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Jia-Yuan Luo
- Department of Pathology, First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yu-Yan Pang
- Department of Pathology, First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Rong-Quan He
- Department of Medical Oncology, First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Xiao-Jiao Li
- Department of Nuclear Medicine, First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Gang Chen
- Department of Pathology, First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Chun-Yan Zhao
- Department of Pathology, First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Ning Qu
- Department of Pathology, First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yan-Mei Chen
- Department of Pathology, First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Li Yang
- Department of Pathology, Second Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Bi-Qi Li
- Department of Pathology, Second Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Lin Shi
- Department of Pathology, Second Affiliated Hospital of Guangxi Medical University, Nanning, China
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Jiang W, Hall M, Newfield R, Berry JG. Short-term pediatric thyroidectomy outcome: Analysis of the Pediatric Health Information System (PHIS) database. Int J Pediatr Otorhinolaryngol 2022; 163:111340. [PMID: 36274324 DOI: 10.1016/j.ijporl.2022.111340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 10/06/2022] [Accepted: 10/09/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Thyroidectomy is the most commonly performed pediatric endocrine surgery. Our objective is to measure the short-term outcome of pediatric thyroidectomies, and report on factors associated with postoperative complications. METHODS This is a retrospective cohort study, performed using the Pediatric Health Information System (PHIS) database on patients ≤18 years of age, from 47 children's hospitals across the United States, who underwent partial or total thyroidectomy from January 1, 2009 to December 31, 2019. RESULTS A total of 6405 patients were included, mostly female (76.8%), and 46.9% were 15-18 years-old. Age <1 year, Hispanic and Black race, comorbidity with complex chronic conditions were associated with more complications. The overall short-term complication rate was 27.7%, with hypocalcemia accounting for the majority (15.6%). Complication rates were lower in benign or non-specific thyroid nodules as compared with malignancy and Graves' disease. Complication rates were significantly lower for partial thyroidectomy versus total thyroidectomy and both neck dissections and parathyroid re-implantations were associated with increased risk of complications. The mean length of stay was 1.4 days. Complications were associated with prolonged hospital stay (2.4 vs. 1.2 days) and increased cost ($19441 vs. $11232) (p < 0.001), but not associated with hospital volume (p = 0.36). CONCLUSION Endocrine-related complications accounts for the majority of surgical morbidity following pediatric thyroidectomies performed at pediatric hospitals, and complications does not appear to be correlate with surgical volume. The calculated Achievable Benchmarks of Care (ABC) pooled complication rates from the top performing hospitals may serve as a goal for improvement.
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Affiliation(s)
- Wen Jiang
- Department of Otolaryngology, University of California San Diego, San Diego, CA, USA; Rady Children's Hospital in San Diego, San Diego, CA, USA.
| | - Matt Hall
- Children's Hospital Association, Lenexa, KS, USA
| | - Ron Newfield
- Rady Children's Hospital in San Diego, San Diego, CA, USA; Department of Pediatrics, Division of Pediatric Endocrinology, University of California, San Diego, CA, USA
| | - Jay G Berry
- Harvard Medical School, Boston, MA, USA; Division of General Pediatrics, Boston Children's Hospital, Boston, MA, USA
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Ziai H, Dixon P, Berman G, Campisi P, Wasserman JD. Incidental Parathyroidectomy Among Pediatric Patients Undergoing Thyroid Surgery. Laryngoscope 2022; 132:2262-2269. [PMID: 35191038 DOI: 10.1002/lary.30056] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 01/19/2022] [Accepted: 01/26/2022] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To evaluate rates of incidental parathyroidectomy(IP) and to determine risk factors among children undergoing thyroid surgery. STUDY DESIGN Retrospective case-control study. METHODS Pediatric patients undergoing thyroidectomy with or without neck dissection were included in this retrospective cohort study over a 20 year period. Demographics, clinical features, and surgical outcomes were evaluated. The primary outcome was the presence of parathyroid tissue in the surgical specimen. RESULTS Two hundred and eighty-six patients were included (100 cases with ≥1 parathyroid gland found in the pathology specimen and 186 controls). The most common surgical indication was cancer (49%), followed by benign nodule (25%). Hemithyroidectomy was performed in 119 (42%) patients, total thyroidectomy in 138 (48%), and completion in 29 (10%). Central neck dissection (CND) and lateral neck dissection were performed in 41% and 13%, respectively. 27 (9%) patients had parathyroid reimplantation. On univariable analysis, diagnosis, adenopathy on preoperative ultrasound, extent of thyroidectomy, neck dissection, and parathyroid reimplantation were significant predictors of IP. On multivariate analysis, CND > 5 nodes were the sole predictor of IP. Patients with IP were more likely to require postoperative calcium/vitamin D supplementation compared to those without (44% vs. 16%; P < .001). CONCLUSIONS Incidental parathyroidectomy during pediatric thyroidectomy is relatively common. CND was independently predictive of IP. There were increased rates of postoperative hypocalcemia when 1 or more parathyroid gland was identified in the specimen. Reimplantation of 1 parathyroid gland was predictive of another gland in the specimen. Anticipating outcomes may help optimize patient care by allowing for early supplementation, frequent monitoring, and consideration of ancillary monitoring modalities in high-risk procedures. LEVEL OF EVIDENCE Level 4 Laryngoscope, 132:2262-2269, 2022.
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Affiliation(s)
- Hedyeh Ziai
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Peter Dixon
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Gavriel Berman
- Division of Endocrinology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Paolo Campisi
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada.,Department of Otolaryngology-Head and Neck Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jonathan D Wasserman
- Division of Endocrinology, The Hospital for Sick Children, Toronto, Ontario, Canada
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De Napoli L, Matrone A, Ambrosini CE, Becucci C, Pieroni E, Vagelli F, Taddei G, Gjeloshi B, Torregrossa L, Elisei R, Spinelli C, Materazzi G. Impact of energy-based devices in pediatric thyroid surgery. J Pediatr Surg 2022; 57:740-745. [PMID: 35469657 DOI: 10.1016/j.jpedsurg.2022.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 02/20/2022] [Accepted: 03/05/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND Energy-based devices are surgical devices increasingly utilized for thyroid surgery, owing to a reduction of operative time and surgical related complications. The aim of the study is to evaluate whether the use of energy-based devices could improve the complication rate in pediatric thyroid surgery. METHODS This is a retrospective observational study. We identified 177 consecutive pediatric patients (Group A) with thyroid diseases, surgically treated by energy-based devices and 237 patients (Group B) treated by conventional clamp and tie technique and matched for sex, age and indication for surgery. Transient and permanent complications rate, operative time and length of hospital stay were compared between the two groups. RESULTS Patients of Group A experienced a lower complication rate compared to Group B. Particularly, transient (11.3 vs. 19% p < 0.05) and permanent post operative hypoparathyroidism (1.7 vs. 5.5%, p < 0.05) were lower in Group A. Moreover, operative time was also shorter in Group A compared to Group B and this difference was statistically significant in patients who performed total thyroidectomy alone and total thyroidectomy associated with central compartment neck dissection (p < 0.05). Length of hospital stay was lower in Group A than in Group B, but this difference was statistically significant only for microfollicular lesion (p < 0.05). CONCLUSION The use of energy-based devices has a key role in reducing surgical related complications, particularly transient and permanent hypoparathyroidism, operative time and length of hospital stay in pediatric patients treated with thyroid surgery. LEVEL OF EVIDENCE Level III. TYPE OF STUDY Retrospective comparative study.
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Affiliation(s)
- Luigi De Napoli
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy.
| | - Antonio Matrone
- Department of Clinical and Experimental Medicine, Unit of Endocrinology, University of Pisa, Pisa, Italy
| | - Carlo Enrico Ambrosini
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Chiara Becucci
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Erica Pieroni
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Filippo Vagelli
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Giacomo Taddei
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Benard Gjeloshi
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Liborio Torregrossa
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Rossella Elisei
- Department of Clinical and Experimental Medicine, Unit of Endocrinology, University of Pisa, Pisa, Italy
| | - Claudio Spinelli
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Gabriele Materazzi
- Department of Surgical, Medical and Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
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Sahyouni G, Osterbauer B, Park S, Paik C, Austin J, Gomez G, Kwon D. Rate of Incidental Parathyroidectomy in a Pediatric Population. OTO Open 2021; 5:2473974X211059070. [PMID: 34805719 PMCID: PMC8597068 DOI: 10.1177/2473974x211059070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 10/20/2021] [Indexed: 11/17/2022] Open
Abstract
Objective Incidental parathyroidectomy is a relatively common occurrence in thyroid surgery, which may lead to hypoparathyroidism and postoperative hypocalcemia, but it is not well studied in children. The objectives of this study were to determine the rate of incidental parathyroidectomy, identify potential risk factors, and investigate postoperative complications in children undergoing thyroidectomy. Study Design Retrospective cohort study. Setting Patients who underwent thyroidectomy over a 10-year period at a tertiary children’s hospital. Methods Pathology reports were reviewed to determine incidental parathyroid gland tissue. Additional data collected included patient demographics, type of procedure, underlying thyroid pathology, as well as immediate and long-term postoperative clinical outcomes. Results Of 209 patients, 65 (31%) had incidental parathyroidectomy. Several variables were associated with incidental parathyroidectomy on univariable analysis. However, in the final multivariable model, only thyroidectomy with lymph node dissection was associated with increased odds of having incidental parathyroidectomy (odds ratio, 3.3; P = .04; 95% CI, 1.1-9.8). After a median follow up of 1 year, a significantly higher percentage of patients with incidental parathyroidectomy had evidence of long-term hypoparathyroidism (9/62 [15%] vs 3/144 [2%], P = .001). Conclusion Incidental parathyroidectomy was relatively common in our pediatric thyroidectomy population, which may be a result of several anatomic, clinical, and surgeon-related factors. Close attention to parathyroid preservation with meticulous surgical technique is the most practical method of preventing long-term hypoparathyroidism and hypocalcemia.
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Affiliation(s)
- Grace Sahyouni
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Beth Osterbauer
- Division of Otolaryngology-Head and Neck Surgery, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Soyun Park
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Connie Paik
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Juliana Austin
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA.,Division of Endocrinology, Diabetes, and Metabolism, Children's Hospital Los Angeles, University of Southern California, Los Angeles, California, USA
| | - Gabriel Gomez
- Division of Otolaryngology-Head and Neck Surgery, Children's Hospital Los Angeles, Los Angeles, California, USA.,Caruso Department of Otolaryngology-Head and Neck Surgery, Keck Medicine, University of Southern California, Beverly Hills, California, USA
| | - Daniel Kwon
- Division of Otolaryngology-Head and Neck Surgery, Children's Hospital Los Angeles, Los Angeles, California, USA.,Caruso Department of Otolaryngology-Head and Neck Surgery, Keck Medicine, University of Southern California, Beverly Hills, California, USA
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Memeh K, Ruhle B, Alsafran S, Vaghaiwalla T, Kaplan E, Angelos P, Keutgen XM. Total Thyroidectomy vs Thyroid Lobectomy for Localized Papillary Thyroid Cancer in Children: A Propensity-Matched Survival Analysis. J Am Coll Surg 2021; 233:39-49. [PMID: 33887483 DOI: 10.1016/j.jamcollsurg.2021.03.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 03/16/2021] [Accepted: 03/16/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Current guidelines recommend total thyroidectomy (TT) and radioablation for most papillary thyroid cancer (PTC) in children. These guidelines have been criticized as aggressive, especially for early-stage PTC, as it likely does not influence patient survival and results in life-long thyroid hormone replacement. We sought to study whether the extent of thyroidectomy (TT vs thyroid lobectomy [TL]) influences overall and disease-specific survival in children with localized PTC. METHODS The National Cancer Database and the Surveillance, Epidemiology, and End Results registries were queried. Patients 18 years or younger with low-risk PTC between 2004 and 2016 were included. Using a 1:1 propensity score matching, patients who underwent TT were matched for age, sex, race, year of diagnosis, and tumor size with a similar cohort of patients who underwent TL. Primary end points were overall survival and disease-specific survival. RESULTS There were 3,500 patients identified as surgically treated for PTC, of which 1,325 patients met inclusion criteria for matching. Three hundred and twenty-six patients were matched. One hundred and sixty-three patients had TT; 140 were female and mean age was 16 years (interquartile range [IQR] 13 to 17 years). One hundred and sixty-three patients had TL; 140 were female and mean age was 16 years (IQR 14 to 17 years). Median follow-up was 5.0 years (IQR 2.8 to 8 years) and 8.3 years (IQR 3.6 to 14.4 years) in the National Cancer Database and Surveillance, Epidemiology, and End Results cohorts, respectively. There was no statistically significant difference in overall survival or disease-specific survival in patients with PTC < 4 cm, regardless of whether patients underwent TT or TL (p = 0.32 for National Cancer Database registry and p = 0.67 for Surveillance, Epidemiology, and End Results registry). CONCLUSIONS This study suggests that the extent of thyroidectomy does not influence survival for pediatric patients with early-stage PTC and that TL might be adequate in this patient population.
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Affiliation(s)
- Kelvin Memeh
- Section of Endocrine Surgery, Department of Surgery, University of Chicago Medicine, Chicago, IL.
| | - Brian Ruhle
- Section of Endocrine Surgery, Department of Surgery, University of Chicago Medicine, Chicago, IL
| | - Salman Alsafran
- Faculty of Medicine, Kuwait University Health Science Center, Kuwait
| | - Tanaz Vaghaiwalla
- Section of Endocrine Surgery, Department of Surgery, University of Chicago Medicine, Chicago, IL
| | - Edwin Kaplan
- Section of Endocrine Surgery, Department of Surgery, University of Chicago Medicine, Chicago, IL
| | - Peter Angelos
- Section of Endocrine Surgery, Department of Surgery, University of Chicago Medicine, Chicago, IL
| | - Xavier M Keutgen
- Section of Endocrine Surgery, Department of Surgery, University of Chicago Medicine, Chicago, IL
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Obiarinze R, Fazendin J, Iyer P, Lindeman B, Chen H. Intraoperative parathyroid hormone measurement facilitates outpatient thyroidectomy in children. Am J Surg 2021; 221:683-686. [PMID: 33648715 DOI: 10.1016/j.amjsurg.2021.02.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 01/29/2021] [Accepted: 02/08/2021] [Indexed: 10/22/2022]
Abstract
INTRODUCTION We hypothesize that intraoperative parathyroid hormone (ioPTH) measurement after a total thyroidectomy predicts children at risk for hypoparathyroidism and allow for outpatient procedure. METHODS Between 2015 and 2019, we reviewed all patients under the age of 21 undergoing a thyroidectomy (total or lobectomy). Based on the ioPTH concentration, the patients were treated by the following protocol: a) PTH ≥20 pg/mL: no treatment; b) PTH = 10-19 pg/mL: 1000 mg calcium orally TID; c) PTH = 5-9 pg/mL: calcitriol 250 μg orally BID plus 1000 mg calcium orally TID; or d) PTH <5 pg/mL calcitriol 500 μg orally BID plus 1000 mg calcium orally TID. RESULTS Fifty-two patients were included with a median age of 16 (range 6-21 years). Thirty-two patients (62%) had normal PTH (≥10 pg/mL) while 20 (38%) had low PTH levels (<10 pg/mL). Of those patients with low PTH, 60% had normalization of levels within 2 weeks of surgery. CONCLUSIONS Thyroid surgery in children can be performed as an outpatient procedure. The ioPTH measurements and a protocol to treat patients with low PTH assists in safe discharge.
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Affiliation(s)
- Ruth Obiarinze
- University of Alabama at Birmingham Department of Surgery, Boshell Diabetes Building, 1808 7th Avenue South, Birmingham, AL 35233, USA.
| | - Jessica Fazendin
- University of Alabama at Birmingham Department of Surgery, Boshell Diabetes Building, 1808 7th Avenue South, Birmingham, AL 35233, USA
| | - Pallavi Iyer
- University of Alabama at Birmingham Department of Pediatrics, CPII M30, 1600 7th Ave S, Birmingham, AL 35233, USA
| | - Brenessa Lindeman
- University of Alabama at Birmingham Department of Surgery, Boshell Diabetes Building, 1808 7th Avenue South, Birmingham, AL 35233, USA
| | - Herbert Chen
- University of Alabama at Birmingham Department of Surgery, Boshell Diabetes Building, 1808 7th Avenue South, Birmingham, AL 35233, USA.
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Karapanou O, Tzanela M, Rondogianni P, Dacou-Voutetakis C, Chiotis D, Vlassopoulou B, Vassiliadi D, Kanaka-Gantenbein C, Tsagarakis S. Long-term outcome of differentiated thyroid cancer in children and young adults: risk stratification by ATA criteria and assessment of pre-ablation stimulated thyroglobulin as predictors of disease persistence. Endocrine 2020; 70:566-574. [PMID: 32533509 DOI: 10.1007/s12020-020-02378-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 06/01/2020] [Indexed: 12/13/2022]
Abstract
PURPOSE Differentiated thyroid cancer (DTC) has an increasing incidence in childhood and adolescence but long-term outcome data are limited. We aimed to identify possible risk factors associated with disease persistence, with special focus on the usefulness of ATA risk stratification system and pre-ablation stimulated thyroglobulin (Tg) levels. METHODS We retrospectively studied 103 patients, 79 females (76.7%), aged 15.6 ± 3.2 years (range 5-21 years) who underwent total thyroidectomy for DTC. Patients were classified by ATA risk stratification criteria as low, intermediate, and high risk for recurrence. All, except five with papillary microcarcinoma, received radioactive iodine (RAI) treatment. RESULTS At diagnosis, 44.7% of patients had cervical lymph node and 7.8% pulmonary metastases. Amongst the 72 patients with long-term follow-up data, 31.9% had persistent disease. Lymph node as well as pulmonary metastases and increased pre-ablation stimulated thyroglobulin (Tg) levels were associated with persistent disease. The risk of persistent disease was significantly higher in both the intermediate- (OR 17.95; 95% CI 2.66-120.94, p < 0.01) and high-risk (OR 17.65; 95% CI 4.47-69.74, p < 0.001) groups. ROC curve analysis showed that a pre-ablation Tg level higher than 14 ng/ml had a sensitivity of 94.7% to predict persistence, corresponding to a positive (PPV) and negative predictive values (NPV) of 66.7% and 93.8%, respectively. CONCLUSIONS ATA risk stratification was validated in our population of children and young adults with DTC. Moreover, pre-ablation stimulated Tg levels of <14 ng/ml were associated with a low risk of long-term persistence and may therefore serve as a marker to identify patients who may need less intensive surveillance.
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Affiliation(s)
- Olga Karapanou
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, 10676, Athens, Greece.
| | - Marinella Tzanela
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, 10676, Athens, Greece
| | - Phoebe Rondogianni
- Department of Nuclear Medicine, Evangelismos Hospital, 10676, Athens, Greece
| | - Catherine Dacou-Voutetakis
- Division of Endocrinology, Diabetes and Metabolism, First Department of Pediatrics, Faculty of Medicine, National and Kapodistrian University of Athens, Medical School, "Aghia Sofia" Children's Hospital, 11527, Athens, Greece
| | - Dimitrios Chiotis
- Division of Endocrinology, Diabetes and Metabolism, First Department of Pediatrics, Faculty of Medicine, National and Kapodistrian University of Athens, Medical School, "Aghia Sofia" Children's Hospital, 11527, Athens, Greece
| | - Barbara Vlassopoulou
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, 10676, Athens, Greece
| | - Dimitra Vassiliadi
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, 10676, Athens, Greece
| | - Christina Kanaka-Gantenbein
- Division of Endocrinology, Diabetes and Metabolism, First Department of Pediatrics, Faculty of Medicine, National and Kapodistrian University of Athens, Medical School, "Aghia Sofia" Children's Hospital, 11527, Athens, Greece
| | - Stylianos Tsagarakis
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, 10676, Athens, Greece
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11
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Ritter A, Hod R, Reuven Y, Shpitzer T, Mizrachi A, Raveh E, Bachar G. Role of intraoperative recurrent laryngeal nerve monitoring for pediatric thyroid surgery: Comparative analysis. Head Neck 2020; 43:849-857. [PMID: 33164301 DOI: 10.1002/hed.26544] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 10/01/2020] [Accepted: 10/30/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The data on the advantages of intraoperative nerve monitoring (IONM) during pediatric thyroid surgeries are limited. We aimed to study the role of IONM by comparing between children who underwent thyroid surgery with and without IONM. METHODS A retrospective study of all children who underwent thyroid surgery between 2001 and 2019. RESULTS The study included 113 patients with 183 recurrent laryngeal nerve (RLN) at risk. Transient paralysis rate was more than 5-fold lower in the IONM group compared to the control group (1.5% vs 8%; P = .114). Permanent paralysis was documented only in the control group (2.5% vs 0%; P = .552). Children <10 years and those who underwent central neck dissection had significantly higher rates of RLN injury. CONCLUSIONS IONM was associated with decreased rate of RLN injury during pediatric thyroid surgery and should be considered especially in children under 10 years of age and those undergoing concomitant central neck dissection.
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Affiliation(s)
- Amit Ritter
- Department of Otolaryngology - Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Roy Hod
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Otorhinolaryngology, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Yonatan Reuven
- Department of Otolaryngology - Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Thomas Shpitzer
- Department of Otolaryngology - Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Aviram Mizrachi
- Department of Otolaryngology - Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eyal Raveh
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Otorhinolaryngology, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Gideon Bachar
- Department of Otolaryngology - Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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12
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Pediatric differentiated thyroid carcinoma: An update from the APSA Cancer Committee. J Pediatr Surg 2020; 55:2273-2283. [PMID: 32553450 DOI: 10.1016/j.jpedsurg.2020.05.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 04/04/2020] [Accepted: 05/03/2020] [Indexed: 12/12/2022]
Abstract
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).
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13
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Sugino K, Nagahama M, Kitagawa W, Ohkuwa K, Uruno T, Matsuzu K, Suzuki A, Tomoda C, Hames KY, Akaishi J, Masaki C, Ito K. Risk Stratification of Pediatric Patients with Differentiated Thyroid Cancer: Is Total Thyroidectomy Necessary for Patients at Any Risk? Thyroid 2020; 30:548-556. [PMID: 31910105 DOI: 10.1089/thy.2019.0231] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background: In the recent American Thyroid Association (ATA) guidelines for adult differentiated thyroid carcinoma (DTC) patients, risk stratification is clearly defined and lobectomy is acceptable for low-risk DTC. However, risk stratification for children with DTC in the ATA pediatric guidelines is rather unclear, and total thyroidectomy is recommended for all patients with any risk. The aim of this study was to attempt risk stratification based on our experience and to consider the appropriate extent of thyroidectomy, especially for low-risk DTC in the pediatric population. Patients and Methods: The subjects were 153 patients with DTC ≤18 years old, including 58 patients ≤15 years old and 136 female patients, who underwent initial curative surgery in our hospital between 1979 and 2014. Underlying pathology was papillary thyroid carcinoma in 130 patients and follicular thyroid carcinoma in 23. Risk factors related to disease-free survival (DFS) were analyzed and risk stratification was performed. Results: No patient died of the disease and 34 patients (22.2%) developed recurrences. At initial surgery, 30 patients (19.6%) had lymph node metastases diagnosed before initial surgery (cN1) and 9 (5.9%) had gross extrathyroidal extension (ETE). Significant factors related to DFS on multivariate analysis were cN1, ETE, and number of metastatic lymph nodes (NMLNs) ≥10, including microscopic MLNs. According to these factors, subjects were divided into three categories: low risk (no risk factors, n = 89); intermediate risk (1 risk factor, n = 37); and high risk (≥2 risk factors, n = 27). Ten-year DFS rates in the low-, intermediate-, and high-risk groups were 96%, 83%, and 48%, respectively. Only 12% of low-risk patients underwent total thyroidectomy. Because NMLNs become obvious only after surgery, another analysis after excluding "NMLNs" as a factor showed that cN and ETE were significant factors related to poor DFS. According to these two factors, risk stratification was attempted in the same manner. Ten-year DFS rates in the low- (no risk factor, n = 117), intermediate- (one risk factor, n = 29), and high-risk (two risk factors, n = 7) groups were 92%, 59%, and 43%, respectively. Only 12% of low-risk patients underwent total thyroidectomy. Conclusions: For low-risk pediatric patients, lobectomy may be sufficient as the initial surgical procedure.
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Affiliation(s)
| | | | | | - Keiko Ohkuwa
- Department of Surgery, Ito Hospital, Tokyo, Japan
| | | | | | | | | | | | | | - Chie Masaki
- Department of Surgery, Ito Hospital, Tokyo, Japan
| | - Koichi Ito
- Department of Surgery, Ito Hospital, Tokyo, Japan
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14
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Wu SY, Chiang YJ, Fisher SB, Sturgis EM, Zafereo ME, Nguyen S, Grubbs EG, Graham PH, Lee JE, Waguespack SG, Perrier ND. Risks of Hypoparathyroidism After Total Thyroidectomy in Children: A 21-Year Experience in a High-Volume Cancer Center. World J Surg 2020; 44:442-451. [PMID: 31686157 DOI: 10.1007/s00268-019-05231-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Hypoparathyroidism occurs relatively frequently after thyroid surgery in children. However, few studies have reported risk factors. We aimed to identify risk factors for hypoparathyroidism that occurred after total thyroidectomy for proven or suspected malignancy in children. METHODS Children (aged ≤ 18 years) who underwent total thyroidectomy for neoplasm or RET germline mutation at our institution between 1997 and 2018 were included. We retrospectively reviewed demographics, surgical indications, perioperative and follow-up laboratory results, pathologic results, and duration of calcium/calcitriol supplementation. Risk factors for hypoparathyroidism were identified by multivariate analysis. RESULTS Of 184 consecutive patients, 111 had undergone surgery for neoplasm; these diseases were primarily malignancies (106, 95.5%), predominantly papillary carcinoma (103, 92.8%). The remaining 73 patients had undergone early thyroidectomy for RET germline mutation. Among all patients, 67 (36.4%) had hypoparathyroidism: 61 transient and 6 permanent. In a multivariate analysis, central neck dissection (odds ratio 4.3, 95% confidence interval 2.0-9.1) and gross extrathyroidal extension (odds ratio 4.9, 95% confidence interval 2.0-12.1) predicted overall hypoparathyroidism; however, no significant factors were associated with permanent hypoparathyroidism. Most patients with permanent hypoparathyroidism (5 of 6) had undergone therapeutic central neck dissection. When central neck dissection was performed, younger children had a higher risk of overall hypoparathyroidism. CONCLUSIONS In pediatric total thyroidectomies, central neck dissection and gross extrathyroidal extension were major predictors for overall hypoparathyroidism. Surgeons performing thyroidectomy in such patients should be aware of the relatively high risk, preserve parathyroid tissue to the extent possible, and be conscientious regarding postoperative calcium monitoring and replacement.
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Affiliation(s)
- Si-Yuan Wu
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1484, Houston, TX, 77030-4095, USA
- Division of General Surgery, Departments of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Yi-Ju Chiang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1484, Houston, TX, 77030-4095, USA
| | - Sarah B Fisher
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1484, Houston, TX, 77030-4095, USA
| | - Erich M Sturgis
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mark E Zafereo
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sa Nguyen
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1484, Houston, TX, 77030-4095, USA
| | - Elizabeth G Grubbs
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1484, Houston, TX, 77030-4095, USA
| | - Paul H Graham
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1484, Houston, TX, 77030-4095, USA
| | - Jeffrey E Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1484, Houston, TX, 77030-4095, USA
| | - Steven G Waguespack
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nancy D Perrier
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1484, Houston, TX, 77030-4095, USA.
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15
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Risk factors of post-surgery complications in children with thyroid cancer. Int J Pediatr Otorhinolaryngol 2019; 127:109673. [PMID: 31546062 DOI: 10.1016/j.ijporl.2019.109673] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 09/05/2019] [Accepted: 09/05/2019] [Indexed: 11/24/2022]
Abstract
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.
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16
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Chen J, Huang N, Ji Q, Wang Y, Zhu Y, Li D. Multifocal papillary thyroid cancer in children and adolescents: 12-year experience in a single center. Gland Surg 2019; 8:507-515. [PMID: 31741881 DOI: 10.21037/gs.2019.09.03] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Thyroid cancer is the most common endocrine malignant disease in children and adolescents. There is a trend of more conservative strategies including lobectomy and less radioactive iodine therapy (RAI) in multifocal papillary thyroid cancer (PTC) for its good survival outcome. The aim of our study was to define long-time outcome of a large cohort of multifocal PTC patients less than 20 years old treated at our institution. Methods Data were collected from 276 cases who were initially diagnosis of PTC under the age of 20 from January 2006 to December 2015 at Fudan University Shanghai Cancer Center. All patients received total/near total thyroidectomy or lobectomy. Therapeutic central-compartment (level VI) and lateral neck lymph node dissection performed for patients with clinically involved neck nodes. RAI therapy used in selected patients. No patients received chemotherapy or kinase inhibitor therapy. Thyroid-stimulating hormone (TSH) suppression therapy was performed in all patients for at least 5 years. Results Ninety among 276 were multifocal PTC patients and included in this study. The median follow-up time was 54.28 months, ranging from 6.10 to 141.27 months. Fifteen patients had tumor recurrence during the follow-up. On Kaplan-Meier survival curves, lymphovascular invasion and extrathyroidal extension was associated with a decline in recurrence-free survival. However, there was no difference in recurrence-free survival curves in patients no matter which treatment they had received, either lobectomy or total thyroidectomy, RAI or not. Conclusions More conservative strategies including lobectomy and less RAI in multifocal PTC among children and adolescents are safe and effective.
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Affiliation(s)
- Jiaying Chen
- Department of Head and Neck Surgery, Furan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Naisi Huang
- Department of Head and Neck Surgery, Furan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Qinhai Ji
- Department of Head and Neck Surgery, Furan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Yu Wang
- Department of Head and Neck Surgery, Furan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Yongxue Zhu
- Department of Head and Neck Surgery, Furan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Duanshu Li
- Department of Head and Neck Surgery, Furan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
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17
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Initial treatment of pediatric differentiated thyroid cancer: a review of the current risk-adaptive approach. Pediatr Radiol 2019; 49:1391-1403. [PMID: 31620841 DOI: 10.1007/s00247-019-04457-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 05/07/2019] [Accepted: 06/18/2019] [Indexed: 10/25/2022]
Abstract
Differentiated thyroid cancer in children is a rare disease, accounting for only 1.4% of all pediatric malignancies. The diagnosis, biological behavior and treatment of differentiated thyroid cancer in children is different from that in adults. While there are many unresolved issues regarding approaches to management of differentiated thyroid cancer in the pediatric population, there is near universal consensus that treatment of this disease, which includes total thyroidectomy, central lymph node dissection at the time of initial surgery in those with nodal metastases, and the possible use of iodine-131 radiotherapy, is best performed by specialists including high-volume endocrine surgeons and experts with experience in calculating and administering radioactive iodine in children, when deemed appropriate.
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18
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Jiang W, Lee E, Newfield RS. The utility of intact parathyroid hormone level in managing hypocalcemia after thyroidectomy in children. Int J Pediatr Otorhinolaryngol 2019; 125:153-158. [PMID: 31323353 DOI: 10.1016/j.ijporl.2019.07.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 07/09/2019] [Accepted: 07/09/2019] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Hypocalcemia is a common complication after thyroidectomy. Intact parathyroid hormone (PTH) has been successfully used as a predictive indicator for hypocalcemia in adults during the postoperative period. We aim to demonstrate the utility of PTH in predicting and managing postoperative hypocalcemia following thyroidectomy in pediatrics. METHODS The study is a retrospective case series including 38 patients up to 18 years of age who underwent total or completion thyroidectomy from 1/1/2010 to 12/31/2016 at a tertiary pediatric academic center. Patient demographics, pathology, postoperative PTH, serum calcium, and length of stay were analyzed. RESULTS The median age was 14.3 years (range of 4.3-18.4 years) with 84.2% being female. Thyroid malignancy was noted in 25 patients, and 13 had benign pathology including 8 patients with multinodular goiter and 5 with Grave's disease. In this serie, 63.2% (24/38) developed hypocalcemia (serum calcium <8.5 mg/dL) postoperatively. The median PTH of 15.8 pg/mL in the hypocalcemic group was significantly lower than the median PTH of 41.6 pg/mL in the normocalcemic group (p < 0.001). Using a PTH threshold of 26 pg/mL, hypocalcemia was predicted with a sensitivity of 75%, and specificity of 100%. Six patients with calcium <7.5 mg/dL received teriparatide injections to avoid intravenous calcium replacement. The length of hospital stay for normocalcemic patients was 1.7 ± 0.8 days vs. 2.9 ± 1.4 days for hypocalcemic patients (p = 0.002). We found no correlation between the incidence of hypocalcemia and pathologic indication for surgery. Completion thyroidectomy was associated with a lower risk of hypocalcemia when compared to total thyroidectomy (p = 0.01) and neck dissections carried an increased risk of postoperative hypocalcemia (p = 0.04). CONCLUSION Postoperative PTH level has an excellent specificity in predicting hypocalcemia in this pediatric cohort using a threshold of PTH ≤ 26 pg/mL. Those with PTH >26 pg/mL may avoid hypocalcemia by oral calcium replacement with outpatient follow-up. We did not identify a reliable PTH cutoff value above which pediatric patients may be safely discharged immediately following surgery. Adult guideline or pathways that advocate for outpatient thyroidectomy surgery based on normal PTH ≥10 pg/mL in the recovery room may not apply to children.
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Affiliation(s)
- Wen Jiang
- Department of Surgery - Division of Otolaryngology, University of California San Diego, Rady Children's Hospital in San Diego, San Diego, CA, USA.
| | - Euyhyun Lee
- Altman Clinical and Translational Research Institute, University of California San Diego, La Jolla, CA, USA.
| | - Ron S Newfield
- Department of Pediatrics - Division of Endocrinology, University of California San Diego, Rady Children's Hospital in San Diego, San Diego, CA, USA.
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19
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Nordenström E, Bergenfelz A, Almquist M. Permanent Hypoparathyroidism After Total Thyroidectomy in Children: Results from a National Registry. World J Surg 2018; 42:2858-2863. [PMID: 29470698 PMCID: PMC6097774 DOI: 10.1007/s00268-018-4552-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Introduction Hypoparathyroidism is the most common complication following thyroidectomy. There are few population-based reports on the rate of hypoparathyroidism in children. The incidence of medical treatment of permanent hypoparathyroidism in children is reported using a national registry. Methods The study population included patients below 18 years of age undergoing total thyroidectomy reported to the Scandinavian Quality Registry for Thyroid, Parathyroid and Adrenal Surgery 2004–2014. Patients with previous thyroid or parathyroid surgery or treatment with vitamin D before surgery were excluded from analysis. Permanent postoperative hypoparathyroidism was defined as treatment with vitamin D for more than 6 months after thyroidectomy. Risk factors for permanent hypoparathyroidism were calculated with uni- and multivariable logistic regression. Using data from the Swedish Inpatient Registry, rates of readmissions and annual number of days in hospital after total thyroidectomy were compared between patients with and without permanent hypoparathyroidism. Results Some 274 children (215 girls and 59 boys) underwent total thyroidectomy. The median age was 14 (range 0–17) years. Indications for surgery were Graves’ disease (214, 78.1%), other benign disease (27, 9.9%) and thyroid cancer (33, 12%). Median follow-up was 4.8 years. Twenty (7.3%) children developed permanent hypoparathyroidism. No statistically significant risk factors for permanent hypoparathyroidism were identified. Rates of readmission and annual number of days in hospital after discharge were similar in patients with and without permanent hypoparathyroidism. Conclusions The rate of permanent hypoparathyroidism following total thyroidectomy in children was high and is a cause of concern.
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Affiliation(s)
- Erik Nordenström
- Department of Clinical Science, Lund University, 221 85, Lund, Sweden.
| | - Anders Bergenfelz
- Department of Clinical Science, Lund University, 221 85, Lund, Sweden
| | - Martin Almquist
- Department of Clinical Science, Lund University, 221 85, Lund, Sweden
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Massimino M, Evans DB, Podda M, Spinelli C, Collini P, Pizzi N, Bleyer A. Thyroid cancer in adolescents and young adults. Pediatr Blood Cancer 2018. [PMID: 29528191 DOI: 10.1002/pbc.27025] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
In adolescents and young adults, thyroid cancer accounts for 13% of all invasive neoplasms, being three times more frequent in females, but overdiagnosis and overtreatment are common. There are two therapeutic approaches, one radical and no longer preferred in all instances, and the other conservative. Permanent complications of surgery and metabolic irradiation can affect quality of life and carry an economic burden. The overall survival rate approaches 100% for patients with differentiated thyroid cancer regardless of the extent of treatment. Medullary thyroid carcinoma is a very different entity, occurring most frequently in the context of hereditary tumor susceptibility syndromes.
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Affiliation(s)
- Maura Massimino
- Pediatric Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Douglas B Evans
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Marta Podda
- Pediatric Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Claudio Spinelli
- Division of Pediatric and Adolescent Surgery, Department of Surgery, University of Pisa, Pisa, Italy
| | - Paola Collini
- Department of Diagnostic Pathology and Laboratory Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Natalia Pizzi
- Department of Otorhinology and Maxillo-Facial Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Archie Bleyer
- Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
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Koney N, Mahmood S, Gannon A, Finkelstein MS, Mody T. Pediatric Thyroid Cancer: Imaging and Therapy Update. CURRENT RADIOLOGY REPORTS 2017. [DOI: 10.1007/s40134-017-0247-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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22
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Garner EF, Maizlin II, Dellinger MB, Gow KW, Goldfarb M, Goldin AB, Doski JJ, Langer M, Nuchtern JG, Vasudevan SA, Raval MV, Beierle EA. Effects of socioeconomic status on children with well-differentiated thyroid cancer. Surgery 2017; 162:662-669. [PMID: 28602495 DOI: 10.1016/j.surg.2017.04.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 04/10/2017] [Accepted: 04/11/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Well-differentiated thyroid cancer is the most common endocrine malignancy in children. Adult literature has demonstrated socioeconomic disparities in patients undergoing thyroidectomy, but the effects of socioeconomic status on the management of pediatric well-differentiated thyroid cancer remains poorly understood. METHODS Patients ≤21 years of age with well-differentiated thyroid cancer remains were reviewed from the National Cancer Data Base. Three socioeconomic surrogate variables were identified: insurance type, median income, and educational quartile. Tumor characteristics, diagnostic intervals, and clinical outcomes were compared within each socioeconomic surrogate variable. RESULTS A total of 9,585 children with well-differentiated thyroid cancer remains were reviewed. In multivariate analysis, lower income, lower educational quartile, and insurance status were associated with higher stage at diagnosis. Furthermore, lower income quartile was associated with a longer time from diagnosis to treatment (P < .002). Similarly, uninsured children had a longer time from diagnosis to treatment (28 days) compared with those with government (19 days) or private (18 days) insurance (P < .001). Despite being diagnosed at a higher stage and having a longer time interval between diagnosis and treatment, there was no significant difference in either overall survival or rates of unplanned readmissions based on any of the socioeconomic surrogate variables. CONCLUSION Children from lower income families and those lacking insurance experienced a longer period from diagnosis to treatment of their well-differentiated thyroid cancer remains. These patients also presented with higher stage disease. These data suggest a delay in care for children from low-income families. Although these findings did not translate into worse outcomes for well-differentiated thyroid cancer remains, future efforts should focus on reducing these differences.
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Affiliation(s)
- Evan F Garner
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Ilan I Maizlin
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Matthew B Dellinger
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, Seattle, WA
| | - Kenneth W Gow
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, Seattle, WA
| | - Melanie Goldfarb
- Department of Surgery, John Wayne Cancer Institute at Providence St. John's Health Center, Santa Monica, CA
| | - Adam B Goldin
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, Seattle, WA
| | - John J Doski
- Department of Surgery, Methodist Children's Hospital of South Texas, University of Texas Health Science Center-San Antonio, San Antonio, TX
| | - Monica Langer
- Department of Surgery, Maine Children's Cancer Program, Tufts University, Portland, ME
| | - Jed G Nuchtern
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Sanjeev A Vasudevan
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA
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23
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Perioperative determinants of transient hypocalcemia after pediatric total thyroidectomy. J Pediatr Surg 2017; 52:684-688. [PMID: 28189449 DOI: 10.1016/j.jpedsurg.2017.01.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 01/23/2017] [Indexed: 11/23/2022]
Abstract
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.
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Kluijfhout WP, Pasternak JD, van der Kaay D, Vriens MR, Propst EJ, Wasserman JD. Is it time to reconsider lobectomy in low-risk paediatric thyroid cancer? Clin Endocrinol (Oxf) 2017; 86:591-596. [PMID: 27896825 DOI: 10.1111/cen.13287] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 11/12/2016] [Accepted: 11/23/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Current guidelines recommend total thyroidectomy for nearly all children with well-differentiated thyroid cancer (WDTC). These guidelines, however, derive from older data accrued prior to current high-resolution imaging. We speculate that there is a subpopulation of children who may be adequately treated with lobectomy. DESIGN Retrospective analysis of prospectively maintained database. PATIENTS Seventy-three children with WDTC treated between 2004 and 2015. MEASUREMENTS We applied two different risk-stratification criteria to this population. First, we determined the number of patients meeting American Thyroid Association (ATA) 'low-risk' criteria, defined as disease grossly confined to the thyroid with either N0/Nx or incidental microscopic N1a disease. Second, we defined a set of 'very-low-risk' histopathological criteria, comprising unifocal tumours ≤4 cm without predefined high-risk factors, and determined the proportion of patients that met these criteria. RESULTS Twenty-seven (37%) males and 46 (63%) females were included in this study, with a mean age of 13·4 years. Ipsilateral- and contralateral multifocality were identified in 27 (37·0%) and 19 (26·0%) of specimens. Thirty-seven (51%) patients had lymph node metastasis (N1a = 18/N1b = 19). Pre-operative ultrasound identified all cases with clinically significant nodal disease. Of the 73 patients, 39 (53·4%) met ATA low-risk criteria and 16 (21·9%) met 'very-low-risk' criteria. All 'very-low-risk' patients demonstrated excellent response to initial therapy without persistence/recurrence after a mean follow-up of 36·4 months. CONCLUSIONS Ultrasound and histopathology identify a substantial population that may be candidates for lobectomy, avoiding the risks and potential medical and psychosocial morbidity associated with total thyroidectomy. We propose a clinical framework to stimulate discussion of lobectomy as an option for low-risk patients.
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Affiliation(s)
- Wouter P Kluijfhout
- Division of General Surgery, University Health Network Toronto, Toronto, Ontario, Canada
- Department of General Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jesse D Pasternak
- Division of General Surgery, University Health Network Toronto, Toronto, Ontario, Canada
| | - Danielle van der Kaay
- Division of Paediatric Endocrinology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Menno R Vriens
- Department of General Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Evan J Propst
- Department of Otolaryngology-Head and Neck Surgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Jonathan D Wasserman
- Division of Paediatric Endocrinology, Hospital for Sick Children, Toronto, Ontario, Canada
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25
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Abstract
Head and neck anatomy is topographically complex and the region is densely populated by vital nerves and vascular and lymphatic structures. Injury to many of these structures is associated with significant morbidity and may even be fatal. A thorough knowledge of regional anatomy is imperative and complications need to be managed in a thoughtful directed manner. The pediatric surgeon may be called upon to address both congenital and acquired conditions and should be prepared to encounter reoperative fields after failed initial surgery. This review summarizes the current literature on four frequently encountered surgical conditions of the head and neck: branchial cleft anomalies, thyroglossal duct cyst, thyroid disease, and lymphatic malformations, with a focus on the prevention and treatment of complications.
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Affiliation(s)
- Emily Christison-Lagay
- Department of Surgery, Yale School of Medicine, PO Box 208062, New Haven, Connecticut 06510.
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26
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Parisi MT, Eslamy H, Mankoff D. Management of Differentiated Thyroid Cancer in Children: Focus on the American Thyroid Association Pediatric Guidelines. Semin Nucl Med 2016; 46:147-64. [PMID: 26897719 DOI: 10.1053/j.semnuclmed.2015.10.006] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
First introduced in 1946, radioactive iodine (I-131) produces short-range beta radiation with a half-life of 8 days. The physical properties of I-131 combined with the high degree of uptake in the differentiated thyroid cancers (DTCs) led to the use of I-131 as a therapeutic agent for DTC in adults. There are two indications for the potential use of I-131 therapy in pediatric thyroid disorders: nonsurgical treatment of hyperthyroidism owing to Graves' disease and the treatment of children with intermediate- and high-risk DTC. However, children are not just miniature adults. Not only are children and the pediatric thyroid gland more sensitive to radiation than adults but also the biologic behavior of DTC differs between children and adults as well. As opposed to adults, children with DTC typically present with advanced disease at diagnosis; yet, they respond rapidly to therapy and have an excellent prognosis that is significantly better than that in adult counterparts with advanced disease. Unfortunately, there are also higher rates of local and distant disease recurrence in children with DTC compared with adults, mandating lifelong surveillance. Further, children have a longer life expectancy during which the adverse effects of I-131 therapy may become manifest. Recognizing the differences between adults and children with DTC, the American Thyroid Association commissioned a task force of experts who developed and recently published a guideline to address the unique issues related to the management of thyroid nodules and DTC in children. This article reviews the epidemiology, diagnosis, staging, treatment, therapy-related effects, and suggestions for surveillance in children with DTC, focusing not only on the differences between adults and children with this disease but also on the latest recommendations from the inaugural pediatric management guidelines of the American Thyroid Association.
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Affiliation(s)
- Marguerite T Parisi
- Department of Radiology, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA; Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA.
| | - Hedieh Eslamy
- Department of Radiology, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
| | - David Mankoff
- Department of Nuclear Medicine, University of Pennsylvania, Philadelphia, PA
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27
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Qu N, Zhang L, Lu ZW, Ji QH, Yang SW, Wei WJ, Zhang Y. Predictive factors for recurrence of differentiated thyroid cancer in patients under 21 years of age and a meta-analysis of the current literature. Tumour Biol 2015; 37:7797-808. [PMID: 26695148 DOI: 10.1007/s13277-015-4532-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 07/07/2014] [Indexed: 01/11/2023] Open
Abstract
The influence of predictors for recurrence in relation to recurrence-free survival was analyzed retrospectively in differentiated thyroid cancer (DTC) patients under 21 years of age who underwent primary surgical treatment and who had a pathological diagnosis of DTC between 1983 and 2012 at Fudan University Cancer Hospital. Recurrences were retrospectively analyzed using a Cox regression model for the hazard ratio (HR) according to the clinicopathological features. A meta-analysis was performed with respect to the potential predictors for recurrence from current related studies. In the present study, there were 146 young patients aged from 7 to 20 years, with a female/male ratio of 2.65/1. Female gender was the only factor significantly associated with recurrence according to univariate (HR = 2.812, P = 0.037) and multivariate (HR = 4.107, P = 0.024) Cox regression analyses. Meta-analyses revealed that multifocality (HR = 1.91, P < 0.05) and presentation at diagnosis (HR = 1.39, P < 0.05) were highly associated with recurrence in young DTC patients. However, female gender and other factors, such as age (≤10 vs. 11-20 years), PTC (PTC vs. FTC), extrathyroidal extension, lymph node metastasis, total thyroidectomy (total vs. less than total), radioiodine therapy, and radiation history, were not associated with recurrence in young DTC patients. In conclusion, multifocality and presentation at diagnosis are strong predictive factors of recurrence in relation to recurrence-free survival. We recommend studies with larger sample sizes and longer follow-up to verify the influence of predictors for disease recurrence in young patients.
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Affiliation(s)
- Ning Qu
- Department of Head and Neck Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, People's Republic of China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, People's Republic of China
| | - Ling Zhang
- Department of Head and Neck Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, People's Republic of China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, People's Republic of China
| | - Zhong-Wu Lu
- Department of Head and Neck Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, People's Republic of China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, People's Republic of China
| | - Qing-Hai Ji
- Department of Head and Neck Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, People's Republic of China. .,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, People's Republic of China.
| | - Shu-Wen Yang
- Department of Head and Neck Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, People's Republic of China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, People's Republic of China
| | - Wen-Jun Wei
- Department of Head and Neck Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, People's Republic of China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, People's Republic of China
| | - Yan Zhang
- Department of Head and Neck Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, People's Republic of China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, People's Republic of China
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28
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Chen Y, Masiakos PT, Gaz RD, Hodin RA, Parangi S, Randolph GW, Sadow PM, Stephen AE. Pediatric thyroidectomy in a high volume thyroid surgery center: Risk factors for postoperative hypocalcemia. J Pediatr Surg 2015; 50:1316-9. [PMID: 25783304 DOI: 10.1016/j.jpedsurg.2014.10.056] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Revised: 10/27/2014] [Accepted: 10/29/2014] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Hypocalcemia is a common complication following thyroid surgery. We seek to report on our experience in pediatric thyroidectomy in a high volume thyroid surgery center and accurately assess the incidence of postoperative hypocalcemia. MATERIALS AND METHODS A retrospective review of patients aged 18 and younger who underwent thyroid surgery between 1992 and 2013. The primary endpoints were the occurrence of postoperative hypocalcemia as by defined as a nadir calcium <8.0mg/dL and being discharged on oral calcium supplementation, need for intravenous calcium and the occurrence of permanent hypoparathyroidism. RESULTS 171 patients who underwent 186 thyroid operations were analyzed. The average age was 15.4years with 82.3% female. The most common indications for surgery were nodular disease (74.7%) and hyperthyroidism (12.4%). 24 patients (12.9%) experienced postoperative hypocalcemia with 13 (7.0%) requiring intravenous calcium infusion. One patient (0.9%) experienced permanent hypoparathyroidism. Risk factors for postoperative hypocalcemia included total thyroidectomy (OR 7.39, p<0.01), central and bilateral lateral neck dissection (OR 22.26, p=0.01), Graves' disease (OR 3.99, p=0.02), and malignancy (OR 2.96, p=0.03). CONCLUSIONS Pediatric patients who undergo total thyroidectomy for underlying malignancy or Graves' disease and those who have more extensive nodal dissections are at increased risk of developing this postoperative hypocalcemia. These patients may benefit from more vigilant preoperative preparation and postoperative calcium and vitamin D supplementation.
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Affiliation(s)
- Yufei Chen
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
| | - Peter T Masiakos
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
| | - Randall D Gaz
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
| | - Richard A Hodin
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
| | - Sareh Parangi
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
| | - Gregory W Randolph
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114, USA.
| | - Peter M Sadow
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
| | - Antonia E Stephen
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
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29
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Francis GL, Waguespack SG, Bauer AJ, Angelos P, Benvenga S, Cerutti JM, Dinauer CA, Hamilton J, Hay ID, Luster M, Parisi MT, Rachmiel M, Thompson GB, Yamashita S. Management Guidelines for Children with Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid 2015; 25:716-59. [PMID: 25900731 PMCID: PMC4854274 DOI: 10.1089/thy.2014.0460] [Citation(s) in RCA: 699] [Impact Index Per Article: 77.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Previous guidelines for the management of thyroid nodules and cancers were geared toward adults. Compared with thyroid neoplasms in adults, however, those in the pediatric population exhibit differences in pathophysiology, clinical presentation, and long-term outcomes. Furthermore, therapy that may be recommended for an adult may not be appropriate for a child who is at low risk for death but at higher risk for long-term harm from overly aggressive treatment. For these reasons, unique guidelines for children and adolescents with thyroid tumors are needed. METHODS A task force commissioned by the American Thyroid Association (ATA) developed a series of clinically relevant questions pertaining to the management of children with thyroid nodules and differentiated thyroid cancer (DTC). Using an extensive literature search, primarily focused on studies that included subjects ≤18 years of age, the task force identified and reviewed relevant articles through April 2014. Recommendations were made based upon scientific evidence and expert opinion and were graded using a modified schema from the United States Preventive Services Task Force. RESULTS These inaugural guidelines provide recommendations for the evaluation and management of thyroid nodules in children and adolescents, including the role and interpretation of ultrasound, fine-needle aspiration cytology, and the management of benign nodules. Recommendations for the evaluation, treatment, and follow-up of children and adolescents with DTC are outlined and include preoperative staging, surgical management, postoperative staging, the role of radioactive iodine therapy, and goals for thyrotropin suppression. Management algorithms are proposed and separate recommendations for papillary and follicular thyroid cancers are provided. CONCLUSIONS In response to our charge as an independent task force appointed by the ATA, we developed recommendations based on scientific evidence and expert opinion for the management of thyroid nodules and DTC in children and adolescents. In our opinion, these represent the current optimal care for children and adolescents with these conditions.
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Affiliation(s)
- Gary L. Francis
- Division of Pediatric Endocrinology, Virginia Commonwealth University, Children's Hospital of Richmond, Richmond, Virginia
| | - Steven G. Waguespack
- Department of Endocrine Neoplasia and Hormonal Disorders and Department of Pediatrics-Patient Care, Children's Cancer Hospital, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Andrew J. Bauer
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, The University of Pennsylvania, The Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Peter Angelos
- Section of General Surgery and Surgical Oncology, Department of Surgery, University of Chicago Medicine, Chicago, Illinois
| | - Salvatore Benvenga
- University of Messina, Interdepartmental Program on Clinical & Molecular Endocrinology, and Women's Endocrine Health, A.O.U. Policlinico Universitario G. Martino, Messina, Italy
| | - Janete M. Cerutti
- Department of Morphology and Genetics. Division of Genetics, Federal University of São Paulo, São Paulo, Brazil
| | - Catherine A. Dinauer
- Department of Surgery, Division of Pediatric Surgery, Department of Pediatrics, Division of Pediatric Endocrinology, Yale University School of Medicine, New Haven, Connecticut
| | - Jill Hamilton
- Division of Endocrinology, University of Toronto, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ian D. Hay
- Division of Endocrinology, Mayo Clinic and College of Medicine, Rochester, Minnesota
| | - Markus Luster
- University of Marburg, Marburg, Germany
- Department of Nuclear Medicine, University Hospital Marburg, Marburg, Germany
| | - Marguerite T. Parisi
- Departments of Radiology and Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital, Department of Radiology, Seattle, Washington
| | - Marianna Rachmiel
- Pediatric Division, Assaf Haroffeh Medical Center, Zerifin, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Geoffrey B. Thompson
- Department of Surgery, Division of Subspecialty GS (General Surgery), Mayo Clinic, Rochester, Minnesota
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30
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Kluijfhout WP, van Beek DJ, Verrijn Stuart AA, Lodewijk L, Valk GD, van der Zee DC, Vriens MR, Borel Rinkes IHM. Postoperative Complications After Prophylactic Thyroidectomy for Very Young Patients With Multiple Endocrine Neoplasia Type 2: Retrospective Cohort Analysis. Medicine (Baltimore) 2015; 94:e1108. [PMID: 26200612 PMCID: PMC4603023 DOI: 10.1097/md.0000000000001108] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
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.
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Affiliation(s)
- Wouter P Kluijfhout
- From the Department of Surgical Oncology and Endocrine Surgery, University Medical Center Utrecht (WPK, D-JVB, LL, MRV, IHMBR); Department of Pediatric Endocrinology, Wilhelmina Children's Hospital (AAVS); Department of Endocrinology; University Medical Center Utrecht (GDV); and Department of Pediatric Surgery, Wilhelmina Children's Hospital, Utrecht, The Netherlands (DCVDZ)
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31
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Nice T, Pasara S, Goldfarb M, Doski J, Goldin A, Gow KW, Nuchtern JG, Vasudevan SA, Langer M, Beierle EA. Pediatric papillary thyroid cancer >1 cm: is total thyroidectomy necessary? J Pediatr Surg 2015; 50:1009-13. [PMID: 25819020 DOI: 10.1016/j.jpedsurg.2015.03.031] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 03/10/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Treatment of pediatric papillary thyroid cancer (p-PTC) often follows adult guidelines, including total thyroidectomy for tumors >1cm. This study examined the association between operation type and overall survival (OS) for tumors >1cm in size in the pediatric population. METHODS Patients ≤ 21 years of age with primary papillary thyroid cancer >1cm were reviewed from the National Cancer Data Base (NCDB) from 1998 to 2011. Kaplan-Meier analysis followed by Cox proportional hazard models estimated the impact of total thyroidectomy (TT) vs. partial thyroidectomy (PT) on overall survival. Models were adjusted for patient, tumor, and treatment factors. RESULTS 3,861 cases (3474 TT, 387 PT) were included. Estimated 15-year overall survival was 96.10% after TT and 96.18% after PT (p=0.0855). In multivariate analysis of 3173 patients, only lowest socioeconomic level (HR 4.93, p=0.001) and unfavorable histology (HR 6.11, p=0.016) were associated with worse OS. Survival for patients undergoing TT was not statistically improved over those undergoing PT (HR 0.81, p=0.694). CONCLUSION p-PTC >1cm has an excellent 15-year overall survival. Treatment with TT did not have an improved OS compared to PT. Lower socioeconomic status and unfavorable histology were associated with decreased OS.
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Affiliation(s)
- Tate Nice
- Department of Surgery, Division of Pediatric Surgery, University of Alabama at Birmingham, Children's Hospital of Alabama, Birmingham, AL.
| | - Sebastian Pasara
- School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Melanie Goldfarb
- Department of Surgery, John Wayne Cancer Institute/Providence St. John's Medical Center, Santa Monica, CA
| | - John Doski
- Department of Surgery/Pediatric Surgery Division, University of Texas Health Science Center, San Rosa Children's Hospital, San Antonio, TX
| | - Adam Goldin
- Division of General and Thoracic Surgery, Seattle Children's Hospital, Seattle, WA
| | - Kenneth W Gow
- Division of General and Thoracic Surgery, Seattle Children's Hospital, Seattle, WA
| | - Jed G Nuchtern
- Division of Pediatric Surgery, Baylor College of Medicine, Houston, TX
| | | | - Monica Langer
- Division of Pediatric Surgery, Maine Medical Center, Portland, ME
| | - Elizabeth A Beierle
- Department of Surgery, Division of Pediatric Surgery, University of Alabama at Birmingham, Children's Hospital of Alabama, Birmingham, AL
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32
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Choi Y, Lee JH, Kim YH, Lee YS, Chang HS, Park CS, Roh MR. Impact of postthyroidectomy scar on the quality of life of thyroid cancer patients. Ann Dermatol 2014; 26:693-9. [PMID: 25473220 PMCID: PMC4252665 DOI: 10.5021/ad.2014.26.6.693] [Citation(s) in RCA: 163] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Revised: 01/27/2014] [Accepted: 02/20/2014] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Surgical scars are crucial cosmetic problem, especially when in exposed areas such as the anterior neck following thyroidectomy. OBJECTIVE To evaluate the impact of post-thyroidectomy scars on quality of life (QoL) of thyroid cancer patients and identify the relationship between scar characteristics and QoL. METHODS Patients with post-thyroidectomy scars on the neck were recruited. QoL was measured using the Dermatology Life Quality Index (DLQI). Scar characteristics were graded according to Vancouver scar scale (VSS) score. RESULTS Ninety-seven patients completed a battery of questions at the time of enrollment. Post-thyroidectomy scars were classified according to morphology as linear flat scars, linear bulging scars, hypertrophic scars or adhesive scars. There were 32 patients (33.0%), 9 patients (9.3%), 41 patients (42.3%) and 15 patients (15.5%), respectively, in each group. The mean total DLQI score was 9.02. Domain 2 (daily activities, 2.87 points), which includes questions about clothing, was the most greatly impacted among patients. The total DLQI scores of patients who have experienced scar-related symptoms were significantly higher than those of patients without symptoms (p<0.05). The VSS scores were 3.09 for linear flat scars, 6.89 for linear bulging scars, 6.29 for hypertrophic scars and 5.60 for adhesive scars. However, the DLQI scores did not significantly differ among scar types or VSS scores. CONCLUSION Post-thyroidectomy scars on the neck affect the QoL of thyroid cancer patients regardless of scar type. Therefore, clinicians should pay attention to the psychological effects of scars on patients and take care to minimize post-thyroidectomy scar.
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Affiliation(s)
- Yuri Choi
- Department of Dermatology, Gangnam Severance Hospital, Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Ji Hye Lee
- Department of Dermatology, Gangnam Severance Hospital, Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | | | - Yong Sang Lee
- Department of Surgery, Thyroid Cancer Center, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hang-Seok Chang
- Department of Surgery, Thyroid Cancer Center, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Cheong Soo Park
- Department of Surgery, Thyroid Cancer Center, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Mi Ryung Roh
- Department of Dermatology, Gangnam Severance Hospital, Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea
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Mihailovic J, Nikoletic K, Srbovan D. Recurrent disease in juvenile differentiated thyroid carcinoma: prognostic factors, treatments, and outcomes. J Nucl Med 2014; 55:710-7. [PMID: 24722527 DOI: 10.2967/jnumed.113.130450] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
UNLABELLED The overall prognosis in pediatric differentiated thyroid carcinoma (DTC) is excellent. Recurrent disease is frequent, however, and requires additional treatment. We analyzed the probability of recurrence, prognostic factors, treatment, and outcome of juvenile DTC. METHODS Fifty-one DTC patients (32 girls and 19 boys; ≤ 20 y old; mean age, 16.5 y) were treated with (131)I (radioiodine, or radioactive iodine [RAI]); the median follow-up was 10 y. Patients underwent different initial treatments: 46 patients received total thyroidectomy and RAI, 3 patients received total thyroidectomy, and 3 patients received subtotal thyroidectomy. The probability of recurrence and prognostic factors were tested with the Kaplan-Meier method. RESULTS Initially, 36 of 51 patients achieved complete remission, 14 of 51 achieved partial remission, and 1 of 51 had progressive disease. By the follow-up, 11 of 51 patients (21.6%) had developed recurrent disease; the median appearance time was 4 y (range, 1-15 y). The probabilities of recurrence were 16.7% at 5 y, 22.3% at 10 y, and 33.3% at 15 and 23 y after the initial treatments. Factors that were strongly predictive of recurrence were age (P = 0.001), initial treatment (P = 0.0001), and tumor multifocality (P = 0.011). Sex, nodal metastases at presentation, distal metastases at presentation, histologic type of the tumor, T stage, and clinical stage had no influence on relapse (P = 0.180, P = 0.786, P = 0.796, P = 0.944, P = 0.352, and P = 0.729, respectively). Patients with recurrent disease, partial remission, and progressive disease were retreated, with either surgery or surgery and RAI, receiving cumulative activities of up to 40 GBq. The overall outcome in our patients was excellent: 90.2% complete remission, 3.92% partial remission, 1.96% stable disease, 1.96% disease-related death, and 1.96% another cause of death. CONCLUSION Younger age at diagnosis, less radical primary surgery without subsequent RAI, and tumor multifocality are factors that are strongly prognostic for recurrence. For reducing the rate of relapse and improving surveillance for recurrent disease, total thyroidectomy followed by RAI appears to be the most beneficial initial treatment for patients with juvenile DTC. The use of RAI seems to be safe, with no adverse effects on subsequent fertility and pregnancy or secondary malignancy.
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Affiliation(s)
- Jasna Mihailovic
- Department of Nuclear Medicine, Oncology Institute of Vojvodina, Sremska Kamenica, Serbia; and
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Norlen O, Glover AR, Gundara JS, Ip JC, Sidhu SB. Best practice for the management of pediatric thyroid cancer. Expert Rev Endocrinol Metab 2014; 9:175-182. [PMID: 30743759 DOI: 10.1586/17446651.2014.877342] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The presentation of differentiated thyroid cancer in children often includes dissemination to lymph nodes. Despite this, the long-term prognosis is excellent with appropriate treatment. A few known hereditary syndromes are associated with paediatric thyroid cancer, although most tumours are sporadic. Ultrasound and cytology is used to evaluate suspect thyroid nodules, and treatment consists of surgery, radioactive iodine and thyroxine suppression therapy. Follow-up includes serum thyroglobulin measurements, serial ultrasounds of the neck, radioiodine whole body scans and occasionally other cross-sectional imaging or positron emission tomography. This review focuses on paediatric well differentiated follicular and papillary thyroid cancer, diagnosis and preoperative evaluation, underlying genetic mechanisms, surgery, other treatment options and follow-up.
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Affiliation(s)
- Olov Norlen
- a Endocrine Surgery Unit, University of Sydney, NSW, Australia
- b Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | | | | | - Julian Cy Ip
- a Endocrine Surgery Unit, University of Sydney, NSW, Australia
| | - Stan B Sidhu
- a Endocrine Surgery Unit, University of Sydney, NSW, Australia
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Kundel A, Thompson GB, Richards ML, Qiu LX, Cai Y, Schwenk FW, Lteif AN, Pittock ST, Kumar S, Tebben PJ, Hay ID, Grant CS. Pediatric endocrine surgery: a 20-year experience at the Mayo Clinic. J Clin Endocrinol Metab 2014; 99:399-406. [PMID: 24423286 DOI: 10.1210/jc.2013-2617] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
CONTEXT Surgically managed endocrinopathies are rare in children. Most surgeons have limited experience in this field. Herein we report our operative experience with pediatric patients, performed over two decades by high-volume endocrine surgeons. SETTING The study was conducted at the Mayo Clinic (a tertiary referral center). PATIENTS Patients were <19 years old and underwent an endocrine operation (1993-2012). MAIN OUTCOME MEASURES Demographics, surgical procedure, diagnoses, morbidity, and mortality were retrospectively reviewed. RESULTS A total of 241 primary cases included 177 thyroid procedures, 13 neck dissections, 24 parathyroidectomies, 14 adrenalectomies, 7 paragangliomas, and 6 pancreatic procedures. Average age of patients was 14.2 years. There were 133 total thyroidectomies and 40 hemithyroidectomies. Fifty-three cases underwent a central or lateral neck dissection. Six-month follow-up was available for 98 total thyroidectomy patients. There were four cases of permanent hypoparathyroidism (4%) and no permanent recurrent laryngeal nerve (RLN) paralyses. Sequelae of neck dissections included temporary RLN neurapraxia and Horner's syndrome. Parathyroidectomy was performed on 24 patients: 20 with primary hyperparathyroidism (HPT), three with tertiary HPT, and one with familial hypocalciuric hypocalcemia. Three patients (16%) had recurrent HPT, all with multiglandular disease. One patient had temporary RLN neurapraxia. We performed seven bilateral and seven unilateral adrenalectomies; eight were laparoscopic. Indications included pheochromocytoma, Cushing's syndrome, adrenocortical carcinoma, congenital adrenal hyperplasia, and ganglioneuroma. One death was due to adrenocortical carcinoma. Five paraganglioma patients had succinate dehydrogenase subunit B mutations, and one recurred. Six patients with insulinoma underwent enucleation (n = 5) or distal pancreatectomy (n = 1). A single postoperative abscess was managed nonoperatively. CONCLUSION Pediatric endocrine procedures are uncommon but can be safely performed with complication rates comparable to those of the adult population. It is imperative that these operations be performed by high-volume surgeons.
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Affiliation(s)
- A Kundel
- Mayo Clinic, Rochester, Minnesota 55905
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Abstract
Very few have been reported on children with differentiated thyroid cancer (DTC), although 15% of them are diagnosed below 20 years of age. Children with DTC present with more advanced disease; however, they have a more favorable outcome. In this paper, we aimed to present the data in our institution on pediatric DTC patients, making an emphasis on the risk factors of metastasis and recurrence, as well as to the outcome of treatment. Clinical data of 50 pediatric patients referred to our institution for radioiodine treatment (RAI) between 1976 and 2010 were obtained. Papillary carcinoma was the most common histopathologic diagnosis (36 patients) followed by papillary carcinoma with follicular variant (10 patients). Multifocality was reported in 66% of the pathology reports. At the time of diagnosis 35 patients had regional lymph node metastasis, 18 had local invasion, and 11 had distant metastasis. No distant metastasis was present in patients with unifocal disease (P=0.018). The mean duration of follow-up was 77.6±62.7 months. Patients with local disease had longer disease-free survival than patients with distant metastasis (P=0.033). Despite the small number of patients, the follow-up was relatively long and the presented results confirmed overall good prognosis in children with DTC.
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Sim Y, Yap F, Soo KC, Low Y. Medullary thyroid carcinoma in ethnic Chinese with MEN2A: a case report and literature review. J Pediatr Surg 2013; 48:e43-6. [PMID: 23331839 DOI: 10.1016/j.jpedsurg.2012.10.065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Revised: 10/29/2012] [Accepted: 10/31/2012] [Indexed: 11/18/2022]
Abstract
Medullary Thyroid Carcinoma (MTC) is the most common cause of death in MEN patients. It is curative by prophylactic total thyroidectomy, but controversies remain as to the optimal timing for prophylactic thyroidectomy. The current recommendation is for prophylactic total thyroidectomy before age 5, but a recent study suggested that in the ethnic Chinese, even "high risk" mutations did not result in early malignant change, and it was suggested that prophylactic thyroidectomy may be performed at a later age. We report a case of an ethnic Chinese girl with MEN2A codon 634 (C634R) mutation, whose operative specimen at prophylactic thyroidectomy at 4 years 8 months showed MTC. We advocate that management of MEN2A patients should be codon-directed, regardless of ethnicity.
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Affiliation(s)
- Yirong Sim
- Department of Paediatric Surgery, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore S229899, Singapore
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Morris LF, Waguespack SG, Warneke CL, Ryu H, Ying AK, Anderson BJ, Sturgis EM, Clayman GL, Lee JE, Evans DB, Grubbs EG, Perrier ND. Long-term follow-up data may help manage patient and parent expectations for pediatric patients undergoing thyroidectomy. Surgery 2012; 152:1165-71. [PMID: 23158186 DOI: 10.1016/j.surg.2012.08.056] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Accepted: 08/27/2012] [Indexed: 02/03/2023]
Abstract
BACKGROUND We investigated the incidence and impact of postoperative complications in children who underwent total thyroidectomy (TTx). METHODS The records of all pediatric patients undergoing TTx (2001-2011) at our institution were retrospectively reviewed for the occurrence of biochemical hypothyroidism (thyroid-stimulating hormone >10 mIU/mL), laboratory assessments, and medication nonadherence. RESULTS The 74 patients (median age, 12.5 years) had thyroid cancer (differentiated, n = 39; medullary, n = 16) or benign pathology (n = 19; 16 with multiple endocrine neoplasia type 2A). The median postoperative follow-up was 3.2 years; 46 patients (62%) had ≥ 1 year follow-up. Forty-one percent had ≥ 1 period of medication nonadherence; this was not associated with age at TTx (P = .30). Non-treatment-related hypothyroidism occurred in 33% of patients during postoperative year (POY) 1. The number of POY1 laboratory assessments among the 30% of patients with parathyroid dysfunction was more than twice that among patients with normal parathyroid function (median assessments per year 8 vs 3; P < .0001). Forty-four percent of patients/families reported behavioral or physiologic changes; 40% were concomitant with abnormal thyroid function. CONCLUSION More than 40% of pediatric patients were unable to fully adhere to postoperative medication regimens, and non-treatment-related hypothyroidism was common. Postoperative hypoparathyroidism doubled the number of laboratory assessments obtained. These data may help families better prepare for TTx sequelae.
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Affiliation(s)
- Lilah F Morris
- Section of Surgical Endocrinology, Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77230-1402, USA
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Burke JF, Sippel RS, Chen H. Evolution of pediatric thyroid surgery at a tertiary medical center. J Surg Res 2012; 177:268-74. [PMID: 22795270 DOI: 10.1016/j.jss.2012.06.044] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2012] [Revised: 04/06/2012] [Accepted: 06/19/2012] [Indexed: 01/16/2023]
Abstract
BACKGROUND Thyroidectomy in the pediatric population is often avoided due to perceived risks in children. With growing subspecialization and establishment of high volume endocrine surgery centers, the indications for thyroid surgery and extent of resection continue to change. We examined the evolution of pediatric thyroid surgery at a high volume tertiary medical center. METHODS From our prospectively collected database, we reviewed medical records of individuals younger than 19 y who underwent thyroidectomy at our institution from 1994 to 2009. Patients were divided into two groups: (1) before establishment of our endocrine surgery center (1994-2001) and (2) since establishment of the center (2002-2009). RESULTS We identified 78 operations performed on 74 patients with a median age of 15 (range 3-18) y. We found that the number of patients doubled in the later time period, with 26 operations in group 1 and 52 in group 2. The age of patients and percentage of females were similar between groups. After establishment of the endocrine surgery center, there was a significant increase in total thyroidectomies for all indications, including significantly more for benign disease. Overall, 9% of the patient population experienced transient complications, with no permanent complications or long-term sequelae. CONCLUSIONS Pediatric thyroid surgery is extremely safe, especially when performed at a high volume endocrine surgery center. We more often select surgical treatment for benign disease and choose total thyroidectomy over limited resection. This may reflect increasing confidence in the safety and efficacy of surgery and reliability of thyroid hormone replacement.
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Affiliation(s)
- Jocelyn F Burke
- Department of Surgery, Section of Endocrine Surgery, University of Wisconsin, Madison, Wisconsin, USA
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Huang CH, Chao TC, Hseuh C, Lin KJ, Ho TY, Lin SF, Lin JD. Therapeutic outcome and prognosis in young patients with papillary and follicular thyroid cancer. Pediatr Surg Int 2012; 28:489-94. [PMID: 22274547 DOI: 10.1007/s00383-012-3054-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/09/2012] [Indexed: 01/28/2023]
Abstract
BACKGROUND Papillary and follicular thyroid cancer is a common malignancy in young patients, and the incidence of this cancer has been increasing. The aims of this study are to assess the clinical characteristics of papillary and follicular thyroid cancer in young patients and evaluate the long-term therapeutic outcomes and prognostic factors for cancer mortality and recurrence. METHODS We performed a retrospective analysis of 116 patients aged ≤20 years who underwent thyroidectomy and a mean follow-up of 11.1 ± 0.6 years. RESULTS There were 28 (24.1%) patients classified into the residual cancer or relapse groups. The progression-free survival rate for the young patients was lower than that of the patients between 20 and 45 years of age; however, the difference between the thyroid cancer survival rates was not statistically different. Two of the 28 patients died of thyroid cancer. Thirteen patients who showed relapsed underwent (131)I whole-body scan; 6 of the 13 patients were diagnosed with distant metastases to the lung and 1 was diagnosed with distant metastases to the bones. Among the young patients, the 5- and 10-year progression-free survival rates were 79.1 and 73.4%, respectively, and the corresponding cancer survival rates were 99.1, and 96.5%, respectively. CONCLUSION The progression-free survival in young patients with papillary and follicular thyroid cancer was lower than the patients of age 20-45 years; otherwise, cancer survival was higher than age group over or equal to 45 years.
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Affiliation(s)
- Chung-Huei Huang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Shin St., Taoyuan Hsien, Kweishan County, Taiwan, ROC
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Roy R, Kouniavsky G, Schneider E, Allendorf JD, Chabot JA, Logerfo P, Dackiw APB, Colombani P, Zeiger MA, Lee JA. Predictive factors of malignancy in pediatric thyroid nodules. Surgery 2012; 150:1228-33. [PMID: 22136845 DOI: 10.1016/j.surg.2011.09.023] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2011] [Accepted: 09/15/2011] [Indexed: 12/01/2022]
Abstract
BACKGROUND Studies suggest that while most pediatric thyroid nodules are benign, there is a higher rate of malignancy than in adults. We investigate clinical factors that may predict malignancy in pediatric thyroid nodules. METHODS A retrospective review of 207 pediatric thyroidectomies was conducted over 15 years at 2 tertiary hospitals. Analyses examined predictive values of 16 clinicopathologic factors associated with cancer. Positive predictive values (PPVs) of fine-needle aspiration biopsy specimens (FNABs) were analyzed independently. RESULTS Malignancy occurred in 41% of patients. After excluding missing data, malignancy was more likely with family history of thyroid cancer (34.2% vs 17.7%; P = .111), palpable lymphadenopathy (34.2% vs 2.9%; P = .001), and hypoechoic nodules (52.2% vs 19.2%; P = .016). Palpable lymphadenopathy indicated greater than 2-fold increased risk for malignancy (relative risk, 2.18; 95% confidence interval, 1.56-3.05). PPVs of FNAB results were 0.94 for malignancy, 0.63 for suspicious for malignancy, and 0.55 for indeterminate lesions. PPV for benign FNAB to be benign on final pathology was 0.71. CONCLUSION While malignancy is associated with family history of thyroid cancer and hypoechoic lesions, palpable lymphadenopathy had the greatest risk. When compared to adults, a benign FNAB in children is not as accurate and the likelihood that an indeterminate nodule is cancer is greater.
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Affiliation(s)
- Rashmi Roy
- Endocrine Surgery Section, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Abstract
Based on strong research evidence, thyroid nodules in children and teenagers are more likely to be malignant than in adults. Based on strong research evidence, a history of ionizing radiation to the head or neck is an independent risk factor for the development of thyroid malignancies. There is strong research evidence, including a recent meta-analysis, supporting the use of fine-needle aspiration biopsy in the evaluation of all pediatric and adolescent patients presenting with a thyroid nodule. The surgical management and postoperative care of pediatric and adolescent patients who have well-differentiated thyroid carcinomas remains controversial, because the rarity of the disease limits the ability to conduct randomized, prospective research studies. Numerous studies have demonstrated that, despite presenting with more advanced disease, pediatric and adolescent patients with thyroid carcinoma have a higher survival rate than adults. The American Thyroid Association has issued strong evidence-based recommendations for the management of medullary thyroid carcinoma, including RET mutation testing and early prophylactic total thyroidectomy in children with high-risk mutations.
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Affiliation(s)
- Jennifer N Osipoff
- Division of Pediatric Endocrinology, Department of Pediatrics, Stony Brook Children's Hospital, State University of New York, Stony Brook, NY, USA
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Gutnick J, Soldes O, Gupta M, Milas M. Circulating thyrotropin receptor messenger RNA for evaluation of thyroid nodules and surveillance of thyroid cancer in children. J Pediatr Surg 2012; 47:171-6. [PMID: 22244412 DOI: 10.1016/j.jpedsurg.2011.10.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2011] [Accepted: 10/08/2011] [Indexed: 01/23/2023]
Abstract
PURPOSE The aim of this study was to determine the role of thyrotropin receptor messenger RNA as a novel blood test for evaluation of thyroid nodules and cancer in children. METHODS We reviewed thyroid disease management of patients younger than 18 years with thyrotropin receptor messenger RNA measurements identified from a prospective, institutional review board-approved registry during 2008 to 2010. RESULTS Thirty-nine thyrotropin receptor messenger RNA measurements were made in 21 female patients (12-17 years old; median, 16 years). Four patients with fine-needle aspiration only had benign thyroid cytology, and 3 of 4 had undetectable thyrotropin receptor messenger RNA. Seventeen patients underwent 22 thyroid operations. Preoperative thyrotropin receptor messenger RNA was measured in 9 patients: 3 of 4 with thyroid cancer had elevated levels and 3 of 5 with goiters undetectable. Postthyroidectomy surveillance (median, 16 months; range, 6-24) of 11 thyroid cancer patients (8 papillary, 3 follicular) showed that thyrotropin receptor messenger RNA was concordant with thyroglobulin in 14 (73%) of 19 measurements. In 3 (16%) of 19 measurements, thyrotropin receptor messenger RNA was the only blood test useful for disease assessment because of elevated antithyroglobulin antibodies. Overall, to predict thyroid cancer, thyrotropin receptor messenger RNA demonstrated 73% sensitivity, 82% specificity, 62% positive predictive value, 88% negative predictive value, and 79% accuracy. CONCLUSION Thyrotropin receptor messenger RNA provides complementary evaluation to thyroglobulin and fine-needle aspiration for pediatric thyroid nodule management.
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Affiliation(s)
- Jesse Gutnick
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
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Wood JH, Partrick DA, Barham HP, Bensard DD, Travers SH, Bruny JL, McIntyre RC. Pediatric thyroidectomy: a collaborative surgical approach. J Pediatr Surg 2011; 46:823-8. [PMID: 21616234 DOI: 10.1016/j.jpedsurg.2011.02.013] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2011] [Accepted: 02/11/2011] [Indexed: 10/18/2022]
Abstract
INTRODUCTION We have developed a collaborative approach to pediatric thyroid surgery, with operations performed at a children's hospital by a pediatric surgeon and an endocrine surgeon. We hypothesize that this strategy minimizes specialist-specific limitations and optimizes care of children with surgical thyroid disease. METHODS Data from all partial and total thyroidectomies performed by the pediatric-endocrine surgery team at a tertiary children's hospital between 1995 and 2009 were collected and analyzed retrospectively. Statistical analyses were performed with IBM SPSS software (SPSS, Chicago, IL). RESULTS Thirty-five children met the inclusion criteria (69% female; median age, 13 years; median follow-up, 1119 days). The indications for operation were thyroid nodule (71%), genetic abnormality with predisposition to thyroid malignancy (17%), multinodular goiter (5.7%), Grave disease (2.9%), and Hashimoto thyroiditis (2.9%). Sixteen children (46%) underwent thyroid lobectomy, and 19 children (54%) underwent total thyroidectomy. Median length of stay was 1 day (1 day after lobectomy vs 2 days after total thyroidectomy, P < .0001). There were 4 cases of transient hypocalcemia after total thyroidectomy, but there were no nerve injuries or other in-hospital complications in either group (overall complication rate, 11%). CONCLUSIONS For pediatric thyroidectomy and thyroid lobectomy, collaboration of high-volume endocrine and pediatric surgeons as well as pediatric endocrinologists at a dedicated pediatric medical center provides optimal surgical outcomes.
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Affiliation(s)
- James H Wood
- Department of Surgery, University of Colorado Denver School of Medicine, Aurora, CO, USA
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Scholz S, Smith JR, Chaignaud B, Shamberger RC, Huang SA. Thyroid surgery at Children's Hospital Boston: a 35-year single-institution experience. J Pediatr Surg 2011; 46:437-42. [PMID: 21376189 DOI: 10.1016/j.jpedsurg.2010.09.009] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2010] [Revised: 09/04/2010] [Accepted: 09/10/2010] [Indexed: 02/02/2023]
Abstract
BACKGROUND/PURPOSE Thyroidectomy is the primary therapy for thyroid cancer and an established treatment of hyperthyroidism. Because of the relative rarity of these conditions in childhood, few single-institution series exist in the pediatric literature. Here we analyze our institution's experience to assess patient demographics, operative risks, and the role of preoperative testing. METHODS This is a retrospective chart review of 175 consecutive patients not older than 18 years who underwent thyroid surgery at Children's Hospital Boston from 1970 to 2004. RESULTS The most common indication for thyroidectomy was thyroid nodules (83%), followed by hyperthyroidism (7%) and goiter (7%). For children referred for nodules, we observed a peak incidence in adolescence and a female to male ratio of 3.7:1. Cancer was found in 36%, with papillary thyroid cancer the most common subtype (85%). Operative complications were rare, with permanent hypocalcemia in 2 (4.7%) of 43 patients who underwent bilateral resection for thyroid nodules (no cases of permanent hypocalcemia in other procedures). Permanent unilateral vocal cord paralysis was documented in 2 children after the resection of malignant nodules. CONCLUSIONS Pediatric thyroidectomy can be performed with low operative risk. Because permanent hypocalcemia remains an obligate risk of bilateral thyroidectomy, we recommend the routine use of preoperative fine-needle aspiration to guide the extent of initial surgical resection, reserving near-total thyroidectomy for those cases where cytology is positive for malignancy.
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Affiliation(s)
- Stefan Scholz
- Department of Surgery, Children's Hospital Boston, Boston, MA 02115, USA
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McFadden DW, Souba WW. The Journal of Surgical Research Editorial Board – 2011. J Surg Res 2011. [DOI: 10.1016/j.jss.2011.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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McFadden D, Souba WW. The Journal of Surgical Research Editorial Board–2010. J Surg Res 2010; 160:1-2. [DOI: 10.1016/j.jss.2010.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Raval MV, Bentrem DJ, Stewart AK, Ko CY, Reynolds M. Utilization of total thyroidectomy for differentiated thyroid cancer in children. Ann Surg Oncol 2010; 17:2545-53. [PMID: 20429037 DOI: 10.1245/s10434-010-1083-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2009] [Indexed: 01/23/2023]
Abstract
PURPOSE Recent recommendations suggest that total thyroidectomy (TT) is the surgical management of choice for differentiated thyroid cancer in children. The objective of this study is to assess trends in extent of surgical resection for differentiated thyroid cancer in children over the past two decades and to identify patient, tumor or hospital factors associated with use of TT. PATIENTS AND METHODS Of 8,013 patients (aged 0-21 years) with differentiated thyroid cancer from the National Cancer Data Base (1985-2007), 5,933 (74%) underwent TT. Trends in extent of surgery were examined. Logistic regression was used to identify factors that predict use of TT. RESULTS Use of TT increased from 50.6% in 1985 to 84% in 2007 (P < 0.001). Patients were more likely to undergo TT if they had higher household income or had private insurance (P = 0.002 and P = 0.037). Patients were more likely to undergo TT if they had larger tumors or if there were nodal metastases present at time of resection (both P < 0.001). After adjusting for patient and tumor factors, patients treated at high-volume or Children's Oncology Group hospitals were more likely to undergo TT than patients treated at low-volume or non-Children's Oncology Group hospitals (P < 0.001). CONCLUSIONS Overall utilization of TT in children with differentiated thyroid cancer has steadily increased over the past 23 years in the USA. Variations in use of TT are not only related to tumor factors including size and nodal involvement, but also are also related to socioeconomic and hospital factors, demonstrating disparities in care.
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Affiliation(s)
- Mehul V Raval
- Division of Research and Optimal Patient Care, Cancer Programs, American College of Surgeons, Chicago, IL, USA.
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