Pediatric Thyroid Carcinoma in Patients with Graves' Disease: The Role of Ultrasound in Selecting Patients for Definitive Therapy

Association of autoimmune thyroid disease with type 1 diabetes mellitus and its ultrasonic diagnosis and management

As a common hyperglycemic disease, type 1 diabetes mellitus (T1DM) is a complicated disorder that requires a lifelong insulin supply due to the immune-mediated destruction of pancreatic β cells. Although it is an organ-specific autoimmune disorder, T1DM is often associated with multiple other autoimmune disorders. The most prevalent concomitant autoimmune disorder occurring in T1DM is autoimmune thyroid disease (AITD), which mainly exhibits two extremes of phenotypes: hyperthyroidism [Graves' disease (GD)] and hypo-thyroidism [Hashimoto's thyroiditis, (HT)]. However, the presence of comorbid AITD may negatively affect metabolic management in T1DM patients and thereby may increase the risk for potential diabetes-related complications. Thus, routine screening of thyroid function has been recommended when T1DM is diagnosed. Here, first, we summarize current knowledge regarding the etiology and pathogenesis mechanisms of both diseases. Subsequently, an updated review of the association between T1DM and AITD is offered. Finally, we provide a relatively detailed review focusing on the application of thyroid ultrasonography in diagnosing and managing HT and GD, suggesting its critical role in the timely and accurate diagnosis of AITD in T1DM.

2022 European Thyroid Association Guidelines for the management of pediatric thyroid nodules and differentiated thyroid carcinoma

At present, no European recommendations for the management of pediatric thyroid nodules and differentiated thyroid carcinoma (DTC) exist. Differences in clinical, molecular, and pathological characteristics between pediatric and adult DTC emphasize the need for specific recommendations for the pediatric population. An expert panel was instituted by the executive committee of the European Thyroid Association including an international community of experts from a variety of disciplines including pediatric and adult endocrinology, pathology, endocrine surgery, nuclear medicine, clinical genetics, and oncology. The 2015 American Thyroid Association Pediatric Guideline was used as framework for the present guideline. Areas of discordance were identified, and clinical questions were formulated. The expert panel members discussed the evidence and formulated recommendations based on the latest evidence and expert opinion. Children with a thyroid nodule or DTC require expert care in an experienced center. The present guideline provides guidance for healthcare professionals to make well-considered decisions together with patients and parents regarding diagnosis, treatment, and follow-up of pediatric thyroid nodules and DTC.

Hyperthyroidism in adolescents

The term 'hyperthyroidism' refers to a form of thyrotoxicosis due to inappropriate high synthesis and secretion of thyroid hormone(s) by the thyroid. The leading cause of hyperthyroidism in adolescents is Graves' disease (GD); however, one should also consider other potential causes, such as toxic nodular goitre (single or multinodular), and other rare disorders leading to excessive production and release of thyroid hormones. The term 'thyrotoxicosis' refers to a clinical state resulting from inappropriate high thyroid hormone action in tissues, generally due to inappropriate high tissue thyroid hormone levels. Thyrotoxicosis is a condition with multiple aetiologies, manifestations, and potential modes of therapy. By definition, the extrathyroidal sources of excessive amounts of thyroid hormones, such as iatrogenic thyrotoxicosis, factitious ingestion of thyroid hormone, or struma ovarii, do not include hyperthyroidism. The aetiology of hyperthyroidism/and thyrotoxicosis should be determined. Although the diagnosis is apparent based on the clinical presentation and initial biochemical evaluation, additional diagnostic testing is indicated. This testing should include: (1) measurement of thyroid-stimulating hormone receptor (TSHR) antibodies (TRAb); (2) analysis of thyroidal echogenicity and blood flow on ultrasonography; or (3) determination of radioactive iodine uptake (RAIU). A 123I or 99mTc pertechnetate scan is recommended when the clinical presentation suggests toxic nodular goitre. A question arises regarding whether diagnostic workup and treatment (antithyroid drugs, radioiodine, surgery, and others) should be the same in children and adolescents as in adults, as well as whether there are the same goals of treatment in adolescents as in adults, in female patients vs in male patients, and in reproductive or in postreproductive age. In this aspect, different treatment modalities might be preferred to achieve euthyroidism and to avoid potential risks from the treatment. The vast majority of patients with thyroid disorders require life-long treatment; therefore, the collaboration of different specialists is warranted to achieve these goals and improve patients' quality of life.

Management of Pediatric Graves Disease: A Review

Importance

The incidence of Graves disease (GD) is rising in children, and adequate care of these patients requires a multidisciplinary approach. Whether patients are seen in the context of endocrinology, nuclear medicine, or surgery, it is important to know the nuances of the therapeutic options in children.

Observations

Given the rarity of GD in children, it is important to recognize its various clinical presenting signs and symptoms, as well as the tests that may be important for diagnosis. The diagnosis is typically suspected clinically and then confirmed biochemically. Imaging tests, including thyroid ultrasonography and/or nuclear scintigraphy, may also be used as indicated during care. It is important to understand the indications for and interpretation of laboratory and imaging tools so that a diagnosis is made efficiently and unnecessary tests are not ordered. Clinicians should be well-versed in treatment options to appropriately counsel families. There are specific scenarios in which medical therapy, radioactive iodine therapy, or surgery should be offered.

Conclusions and Relevance

The diagnosis and treatment of pediatric patients with GD requires a multidisciplinary approach, involving pediatric specialists in the fields of endocrinology, ophthalmology, radiology, nuclear medicine, and surgery/otolaryngology. Antithyroid drugs are typically the first-line treatment, but sustained remission rates with medical management are low in the pediatric population. Consequently, definitive treatment is often necessary, either with radioactive iodine or with surgery, ideally performed by experienced, high-volume pediatric experts. Specific clinical characteristics, such as patients younger than 5 years or the presence of a thyroid nodule, may make surgery the optimal treatment for certain patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TYPE OF STUDY

Summary review.

LEVEL OF EVIDENCE

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

Clinical features may help to identify children and adolescents with greatest risk for thyroid nodules

BACKGROUND

Thyroid nodules (TN) are detected in a small number of asymptomatic children and adolescents but are more frequently malignant (22-26%) than in adults leading some clinicians to perform thyroid ultrasound (US) for all children with goiter or autoimmune thyroiditis (AIT). Our study was designed to determine if suspicious clinical features predict the presence of TN in children with goiter or AIT so that US could be performed on those at highest risk.

METHODS

This was a retrospective review of 223 children and adolescents with goiter or AIT evaluated at a single institution. US was not performed on all patients. It is our practice to define glands that are large, firm, or nodular to palpation as "suspicious". Suspicious glands were interrogated by US and if TN was confirmed, this was further evaluated by fine-needle aspiration followed by surgery if indicated.

RESULTS

The median age was 12.9 years with 74.4% female. TN were confirmed by US in 16.6% of all patients but only 4.8% of those with AIT. By univariate analysis, TN were more common in those with family history of TN or differentiated thyroid carcinoma (DTC), thyroid asymmetry, and lower thyrotropin (TSH) levels. Differentiated thyroid carcinoma (DTC) was identified in 10.8% of TN and 1.8% of all patients. Firmness was significantly more common in patients with DTC (p = 0.0013).

CONCLUSION

TN were less common in those with AIT than reported in previous studies, suggesting that clinical features might fail to identify the majority of TN in patients with AIT. However, patients with asymmetric thyroid and a family history of TN or DTC have greatest risk for TN.

Thyroid nodules in children and adolescents

PURPOSE OF REVIEW

Compared with adults, there is a two-fold to three-fold increased risk of malignancy for a pediatric patient undergoing evaluation of a thyroid nodule. In 2015, the American Thyroid Association published guidelines on the evaluation and management of pediatric patients with thyroid nodules and differentiated thyroid cancer. The goal of this clinical update is to review recent additions to the literature and propose opportunities how to best incorporate these findings into clinical practice.

RECENT FINDINGS

Recent additions to the literature include assessment of ultrasound-based scoring systems to improve selection of patients for fine needle aspiration, defining the pediatric-specific risk of malignancy within The Bethesda System for Reporting Thyroid Cytopathology, and broadening our knowledge of the oncogene landscape that supports incorporation of adjunct oncogene testing to rule-in malignancy of nodules with indeterminate cytology.

SUMMARY

There have been significant additions to the literature on the evaluation and management of children and adolescents with thyroid nodules since publication of the 2015 American Thyroid Association guidelines. Incorporating these changes into clinical care, within the setting of multidisciplinary, pediatric-specific, regional centers, will maximize ongoing efforts to improve the care of children and adolescents with thyroid nodules.

Surgical management of pediatric thyroid disease: Complication rates after thyroidectomy at the Children's Hospital of Philadelphia high-volume Pediatric Thyroid Center

BACKGROUND

Recent studies suggest improved outcomes for children undergoing thyroidectomy at high-volume pediatric surgery centers. We present outcomes after thyroid surgery at a single center and advocate for referral to high-volume centers for multidisciplinary management of these children.

METHODS

Medical records were reviewed for all pediatric patients undergoing thyroid surgery at a single institution from 2009 through 2017. Routine recurrent laryngeal nerve and parathyroid hormone monitoring was used. Lymph node dissections were performed in appropriately selected cancer patients. Data collection focused on pathologic diagnosis, surgical technique, and surgical complications, including postoperative hematoma, neurapraxia, permanent nerve damage, hypocalcemia, and transient and permanent hypoparathyroidism.

RESULTS

From 2009 through 2017, 464 patients underwent thyroid surgery. Median age of the cohort was 15 years (range 2-24). Thirty-three percent were diagnosed with benign nodules (n=151), 36% with papillary or follicular thyroid cancer (n=168), 27% with Graves' disease (n=124), 3% with medullary thyroid cancer (n=14), and 1.5% underwent prophylactic thyroidectomy for MEN2a (n=7). Six patients required return to the OR for hematoma evacuation including 5 patients after surgery for Graves' disease (RR 8.7, 95% CI 1.06-71.85). In sixteen cases, concern about neurapraxia resulted in laryngoscopy, revealing eleven patients with vocal cord paresis. Two of these patients demonstrated a persistent deficit at 6 months postoperatively (0.4%). Thirty-seven percent of patients had transient hypoparathyroidism (n=137), and two patients had persistent hypoparathyroidism 6 months after total thyroidectomy (0.6%). There was no significant difference in either hypocalcemia or hypoparathyroidism after total thyroidectomy based on age or diagnosis.

CONCLUSIONS

Characterizing outcomes for pediatric patients based on diagnosis will assist in preoperative counseling for patients and their families. This high-volume center reports low complication rates after pediatric thyroid surgery, highlighting that referral to high-volume centers should be considered for children and adolescents with thyroid disease requiring surgery.

LEVEL OF EVIDENCE

Level IV.

Thyroid Cancer in the Pediatric Population

Thyroid cancer is rare in the pediatric population, but thyroid carcinomas occurring in children carry a unique set of clinical, pathologic, and molecular characteristics. In comparison to adults, children more often present with aggressive, advanced stage disease. This is at least in part due to the underlying biologic and molecular differences between pediatric and adult thyroid cancer. Specifically, papillary thyroid carcinoma (which accounts for approximately 90% of pediatric thyroid cancer) has a high rate of gene fusions which influence the histologic subtypes encountered in pediatric thyroid tumors, are associated with more extensive extrathyroidal disease, and offer unique options for targeted medical therapies. Differences are also seen in pediatric follicular thyroid cancer, although there are few studies of non-papillary pediatric thyroid tumors published in the literature due to their rarity, and in medullary carcinoma, which is most frequently diagnosed in the pediatric population in the setting of prophylactic thyroidectomies for known multiple endocrine neoplasia syndromes. The overall shift in the spectrum of histotypes and underlying molecular alterations common in pediatric thyroid cancer is important to recognize as it may directly influence diagnostic test selection and therapeutic recommendations.

Disease Burden and Outcome in Children and Young Adults With Concurrent Graves Disease and Differentiated Thyroid Carcinoma

CONTEXT

Adults with differentiated thyroid cancer (DTC) and Graves disease (GD) demonstrate a greater reported disease burden and aggressive DTC behavior. To date, no studies have examined the impact and long-term outcome of concurrent GD and DTC (GD-DTC) in children and young adults.

DESIGN

Single institution, retrospective longitudinal cohort study between 1997 and 2016.

PARTICIPANTS

One hundred thirty-nine children and young adults with DTC, diagnosed at median age 15 (range, 5 to 23) years, compared with 12 patients with GD-DTC, median age 18 (range, 12 to 20) years.

MAJOR OUTCOME MEASURES

Patient demographics, preoperative imaging, fine needle aspiration (FNA) cytology, operative and pathological reports, laboratory studies, treatment, and subsequent 2-year outcomes.

RESULTS

Compared with DTC, patients with GD-DTC were significantly older at the time of DTC diagnosis (P < 0.01). Patients with GD-DTC were more likely to exhibit microcarcinoma (P < 0.01), and 2 of 12 (17%) demonstrated tall cell variant papillary thyroid cancer (PTC) vs 2 of 139 (2%) in patients who had DTC alone (P = 0.03). Although patients with DTC showed greater lymphovascular invasion (60% vs 25%; P = 0.03), no group differences were noted in extrathyroidal extension, regional lymph node, and distant or lung metastasis. There were no group differences in the 2-year outcome for remission, persistent disease, or recurrence.

CONCLUSIONS

Concurrent DTC in pediatric patients with GD is not associated with a greater disease burden at presentation and shows no significant difference in 2-year outcomes compared with DTC alone. Similar to adults, microcarcinoma and tall cell variant PTC is prevalent in pediatric patients with GD-DTC. For patients who have GD-DTC with an identified nodule on ultrasound imaging prior to definitive therapy, FNA biopsy is recommended to guide definitive treatment.

Autoimmune thyroid diseases in children

Autoimmune thyroid diseases (AIT) are common in children and may present with a variety of signs and symptoms including: euthyroid goiter, hypothyroidism, or hyperthyroidism. The natural history of AIT may be different in children but in all age groups, there appear to be genetic risk factors and environmental triggers that initiate thyroid autoimmunity. Areas covered: In this review, we summarize recent studies that investigate the genetics and environmental triggers believed to be involved in thyroid autoimmunity. We also discuss the approach and controversies in the treatment of children with AIT. Expert commentary: Much has been learned about the major roles for genetics, cytokines, regulatory lymphocytes, and environmental triggers in CLT but controversies remain.

Evaluation and management of thyroid nodules in children

PURPOSE OF REVIEW

The review is focused on new information about the presentation and management of thyroid nodules in children and adolescents.

RECENT FINDINGS

Palpable thyroid nodules are uncommon in children but many children have nodules detected by radiologic imaging. How to evaluate them, when to suspect thyroid cancer, and how best to follow apparently benign nodules has become an area of great interest. The American Thyroid Association recently published treatment guidelines for children with thyroid nodules and cancers but much has been learned since that publication.

SUMMARY

Personal and family history, ultrasound features, and fine needle aspiration cytology are used to determine the risk of cancer in thyroid nodules, which are then managed according to cancer risk.