Pediatric endocrine surgery

Papillary Thyroid Carcinoma in Children: Clinicopathological Profile and Outcomes of Management

BACKGROUND

We aim to analyze the clinicopathological profile and outcomes of management for children with papillary thyroid carcinoma (PTC).

METHODS

Relevant clinical data of children ≤ 18 years of age managed for PTC between January 2006 and July 2018 as well as details of their follow-up till December 2019 were retrospectively collected and analyzed.

RESULTS

There were 82 children with PTC that were managed during the study period. At presentation, 39 (47.6%) had cervical lymphadenopathy, while 9 (11%) had systemic metastasis. Majority of patients 39 (47.6%) underwent total thyroidectomy with a selective neck dissection, while total thyroidectomy alone was performed in 26 (31.7%). Following surgery, hypocalcemia was seen in 39 (47.6%): 28 (34.1%) were temporary, while 11 (13.4%) were permanent. Twenty-eight (34%) developed persistent disease after surgery and ¹³¹I therapy. Significant risk factors for persistence and metastatic disease were metastatic cervical lymph node at presentation (p = 0.002) and tumor size (p = 0.014), respectively. The mean duration of follow-up was 60.3 (range 12-150) months with a mean overall disease-free survival of 60 months (95% CI 57.11, 77.95).

CONCLUSION

Children with papillary thyroid cancers present with aggressive disease, 47.6% with cervical nodal metastasis and 11% with distant metastasis in this cohort. The rate of post-thyroidectomy hypocalcemia in this study is substantial, and efforts to reduce it are actively being pursued. The presence of metastatic cervical lymph node at presentation (p = 0.002) and tumor size (p = 0.014) were the only significant risk factors for persistent and metastatic disease, respectively, in this study.

Frequency of Thyroid Carcinoma in a Recent Series of 539 Consecutive Thyroidectomies for Multinodular Goiter

Aims and background

The aim of the study was to analyze the frequency of thyroid carcinoma in a consecutive series of 539 thyroidectomies for multinodular goiter (MNG) and to assess the influence of sex and age as cancer risk factors.

Methods

In a 2-year period, 539 patients underwent subtotal or total thyroidectomy for MNG at the Institute of General Surgery, University of Padova, Padova, Italy: 455 were females and 84 males (F/M = 5.5/1); mean age was 46 years (min. 17, max 78). Only 17 patients (3.1%) (16 females and 1 male) were aged 21 years or less.

Results

A malignancy was found in 41 patients: 38 females and 3 males; 39 older and 2 younger than 21 years. The frequency of cancer in MNG was 7.6%: 8.3% in females and 3.6% in males; 7.5% in patients older than 21 and 11.7% under 21 years.

Conclusions

The combination of MNG and carcinoma should always be carefully considered but not overemphasized, and the policy of surgically treating all patients with MNG is not justified. Sex and age cannot be considered as factors of a higher risk of cancer.

Evaluation and management of the pediatric thyroid nodule

Thyroid nodules are commonly diagnosed in adults. Although rare in children, the risk for thyroid cancer is much higher in the pediatric population compared with adults. Presenting as either a solitary nodule or a multinodular goiter, thyroid nodular disease in children requires a thorough workup that includes a detailed clinical examination comprised of prior history of thyroid disease in the patient or in their family, history of radiation exposure, careful palpation of the thyroid and lymph nodes, blood tests, ultrasonography, and cytological assessment. Thyroid surgery is the gold-standard treatment for pediatric thyroid nodules; nonetheless, the extent of surgery remains controversial. Because surgery is not without risk, the decision matrix necessitates focus on the benefits of surgery for the child contingent upon all the preoperative exams. New diagnostic technology such as molecular testing with fine needle aspiration biopsy may help distinguish between benign and malignant lesions while potentially decreasing surgery for benign disease. The objective of this review is to summarize new concepts in clinical disease management of nodular thyroid disease in the pediatric population, including patient history, medical examination, and diagnosis workup.

Efficacy and Pitfalls of FNAC of Thyroid Lesions in Children and Adolescents

BACKGROUND AND OBJECTIVES

Fine-needle aspiration has proven safe and efficacious in the evaluation of nodular diseases in the adults. It has been used extensively to select patients for surgical exploration with a high degree of reliability. The purpose of this study was to assess the extent of its applicability in thyroid lesions in children and adolescents, as well as to determine distribution of thyroid lesions in pediatric and adolescent patients in whom the prevalence of thyroid nodules and probability of malignancy are different.

METHODOLOGY

This is a four-year study undertaken between January 2009 and December 2012, during which, 284 fine-needle aspiration cytology were performed for palpable thyroid lesions in children and adolescents and analysed. Out of these 11, 52, 82 and 116 aspirates belonged to the age group between 7-<12 years, 12 -<16 years, 16 -<19 years, 19-21 years respectively. There were 261 (91.9%) satisfactory aspirates and 23 unsatisfactory aspirates (8.1%). These 261 satisfactory aspirates with adequate cellular material were taken up for interpretation and analysed. Thirty one patients underwent thyroidectomy. There were 4 true positives, 24 true negatives, 2 false positives and one false negative case in this study. Sensitivity, Specificity, Accuracy, Positive predictive value and Negative predictive value were calculated.

RESULTS

Benign cytology was reported in 89 cases (34.2%) where 11 cases (4.2%) were males. Thyroiditis was observed in 154 cases (59%) and 8 cases (3.1%) were males. Suspicious cytology was reported in 12 cases and comprised of 2 cases with a suspicion of Papillary Carcinoma and 10 cases (3.8%), with a suspicion of a Follicular lesion. Papillary Carcinoma was detected on 6 cases where all were females. The Sensitivity was 96%, Specificity was 66% and the Accuracy was 90%, Positive predictive value was 66%, Negative predictive value was 96%.

CONCLUSION

Fine-needle aspiration cytology of palpable thyroid lesions in children and adolescents is a good screening test because of its high sensitivity. Majority of the nodules in this age-group are benign and fine-needle aspiration cytology helps prevent unnecessary surgery.

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.

Thyroid cancer in children

In 1996, the authors were asked to review the subject of thyroid cancer in children. Over the subsequent decade, much has been learned about the treatment and outcome of these uncommon tumors. We now recognize quantitative and perhaps qualitative differences in genetic mutations and growth factor expression patterns in childhood thyroid cancers compared with those of adults. We also know that thyroid cancers induce a robust immune response in children that might contribute to their longevity. Patients under 10 years of age probably represent a unique subset of children at particularly high risk for persistent or recurrent disease; the management of these patients is under evaluation. We remain limited in our knowledge of how to stratify children into low- and high-risk categories for appropriate long-term follow-up and in our knowledge of how to treat children who have detectable serum thyroglobulin but negative imaging studies. In this article, the authors update our understanding of thyroid cancers in children with special emphasis on how these data relate to the current guidelines for management of thyroid cancer developed by the American Thyroid Association Taskforce. The limited data regarding management of children who have detectable serum thyroglobulin but negative whole-body scans are also reviewed.

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.

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.

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.

Recurrent adrenocortical carcinoma in a 4 year old girl

Adrenocortical tumours are rare in the paediatric age group. This is a report of a 4 year old girl with recurrent adrenocortical carcinoma emphasizing the role of surgery as the definitive form of therapy even in recurrent cases.

Phaeochromocytoma and functioning paraganglioma in childhood and adolescence: role of iodine 131 metaiodobenzylguanidine

Phaeochromocytomas and functioning paragangliomas are rare tumours in childhood and adolescence. We review our experience of 43 cases (24 men, 19 women) who were first diagnosed at the age of less than or equal to 18 years. All patients were evaluated at some point in their illness with iodine 131 metaiodobenzylguanidine (131I-mIBG) scintigraphy. Eight patients (19%) had bilateral adrenal tumours, 12 (28%) had solitary extra-adrenal tumours, and 8 (19%) had multiple tumours. In 10 patients (23%), the tumours were associated with a familial neurocristopathic syndrome. Thirteen of 24 (54%) unifocal tumours which were initially considered to be benign ultimately proved to be multi-focal and/or malignant. The final prevalence of malignancy was 60%--26 patients, of whom only 15 (57%) had obviously malignant tumours at the time of diagnosis. Primary tumour size greater than or equal to 5 cm was more commonly associated with a malignant course in adrenal but not extra-adrenal tumours. No other clinical, biochemical or morphological characteristic was significantly associated with malignancy. Although the high prevalence of malignancy in this series at least partly reflects referral bias, the need for lifelong follow-up of these patients is underscored. 131I-mIBG scintigraphy was positive in 36 patients (84%), with a somewhat lower false-negative rate (12%) than X-ray computed tomography (20%). Eight patients with malignant tumours received therapeutic doses of 131I-mIBG, with partial tumour responses in 3. Thus, 131I-mIBG is an efficacious, non-invasive, localising agent and may be considered as a palliative therapeutic agent when alternatives have failed.

Adrenocortical tumors in childhood: a report of four cases

In the last 10 years, four children with adrenocortical tumors were treated in our hospital. Three of them had symptoms of adrenogenital virilizing syndrome, and another, nonfunctional, was found during a routine examination. A diagnosis of adrenocortical tumor was established given the symptoms, hormonal tests, and radiologic studies. Two of the tumors were located in the left side, and the histologic diagnosis was pleomorphic cortical adenoma; the ones that affected the right side were adenocarcinomas. All the patients were treated by surgery and none received chemotherapy. At both presurgical and postsurgical stages, the patients were treated with cortisol. All four children have had a favorable course, with normal growth and the disappearance of public hair and hirsutism; however, macrogenitals still persist.

Endocrine disorders of the pancreas and adrenal cortex in pediatric patients

Hyperinsulinemia, a common cause of persistent hypoglycemia in infants and children, can result in permanent damage to the central nervous system. Thus, early diagnosis and treatment are important. The typical clinical manifestation of hyperinsulinemic hypoglycemia is symptomatic hypoglycemia that responds poorly to medical therapy. Affected infants may have tremors, jitteriness, apnea, cyanosis, or seizures. If initial medical therapy (frequent feedings, large amounts of intravenously administered glucose, diazoxide, and glucocorticoids) fails to stabilize plasma glucose levels, subtotal pancreatectomy is indicated. This surgical intervention does not completely correct the hypoglycemia in all patients, but it effectively reduces the severity of the condition. Surgical treatment of pediatric patients with Cushing's syndrome or aldosteronoma has also been effective. In our experience, survival of patients with adrenocortical adenomas has been 100%, whereas only five of nine children with adrenocortical carcinomas survived, and four of the five were younger than 10 years of age.