Solitary thyroid nodules in children and adolescents

A synchronous papillary and follicular thyroid carcinoma presenting as a large toxic nodule in a female adolescent

Case presentation

We report for the first time a synchronous papillary and follicular thyroid carcinoma in a 12-year-old girl presenting with a large (5 cm diameter) left thyroid nodule, an increased left and right upper pole technetium tracer uptake at scintigraphy and hyperthyroidism. The uptake at the right lobe was explained by the crossing of the left nodule to the right site of the neck at Computed Tomography (CT) scanning.

Background

Although thyroid nodules are less common in children than in adults, there is more vigilance required in children because of the higher risk of malignancy. According to literature, about 5% of the thyroid nodules in adults are malignant versus 20–26% in children. The characteristics of 9 other pediatric cases with a differentiated thyroid carcinoma presenting with a toxic nodule, which have been reported during the last 20 years, are summarized. A nodular size of more than 3.5 cm and female predominance was a common finding.

Conclusions

The presence of hyperthyroidism in association with a hyperfunctioning thyroid nodule does not rule out thyroid cancer and warrants careful evaluation, even in the absence of cervical lymph node invasion.

Nodular Thyroid Disease in Children and Adolescents

Thyroid nodules in children are extremely uncommon. Most thyroid nodules, both benign and malignant, present as asymptomatic neck masses. A thyroid nodule in a child is significant because of the risk of malignancy. A review of medical records at our institution demonstrated 71 patients 20 years of age and younger with surgically managed thyroid nodules, of which 45 were benign and 26 were malignant. Our diagnostic workup, including serum thyroid studies, radiologic evaluation, and fine-needle aspiration, is discussed. Because of the possibility of malignancy, we recommend that all solitary thyroid nodules be excised in children unless fine-needle aspiration definitively determines a benign histology. The extent and type of surgical management is controversial and is still subject to much debate. Partial thyroidectomy appears adequate for benign disease, but even though there is no statistical difference in survival, we recommend total thyroidectomy for the management of malignant disease.

Fine-needle aspiration in the evaluation of thyroid lesions in children

The role of fine-needle aspiration (FNA) cytology in the evaluation of thyroid lesions in not as well established in children when compared with adults. Hence we aimed to ascertain the utility and limitations of FNA in childhood thyroid lesions. This was a retrospective analysis of all thyroid FNA performed in children less than 14 years of age over a 4-year period (2005-2009). Histopathological follow-up was available in six cases. A total of 77 cases were included in the analysis. The most common cytological diagnosis was lymphocytic thyroiditis (49.3%), followed by colloid goiter (18.2%), hyperplasia (10.4%), and benign aspirate (7.8%); malignancy was identified in six cases (7.8%). Of these six cases, three were papillary thyroid carcinoma. There was one false-positive case reported as a Hurthle-cell neoplasm, which on histology showed Hashimoto's thyroiditis. One case each of rhabdomyosarcoma and spindle epithelial tumor with thymus like differentiation was wrongly diagnosed as thyroid neoplasm, NOS, and medullary carcinoma (spindle variant), respectively. The overall diagnostic accuracy was 98.6% with 100% sensitivity, 98.6% specificity, 80% positive predictive value, and 100% negative predictive value. FNA is extremely valuable in the initial evaluation of thyroid swelling in children. Rare neoplasms masquerading as thyroid nodules in children can pose difficulties in diagnosis; however, papillary carcinoma is easily recognized. In lymphocytic thyroiditis, it provides a tissue diagnosis, thereby avoiding more invasive procedure for merely diagnostic purposes.

Cytopathologic analysis of thyroid lesions in the pediatric population

Fine-needle aspiration (FNA) of the thyroid is seldom performed in the pediatric population. Therefore, the clinical utility of thyroid FNA in this patient group has not been adequately addressed. A 15 yr retrospective review of the cytopathology archives at the participating institutions was performed to identify cases of thyroid FNA performed in pediatric patients. The medical records of these cases were reviewed, including the surgical pathology reports of those patients who had subsequently undergone surgical resection. One hundred one specimens from 82 patients were identified. Of these, 40 had a cytopathologic diagnosis of carcinoma, "suspicious" for carcinoma, neoplasm, or atypia, 48 were benign, and 13 were unsatisfactory. Of the 82 patients, 45 underwent partial or total thyroidectomy. Twenty-two (49%) of these were found to harbor a malignant neoplasm (18 papillary carcinomas). The diagnostic sensitivity for identifying a lesion was 87% (26/30) and the diagnostic specificity was 92% (47/51). There were four false-positives and four false-negatives in the review, yielding a positive predictive value of 87% and a negative predictive value of 92%. We conclude that FNA is a useful adjunct to the management of thyroid lesions in the pediatric population, with good diagnostic accuracy. Although thyroid neoplasms are relatively rare in children, our experience demonstrated that 40% of thyroid masses referred for FNA had an interpretation that caused concern, ranging from "atypical" to carcinoma. Additionally, a benign diagnosis by FNA may avoid unnecessary surgery with its potential complications, a significant consideration for this age group.

A prospective study of thyroid nodular disease in children and adolescents in western Poland from 1996 to 2000 and the incidence of thyroid carcinoma relative to iodine deficiency and the Chernobyl disaster

BACKGROUND

In Poland, where soil is deficient in iodine, supplementation of iodine was introduced in 1935, discontinued in 1980, and then re-introduced in 1997. One of the effects of inadequate iodine intake, prior to 1997, was an increase in the prevalence of thyroid nodular disease (TND) in children. Chernobyl, located in the neighbouring country of Ukraine, suffered a catastrophic nuclear explosion in April 1986.

PROCEDURE

A total of 411 children with TND (an incidence of 7.53/100,000) were diagnosed and registered in western Poland between 1996 and 2000 and further evaluated as a population-based study.

RESULTS

Based on the patient's clinical status, ultrasound examination, scintiscan, laboratory tests, cytology and the family history, many of the patients qualified for surgery and, as a result, histopathologic data were obtained from 155 of the 411 patients operated on to date (37.7% of all TND). Thyroid carcinoma was detected in 37 of the operated children, i.e. 23.9% or 9.0% of all children with TND with a median incidence of 0.68/100,000. Papillary carcinoma was the predominant histologic type (26-70.3%) compared to follicular carcinoma (10-27.0%) and medullary carcinoma (1-2.7%). Retrospective analysis of the figures for the 23 years (1972-1995) showed that in that period a total of 23 thyroid carcinomas were registered. However, only 12 of these were detected in the 20-year period between 1972 and 1991, none in the years 1992-1993 and, significantly, 11 from 1994 to 1995.

CONCLUSIONS

Thyroid carcinoma appears to be an ongoing and increasing problem in the children and adolescents of our region, and it is developing more intensively when compared, both to other parts of Poland and to previous statistics (2000 vs. 1985; P<0.002). Iodine deficiency and radiation resulting from the Chernobyl disaster might be important risk factors in the development of thyroid carcinoma in the young population analysed in our region in the period since 1994. The high percentage of follicular carcinoma and follicular adenoma with an undetermined prognosis (19 out of 46) indicates that the long-term iodine deficiency in our region may be more significant in the pathogenesis of malignant transformation than has previously been postulated.

Hot nodules in children and adolescents in western Poland from 1996 to 2000: clinical analysis of 31 patients

In an iodine deficient area, a high incidence of hot thyroid nodules was observed in children after the introduction of iodine supplementation in 1997. Thirty-one children (28 girls, 3 boys) were identified with hot nodules between the years 1996-2000 (3 patients in 1996, 4 in 1997, 10 in 1998, 7 in 1999, and 7 in 2000). The incidence ratio of hot nodules in this study population increased significantly from 0.23 in 1996 to 0.80 in 1998. In 17 children, radionuclide uptake was confined exclusively to areas corresponding to the nodules. Cancer was detected in one child in post-operative histological examination. In the other 14 children, the predominant uptake was in nodules, but it was also registered within extranodular tissue. In the latter group, eight tumors were eventually diagnosed as cancer and six as benign tumors. The majority of tumors in the entire group was located in the right lobe (19/31) and was accompanied by reduced TSH levels (23/31), but only 14 of the 31 patients had signs of hyperthyroidism. The years 1996-2000, in which the increase in the incidence of "hot" nodules in children with nodular goiter was observed, correspond to a period of enforced salt iodinization. The existence of cancer within hot nodules is rare, ranging from 2-5% of all nodules. By contrast, the risk of cancer in hot nodules in the cohort of this study was significantly higher (9/31; 29.0%), especially in cases of hot nodules with a rudimentary radionuclide uptake in the extranodular area. We conclude that, in geographical regions affected with iodine deficiency, the therapeutic protocol for children with hot nodules should be based primarily on surgery rather than on radioiodine.

Pediatric hemorrhagic thyroid nodule: a case report

Hemorrhagic thyroid nodules are rare in the pediatric age group. They present as rapidly enlarging neck masses. Diagnostic modalities available are laboratory evaluation, ultrasound, radionuclide imaging, and fine needle aspiration. Depending on the pattern of growth of the lesion, one may observe or proceed with surgery. A rapidly enlarging thyroid mass raises the suspicion of malignancy, and hemorrhagic nodules, though rare, must be considered in the differential diagnosis.

Pediatric thyroid nodules: management in the era of fine needle aspiration

BACKGROUND/PURPOSE

Thyroid nodules are rare in children. The need to uncover malignancy is the most challenging dilemma in management. The aim of this report was to determine whether management of pediatric thyroid nodules has changed in the era of fine-needle aspiration (FNA) cytology.

METHODS

Twenty-four children with thyroid nodules comprised the study group. Demographic characteristics, clinical manifestations, imaging results, FNA cytology results, surgical therapy, complications, and pathological reports were reviewed retrospectively. FNA cytology results were categorized as either benign, malignant, suspicious, or insufficient.

RESULTS

Girls outnumbered boys (five to one) with a mean age of 14.9 years. Nineteen nodules were benign and five malignant. Malignancy was characterized by localized tenderness, multiglandular appearance, and fixation to adjacent tissues. Ultrasound scans and nuclear scans gave no clue toward management because cystic, hot, and warm nodules figured among malignant cases. FNA in 18 children achieved 80% accuracy, 60% sensitivity, 90% specificity, 75% positive, and 81% negative predictive value. Physical examination findings, persistence of the nodule, and progressive growth decided for surgery in most children.

CONCLUSIONS

FNA is a safe adjunctive test that plays a minor role in the decision to withhold surgery. Its greatest strength is to resolve, in case of suspicious or malignant cytology, that a more radical procedure will be needed. Clinical judgement as determined by serial physical findings continues to be the most important factor in the management of thyroid nodules in children.

Cold nodule thyroid - A 5 year retrospective study

FNAC and histopathological reports of 50 patients with cold nodule thyroid who underwent surgery during the last 5 years were analysed. FNAC showed malignancy in 12% of cases whereas histopathological examination in 16% of cases. In this study an attempt has been made to find out the role of frozen section in cold nodule thyroid.

Metastatic pure papillary thyroid carcinoma presenting as a toxic hot nodule

In the majority of cases, carcinoma of the thyroid presents as a cold nodule by radioiodine and Tc-99m sodium pertechnetate scintigraphy. Whereas the presence of a hot nodule usually implies a benign entity, it does not provide complete assurance against thyroid malignancy. Presented is a rare case of metastatic pure papillary thyroid carcinoma appearing as a hot nodule on Tc-99m sodium pertechnetate and I-123 sodium iodide scintigraphy. The implications of such a case, its management, and review of the pertinent literature are discussed.

The epidemiology of thyroid disease and implications for screening

The burden of thyroid disease in the general population is enormous. As many as 50% of people in the community have microscopic nodules, 3.5% have occult papillary carcinoma, 15% have palpable goiters, 10% demonstrate an abnormal thyroid-stimulating hormone level, and 5% of women have overt hypothyroidism or hyperthyroidism. Despite this high prevalence of thyroid disease, screening for these disorders is not recommended by any major health agency. This article explores the epidemiologic issues surrounding this complex problem by analyzing prevalence, incidence, and mortality data from a worldwide variety of sources.

Thyroid cancer in children, pregnant women, and patients with Graves' disease

Differentiated thyroid cancer may have a different clinical course when it develops in children, pregnant women, and patients with Graves' disease. Thyroid nodules which develop in these patients appear to have a greater risk of malignancy and should be evaluated aggressively. Treatment in all cases includes operation followed by radioactive iodine ablation (in the nonpregnant patient) and thyroid hormone suppression. Follow-up, including serum Tg and yearly thyroid scans, should be continued as long as possible.

Fine-Needle Aspiration Biopsy: Use in Diagnosis and Management of Pediatric Thyroid Diseases

Fine-needle aspiration (FNA) biopsy of the thyroid is a reliable, safe, cost-effective, and widely used test. Its introduction and application have had a significant impact in the management of nodular thyroid diseases in adults. However, its utility in pediatric practice is not recognized or emphasized. During the last 12 years we performed 10,971 FNAs; 57 (0.5%) were in patients younger than age 17 years. Among 47 of these biopsies, 66% were benign, 15% were malignant, 6% were suspicious for malignancy and 13% were nondiagnostic. Biopsy was most often (96%) performed for the evaluation of diffuse or nodular goiter. The most common benign cytologic diagnosis was colloid goiter in 17 of 31 patients (55%) and Hashimoto's thyroiditis in 9 of 31 patients (29%). There were no false-positive results and there was one false-negative cytologic result. Among patients who had malignancy proved histologically, nine patients (75%) had papillary thyroid cancer. In this study, FNA biopsy was crucial in deferring surgery in 28 of 47 patients (60%). It is clear that the application of FNA biopsy prevents unnecessary surgery and improves surgical selection of patients with thyroid malignancy. On the basis of our extensive experience, we recommend FNA biopsy as the first diagnostic test for pediatric patients with nodular thyroid lesions.

Hürthle cell carcinoma in an autonomous thyroid nodule in an adolescent

A 16-year-old girl presented with a palpable thyroid nodule which was found to be functioning autonomously by radioiodine (123I) scintigraphy. After needle biopsy proved non-diagnostic, surgical excision showed the nodule to be Hürthle cell carcinoma. Functional thyroid nodules are rarely malignant, thyroid carcinoma is rare in childhood, and Hürthle cell carcinoma is a rare thyroid neoplasm, so the presence of these three rare conditions in one patient makes it a very unusual case.

Sonography in thyroid carcinoma in children

This paper reviews the clinical, sonographic and pathological findings of 20 children with thyroid carcinoma in an attempt to determine the value and limitations of sonography in thyroid neoplasms in this age group. Although sonography is an excellent technique for the evaluation of thyroid disorders and masses, certain limitations must be kept in mind. Microscopic foci of tumour might be missed and sonography cannot predictably differentiate benign from malignant disease. Previous radiation exposure should increase the level of suspicion for malignancy.

Solitary thyroid nodules in 71 children and adolescents

Seventy-one children and adolescents with a solitary nodule of the thyroid gland were seen over a 27-year period and all had their nodules removed surgically. All of the patients had preoperative thyroid scintiscans, 55 of which showed a cold nodule. The most common cause of solitary thyroid nodules was follicular adenoma. Fourteen of the 55 cold nodules were malignant (25.5%) while no malignancies were present in warm or hot nodules. Available diagnostic methods for attempting differentiation of benign from malignant solitary nodules are reviewed and recommendations to their clinical management as derived from our experience are presented.

Nodular thyroid disease and thyroid carcinoma

The primary challenge in the management of a solitary nodule of the thyroid or a multinodular thyroid gland is to rule out a malignancy.

Iodine-123 scintigraphy in the evaluation of pediatric thyroid disorders: a ten year experience

Few studies have been published that describe the role of scintigraphy in the evaluation of the spectrum of pediatric thyroid disorders. Between 1978 and 1987, we studied 280 children with iodine-123 (123I) scintigraphy. Clinical information and follow-up were available in 246. We analyzed the indications for referral and determined whether the information obtained with this technique was useful in subsequent management. Indications for scintigraphy included hypothyroidism, neck masses, hyperthyroidism, and miscellaneous reasons. Scintigraphy was helpful in distinguishing anatomic from functional causes of hypothyroidism. It reliably identified the location of the thyroid gland in patients with neck masses. The functional status of thyroid nodules was readily assessed and was important in directing further treatment. Scintigraphy added little to the management of children with post-irradiation hypothyroidism without a palpable nodule, patients with Hashimoto thyroiditis or Graves disease when the clinical diagnosis was straightforward.

Diagnostic dilemma. The goiter

The incidence of goiters in children is about 4% to 5%. The first step in the evaluation is to decide whether the swelling indeed involves the thyroid. After careful examination, one determines if the thyroid is diffusely or focally enlarged. A solitary nodule merits an extensive workup because of the high rate of malignancy. The evaluation of a diffuse goiter proceeds after deciding if the patient is euthyroid, hypothyroid, or hyperthyroid. In most cases, the child is euthyroid and the diagnosis is either CLT or simple colloid goiter. Laboratory tests for thyroid function and antibodies usually make the diagnosis. The hypothyroid patient most likely has CLT, although drugs or goitrogens, dyshormonogenesis, and thyroid resistance are also possible. The hyperthyroid patient usually has Graves' disease. The incidence of malignancy of solitary thyroid nodules is 15% to 40%; therefore, evaluation must be sensitive enough not to miss cancer. Ultrasonography helps to delineate the anatomy and to reveal if the nodule is cystic. Radionuclide scans are useful, as warm or hot lesions are rarely malignant. Cold nodules require further investigation, and in most institutions, this amounts to open biopsy. Fine-needle aspiration may be used if the clinician and pathologist are experienced. With this aggressive approach to thyroid nodules, malignancies are given early treatment. The prognosis is good in most thyroid carcinomas.

Imaging paediatric endocrine disorders

Disorders of growth and development, including delayed and precocious puberty may be idiopathic, constitutional or due to a disorder of one of several endocrine systems including the hypothalamic-pituitary system, the adrenal and the thyroid. Sonography is of great importance in the classification of precocious puberty in children. Skeletal maturation assessment is useful to evaluate the severity of the growth disorder and to monitor subsequent therapy. Magnetic resonance imaging and computed tomography are essential in the study of the pituitary and central nervous system. MRI has special advantages in the imaging of the hypothalamic-pituitary region. The thyroid gland and its function are still best imaged with radionuclide scintigraphy. Sonography can play a complementary though less important role. Hypoparathyroidism, pseudohypoparathyroidism and pseudopseudohypoparathyroidism although rare are more common in children than primary hyperparathyroidism. Valuable clues as to the presence of these conditions can be gained by examination of the plain radiographs. Confirmation of their diagnosis still rests with the biochemical and endocrine profile.

Management of thyroid nodules

This review describes the frequency of solitary thyroid nodules and their relationship to thyroid cancer. The importance of selecting patients appropriately for surgical excision is stressed. The factors predisposing to nodule formation and to a nodule being malignant are reviewed with emphasis that prior radiation exposure does not appear to increase the likelihood that a given nodule harbors a malignancy. In considering the laboratory evaluation of thyroid nodules, the limitations of isotope scans and ultrasonography are noted. Fine needle aspiration biopsy is described as revolutionizing the management of thyroid nodules and decreasing unnecessary operations. In the context of the natural history of differentiated thyroid cancer, the application of a decision analysis model to management options is described in some detail, and a cost-effective management regimen is recommended with fine needle aspiration biopsy as the initial procedure.

Solitary thyroid nodule: diagnosis and management

Thyroid nodules are common. Most are benign lesions since clinically important thyroid carcinoma is a relatively rare disease. The most sensitive and specific test for the diagnosis of thyroid cancer is fine-needle aspiration biopsy, but its diagnostic accuracy depends upon whether or not one excises all suspicious nodules, thus including them as correctly diagnosed. Nevertheless, fine-needle aspiration biopsy is the most sensitive, specific, and cost-effective test for thyroid cancer. Therapy depends upon the cause of the thyroid nodule.

Management of thyroid nodules in children: a 20-year experience

The medical records and surgical slides of 58 patients with the diagnosis of thyroid nodules (solitary nodule in 50 patients) are reviewed. The most common cause of thyroid nodules in this series is follicular adenoma (27 patients or 46%). A nuclear scan (technetium or radioactive iodine) was performed in 55 patients, of which 40 showed a cold nodule. Twelve of the 40 cold nodules were malignant (30%). However, for solitary nodules the incidence of cancer is 27%. This last figure is significantly greater than the one recently reported by Hung et al (18.5%). Available diagnostic methods are reviewed and the clinical management as derived from our experience is presented.

Differential diagnosis of goiter

Goiters can be detected in about 5 per cent of school-aged children. Goiters appearing during childhood are the result of distinct diseases and should be investigated rather than attributed to "physiologic hyperplasia." The etiology of the diffuse goiter can often be established by clinical evaluation, performing thyroid function tests, and measurement of serum thyroid antibodies. Unlike diffuse goiters, thyroid nodules frequently require tissue examination to exclude malignancy. The goal in evaluating children with nodular goiters is to be as selective as possible in submitting children to surgery without missing cases of cancer. The decision to perform an open biopsy should be based on detecting increased risk for cancer in the medical history, physical examination, or laboratory tests as outlined in Figure 1. Ultrasonography and fine-needle aspiration of nodules are two new methods that aid in the selection of patients for surgery or a trial of thyroid hormone suppression.

Thyroid nodules in children

Thyroid nodules are infrequently encountered in children. During the era of low-dose therapeutic irradiation, the incidence of malignancy in these lesions was 40% to 70%. Recent studies suggest that this incidence is declining, resulting in a concomitant relative increase in the proportion of benign nodular conditions. There is also a heightened awareness that secondary thyroid neoplasms may occur in children surviving primary malignant diseases. Records of 38 children treated surgically at Texas Children's Hospital between 1972 and 1984 have been reviewed to determine the incidence of benign vs. malignant pathosis and to study the role of prior irradiation or chemotherapy in the pathogenesis of thyroid disease. Benign conditions were diagnosed in 27 children (71%), with diffuse hyperplasia (10 children, 26%) and follicular adenoma (8 children, 21%) occurring most frequently. Thyroid carcinoma was diagnosed in the remaining 11 children (29%). All of these patients were euthyroid at presentation, none had received multimodal therapy for a prior malignant condition, and only one had a history of head and neck irradiation in infancy for a treatment of a benign condition (a congenital hemangioma). The clinical presentation, diagnostic evaluation, and surgical management of these patients are reviewed and closely parallel those of patients in other recently published series. No conclusions can be drawn regarding the development of thyroid neoplasia following multimodal therapy for primary disease; however, this incidence must be very low.

Endocrine disorders in children

The childhood endocrine disorders in which surgical intervention is a common or indispensable part of management are succinctly reviewed. Pathophysiology and rational approaches to diagnosis are emphasized.

Pediatric endocrine surgery

The pediatric surgeon is in a unique position to understand endocrine surgery and, therefore, is expected to develop considerable expertise in this area. In recent years numerous advances and changes have occurred in pediatric endocrine surgery that have led to greater understanding of the disease processes and syndromes and the development of new diagnostic techniques and surgical approaches.

Differentiated thyroid cancer in children

Differentiated thyroid cancer in children remains a controversial disease entity. Its incidence has markedly declined over the last decade since the use of radiotherapy in the treatment of benign conditions of the head, neck, and thorax was abandoned. Other etiologic factors have become relatively more important. The clinical presentation of childhood thyroid cancer is similar to that found in adults, except for a higher frequency of local and distant metastases at the time of initial diagnosis. The specificity and sensitivity of diagnostic tests are limited; however, like in adults, fine-needle aspiration compares favorably with other available diagnostic methods. The therapeutic approach to a child with thyroid cancer represents the most controversial issue associated with the disease. This review provides a discussion of the rationale for the different therapeutic options and emphasizes the excellent prognosis and survival rates, especially when patients are subjected to aggressive treatment with total thyroidectomy followed by the administration of radioactive iodine.

Use of ultrasound in childhood thyroid disorders

Thyroid ultrasound findings in 55 patients aged 6 days to 19 years were reviewed to assess the importance of this technique in evaluating childhood thyroid disorders. Findings were correlated with the available clinical, radionuclide, and pathologic data. In 25 patients with diffuse thyroid lesions (thyroiditis, Graves disease, euthyroid goiter, iodine-induced goiter, goitrous cretinism), ultrasound revealed only homogeneous thyroid enlargement or a nonspecific patchy echo pattern. In two infants with poorly visualized glands on radionuclide scans, ultrasound confirmed the presence of anatomically normal thyroid tissue. Twenty patients had at least one focal thyroid lesion seen by ultrasound, including nodules not detected by palpation in one child or by technetium scan in three. Thyroid malignancies were found in four of 13 patients with solitary thyroid nodules, occurring in two of four patients with echogenic nodules, two of five children with complex lesions, and none of four with echofree nodules. Thyroid ultrasound is a sensitive, noninvasive means of evaluating thyroid anatomy. Because it can detect thyroid tissue in the neck not seen on radionuclide scan in patients at all ages and can define the number and consistency of focal lesions, this technique offers definite advantages in assessing a variety of childhood thyroid disorders.