Recurrent disease in juvenile differentiated thyroid carcinoma: prognostic factors, treatments, and outcomes

Current approach to pediatric differentiated thyroid cancer

Differentiated thyroid cancers (DTC) is a rare cancer in children and adolescents, having features of different clinical presentation, biological behavior, and treatment from adult population. Most of the patient management guidelines are based on literature on adult population and the literature on children and adolescents still limited. There are still unsettled issues regarding both patient management and the therapy. However, the current approach for treatment of DTC includes thyroidectomy, lymph node dissection in patients with nodal metastases and possible use of Iodine-131 radiotherapy. The incidence of DTC is low in pediatric population, and the characteristics of the disease vary among different age groups within this population. Therefore, the literature depends on small cohorts and heterogeneous retrospective studies. This paper aims to review the current literature and give an overview to the approach in the management of DTC in pediatric population. DTC in pediatric population, has an aggressive nature, however the patient's overall survival is excellent. A multidisciplinary approach in the management of pediatric DTC patients would yield fewer side effects and a better life quality.

Recurrence and survival for patients with thyroid carcinoma in the pediatric age group in the Emirate of Abu Dhabi: retrospective analysis of a multicentre cohort

OBJECTIVES

Pediatric thyroid cancer represents 2.3 % of thyroid cancers, and its long-term outcome data are sparse. There have not been studies in the UAE delineating its epidemiology, clinical and histological characteristics, and follow-up outcomes. We aimed to evaluate the clinical-pathological behavior, recurrence and survival rates in pediatrics with all types of thyroid cancer in the UAE.

METHODS

Multicentre retrospective chart review analysis of pediatric patients with thyroid carcinoma from January 2010 to December 2020 in Abu Dhabi, UAE.

RESULTS

Thirty-four patients were included, 85 % being females. Papillary thyroid carcinoma (PTC) was the commonest type of thyroid cancer (88 %) vs. follicular thyroid carcinoma (FTC) (11.8 %). Almost half of our patients had a multifocal disease, 26 % had lymphovascular invasion (LVI), and 21 % had extrathyroidal extension (ETE). There were no mortalities during follow-up. 85 % of patients exhibited complete remission, while 15 % of patients showed evidence of progressive residual or recurrent disease. One patient had metastasis to lymph nodes and lungs.

CONCLUSIONS

There were similar trends of incidence, sex prevalence, and histopathological patterns as the ones observed internationally. Potential risk factors in our population include a family history of thyroid cancer and obesity. The lower rate of ETE, LVI, metastasis, and recurrence indicates a possibly less aggressive disease.

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

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

Risk factors for recurrence of differentiated thyroid carcinoma in children and adolescents: A retrospective cohort study

This study aimed to provide a recent clinical evaluation of the outcome of treatment and the predictors of recurrence for Chinese children and adolescents with differentiated thyroid carcinoma (DTC). This is a retrospective cohort study at the Yunnan Cancer Hospital from May 2002 to August 2021. We analyzed several risk factors related to the recurrence of DTC in children and adolescents. The Chi-square test, Kaplan-Meier log-rank tests, and Cox regression analysis were used in the statistical analysis. A P-value <.05 was considered statistically significant. A total of 103 patients were enrolled, including 68 girls (66.0%) and 35 boys (34.0%) with a median age of 18 years (range: 7-20 years). All enrolled patients received standard treatment. Children (≤14years) tended to have multifocality and higher levels of thyroid imaging reporting and data system, higher pN stage, and higher American Thyroid Association (ATA) pediatric risk compared with adolescents (P < .05). The chief complaints and clinical treatment differed between children and adolescents. During a follow-up of 6 to 239 months (average 74.7 months, median 59 months), all patients survived, but recurrence occurred in 22 patients (22.4%). The disease-free survival rates at 1, 2, 5, and 10 years were 91.2%, 78.4%, 77.1%, and 77.1%, respectively. Univariate Cox regression and log-rank tests showed that positive preoperative thyroglobulin level, bilaterality, extrathyroidal extension, high pT/pN/pM stage, and high ATA pediatric risk were the risk factors for DTC recurrence in children and adolescents. Multivariate Cox regression found that extrathyroidal extension and ATA pediatric risk were independent risk factors for the recurrence of DTC in children and adolescents. Additionally, among the 38 cases with cN0 stage, one who had bilateral, and multifocal thyroid nodules experienced recurrence, while the remaining 37 cases with cN0 stage had no recurrence. In conclusion, compared with adolescents, children present with more highly malignant disease and are more prone to metastasis. The significant risk factors associated with the recurrence of DTC in children and adolescents were positive preoperative thyroglobulin level, bilaterality, high pT/pN/pM stage, extrathyroidal extension, and high ATA pediatric risk, with the latter 2 being independent risk factors. The surgical approach for cN0 patients should be personalized taking into account invasive features.

Prognostic Value of Tumor Multifocality in Pediatric Papillary Thyroid Carcinoma: A Real-Life Multicentric Study

OBJECTIVE

To investigate the association of multifocality with clinical outcomes in pediatric papillary thyroid cancer.

STUDY DESIGN

Multicenter retrospective study of prospectively collected data.

SETTING

Tertiary referral center.

METHODS

This study included patients 18 years or younger who underwent total thyroidectomy and radioiodine ablation for papillary thyroid carcinoma (PTC) between 2005 and 2020 at 3 tertiary adult and pediatric hospitals in China. For disease-free survival (DFS), events were defined as persistent and/or recurrent diseases. The primary outcome was the association of tumor multifocality and DFS, assessed using Cox proportional hazards regression models.

RESULTS

One hundred and seventy-three patients (median age 16 years [range, 5-18 years]) were recruited. Multifocal diseases were seen in 59 patients (34.1%). After a median follow-up of 57 (range, 12-193 months) months, 63 (36.4%) patients had persistent diseases. There was a significant association between tumor multifocality and decreased DFS on univariable analysis (hazard ratio [HR] = 1.90, p = .01), yet it was nonsignificant after multivariate adjustment (HR = 1.20, p = .55). In a subgroup analysis of 132 pediatric patients with clinically M0 PTC, neither unadjusted HR (2.21, p = .06) nor adjusted HR (1.70, p = .27) of multifocal PTC was significantly higher in comparison to unifocal PTC.

CONCLUSION

In this highly selective surgical pediatric patient cohort with PTC, tumor multifocality was not an independent risk factor for decreased DFS.

Primary presentation and clinical course of pediatric and adolescent patients with differentiated thyroid carcinoma after radioiodine therapy

Introduction

Differentiated thyroid carcinoma (DTC) in childhood and during adolescence is extremely rare. Pediatric DTC commonly presents with advanced disease at diagnosis including a high prevalence of cervical lymph node metastases and pulmonary metastases. Studies in children with DTC are limited. Therefore, we aimed to evaluate the initial presentation, effectiveness of radioiodine therapy (RIT), and long-term outcome of prepubertal in comparison to pubertal/postpubertal patients.

Methods

Eighty-five pediatric and young patients aged 6.4 to 21.9 years with histopathologically confirmed DTC were retrospectively included. They all underwent total thyroidectomy followed by RIT. Initial presentation and outcome of prepubertal and pubertal/postpubertal patients were compared 1 year after RIT, during follow-up, and at the last visit of follow-up.

Results

Prepubertal patients presented with significantly higher T and M stages. One year after RIT, 42/81 (52%) patients still presented with evidence of disease (ED). During follow-up of a median of 7.9 years, prepubertal patients were less often in complete remission (58% vs. 82% in pubertal patients). At the last visit of follow-up, 19/80 (24%) patients still had ED without statistical differences between the two groups (42% prepubertal vs. 18% pubertal/postpubertal, p-value 0.06). None of our patients died disease-related over the observed period.

Conclusion

Prepubertal children with DTC presented with a more advanced tumor stage at the initial presentation. During follow-up, they present more often with ED. However, at the end of our study, we did not observe statistically relevant differences in patient outcomes between the prepubertal and pubertal/postpubertal groups.

Identification of crucial genes involved in thyroid cancer development

BACKGROUND

A malignancy of the endocrine system, one of the most common types, is thyroid cancer. It is proven that children who receive radiation treatment for leukemia or lymphoma are at a heightened risk of thyroid cancer due to low-dose radiation exposure throughout childhood. Several factors can increase the risk of thyroid cancer (ThyCa), such as chromosomal and genetic mutations, iodine intake, TSH levels, autoimmune thyroid disorders, estrogen, obesity, lifestyle changes, and environmental contaminants.

OBJECTIVES

The study aimed to identify a specific gene as an essential candidate for thyroid cancer progression. We might be able to focus on developing a better understanding of how thyroid cancer is inherited.

METHODS

The review article uses electronic databases such as PubMed, Google Scholar, Ovid MEDLINE, Embase, and Cochrane Central. The most frequently associated genes with thyroid cancer found on PubMed were BAX, XRCC1, XRCC3, XPO5, IL-10, BRAF, RET, and K-RAS. To perform an electronic literature search, genes derived from DisGeNET: a database of gene-disease associations, including PRKAR1A, BRAF, RET, NRAS, and KRAS, are used.

CONCLUSION

Examining the genetics of thyroid cancer explicitly emphasizes the primary genes associated with the pathophysiology of young and older people with thyroid cancer. Developing such gene investigations at the beginning of the thyroid cancer development process can identify better outcomes and the most aggressive thyroid cancers.

Paediatric differentiated thyroid carcinoma: a UK National Clinical Practice Consensus Guideline

This guideline is written as a reference document for clinicians presented with the challenge of managing paediatric patients with differentiated thyroid carcinoma up to the age of 19 years. Care of paediatric patients with differentiated thyroid carcinoma differs in key aspects from that of adults, and there have been several recent developments in the care pathways for this condition; this guideline has sought to identify and attend to these areas. It addresses the presentation, clinical assessment, diagnosis, management (both surgical and medical), genetic counselling, follow-up and prognosis of affected patients. The guideline development group formed of a multi-disciplinary panel of sub-speciality experts carried out a systematic primary literature review and Delphi Consensus exercise. The guideline was developed in accordance with The Appraisal of Guidelines Research and Evaluation Instrument II criteria, with input from stakeholders including charities and patient groups. Based on scientific evidence and expert opinion, 58 recommendations have been collected to produce a clear, pragmatic set of management guidelines. It is intended as an evidence base for future optimal management and to improve the quality of clinical care of paediatric patients with differentiated thyroid carcinoma.

Predictive Factors for Recurrence of Papillary Thyroid Carcinoma in Children and Adolescents

Background

The incidence of papillary thyroid carcinoma (PTC) in children and adolescents has increased, but the data on long-term outcomes are limited. There are few literatures on the clinicopathological characteristics and prognosis of PTC in children and adolescents in China. Therefore, it is necessary to identify clinicopathological features to precisely predict clinical prognosis and to help choose the optimal method and perform the best therapeutic regimen.

Methods

This study was a retrospective analysis of patients undergoing thyroidectomy at Tianjin Medical University Cancer Institute and Hospital. We analyzed the factors related to the clinicopathological features and prognosis of PTC in children and adolescents.

Results

A total of 95 juvenile PTC patients who underwent thyroidectomy were enrolled. Our research found that patients with younger age (<14 years) were predominantly multifocal and have positive preoperative thyroglobulin (Tg) and higher recurrence rate, and their number of lymph node metastases (LNMs) was more than that of the older group (14–18 years). Maximal tumor size >2 cm, T stage, and multifocality were the risk factors for LNM and the number of LNM (p < 0.05). Multivariate analysis displayed the number of central LNM as the independent risk factor for lateral LNM, and multifocality was the independent risk factor for the number of central and lateral LNM. Younger age at diagnosis, positive preoperative thyroid-stimulating hormone (TSH), maximal tumor size >2 cm, lateral LNM, number of LNM, N staging, and American Thyroid Association (ATA) pediatric risk were related to poor prognosis in PTC patients (p < 0.05). Cox regression analysis found that younger age at diagnosis and positive preoperative TSH were independent risk factors for recurrence of PTC in children and adolescents.

Conclusions

Our study showed that the clinicopathological characteristics of younger age compared with older age were as follows: highly aggressive, prone to metastases, and higher recurrence rate. In our opinion, patients with characteristics such as younger age at diagnosis, positive preoperative TSH, maximal tumor size >2 cm, lateral LNM, and number of LNM >5 may be considered for prophylactic or therapeutic dissection of additional metastatic LNs by high-volume surgeons to prevent and reduce the recurrence rate of patients during long-term follow-up.

Age, American Thyroid Association Risk Group, and Response to Therapy Are Prognostic Factors in Children With Differentiated Thyroid Cancer

CONTEXT

Against the background of increasing incidence, pediatric differentiated thyroid carcinoma (DTC) frequently presents with advanced disease and high recurrence rates while prognosis remains excellent.

BACKGROUND

We investigated the use of a pediatric classification and an adult response to therapy risk stratification for pediatric DTC patients and their implications for adaptation of treatment and follow-up.

METHODS

Data from patients aged <18 years with a diagnosis of primary DTC, registered with the German Pediatric Oncology Hematology-Malignant Endocrine Tumor registry since 1995, were analyzed. For risk prediction, patients were retrospectively assigned to the American Thyroid Association (ATA) risk groups and evaluated for response to therapy.

RESULTS

By October 2019, 354 patients with DTC had been reported (median age at diagnosis 13.7 years, range 3.6-17.9) with lymph node and distant metastases in 74.3% and 24.5%. Mean follow-up was 4.1 years (range 0-20.6). Ten-year overall and event-free survival (EFS) rates were 98.9% and 78.1%. EFS was impaired for patients with lymph node and distant metastases (P < .001), positive postoperative thyroglobulin (P = .006), incomplete resection (P = .002), sequential surgeries to achieve total thyroidectomy (P = .042), invasion of capsule (P < .001) and lymph vessels (P = .005), infiltration of surrounding soft tissues (P < .001), tumor multifocality (P < .001), ATA intermediate- and high-risk group (P < .001), and age <10 years (P < .001). Multivariate analysis revealed age <10 years at diagnosis, ATA high-risk level, and poor response to therapy as significant negative prognostic factors for EFS.

CONCLUSION

Age, ATA risk group, and response to therapy emerged as significant prognostic factors for EFS in pediatric patients with DTC, requiring risk-adapted individualized therapy and follow-up.

Tumor size is an independent negative prognostic factor for event free survival in children with differentiated thyroid cancer

BACKGROUND

The incidence of pediatric differentiated thyroid carcinoma (DTC) is increasing. Despite the advanced disease at presentation, the overall prognosis of DTC in children is excellent. The aim of this study is to investigate the risk stratifying factors for event free survival (EFS) of pediatric DTC from Middle Eastern ethnicity.

METHODS

Eighty-eight patients aged ≤18 years with diagnosis of primary DTC were retrospectively analyzed. Cox proportional hazards model were used to calculate Hazard Ratios (HR) and Kaplan-Meier analysis were conducted to investigate EFS.

RESULTS

Eighty-eight (23 males and 65 females) pediatric DTCs who underwent surgery and radioactive iodine therapy had been reported (median age at diagnosis 15 years; range 5.9-17.9), with lymph node metastasis (LNM) noted in 70.5% and distant metastasis in 13.6%. Mean follow-up was 8.4 years. Ten-year overall survival rate was 98.4% while 10-year EFS was 79.2%. EFS was negatively impacted by the presence of LNM, distant metastasis and tumor size >4cm. American Thyroid Association risk stratification did not impact EFS in our cohort. Multivariate analysis revealed tumor size >4cm (HR = 5.34; 95% confidence interval (CI) = 1.36 - 20.22; p = 0.0177) and distant metastasis (HR = 8.73; 95% CI = 1.48 - 60.05; p = 0.0154) as independent negative prognostic factors for EFS.

CONCLUSIONS

Primary tumor size and the presence of distant metastasis at diagnosis are the only independent prognostic risk factors for EFS in pediatric DTC in Middle Eastern ethnicity. Children with tumor size over 4cm had poor EFS, which may justify the need of more aggressive treatment and frequent follow-up.

Prevalence and Risk Factors for Multifocality in Pediatric Thyroid Cancer

Importance

Current guidelines recommend total thyroidectomy for the majority of pediatric thyroid cancer owing to an increased prevalence of multifocality. However, there is a paucity of information on the exact prevalence and risk factors for multifocal disease-knowledge that is critical to improving pediatric thyroid cancer management and outcomes.

Objective

To determine the prevalence and risk factors for multifocal disease in pediatric patients with papillary thyroid carcinoma (PTC).

Design, Setting, and Participants

This multicenter retrospective cohort study included patients 18 years or younger who underwent thyroidectomy for PTC from 2010 to 2020 at 3 tertiary pediatric hospitals and 2 tertiary adult and pediatric hospitals in the US.

Main Outcomes and Measures

Demographic and clinical variables, including age, family history of thyroid cancer, autoimmune thyroiditis, prior radiation exposure, cancer predisposition syndrome, tumor size, tumor and nodal stage, PTC pathologic variant, and preoperative imaging, were assessed for association with presence of any multifocal, unilateral multifocal, and bilateral multifocal disease using multiple logistic regression analyses. Least absolute shrinkage and selection operator analysis was performed to develop a model of variables that may predict multifocal disease.

Results

Of 212 patients, the mean age was 14.1 years, with 23 patients 10 years or younger; 173 (82%) patients were female. Any multifocal disease was present in 98 (46%) patients, with bilateral multifocal disease in 73 (34%). Bilateral multifocal disease was more accurately predicted on preoperative imaging than unilateral multifocal disease (48 of 73 [66%] patients vs 9 of 25 [36%] patients). Being 10 years or younger, T3 tumor stage, and N1b nodal stage were identified as predictors for multifocal and bilateral multifocal disease.

Conclusions and Relevance

This large, multicenter cohort study demonstrated a high prevalence of multifocal disease in pediatric patients with PTC. Additionally, several potential predictors of multifocal disease, including age and advanced T and N stages, were identified. These risk factors and the high prevalence of multifocal disease should be considered when weighing the risks and benefits of surgical management options in pediatric patients with PTC.

Prognostic value of lymph node ratio in children and adolescents with papillary thyroid cancer

OBJECTIVE

Neck lymph node (LN) metastasis is a common feature of paediatric papillary thyroid cancer, and LN ratio (LNR) is defined as the ratio of the number of positive LNs excised to the total number of removed. Unlike in adults, few data are available regarding the clinical implication of LNR in the paediatric population. Our purpose was to investigate the association of LNR with clinical outcomes in paediatric papillary thyroid cancer.

DESIGN & METHODS

The study retrospectively reviewed 136 consecutive children and adolescents with papillary thyroid cancer and LN involvement but no initial distant metastasis. Initial treatment, included in all patients a total thyroidectomy with central and/or lateral neck dissection followed by radioactive iodine ablation. Within the neck dissections, total number of LNs removed, total positive LNs and LN ratios were determined. The effect of clinicopathologic characteristics and intraoperative findings on persistent and recurrent diseases were analysed by univariate and multivariate analyses.

RESULTS

Median number of positive LNs was 9, and median LNR was 0.4. During a median follow-up of 49 months (range, 12.0-139 months), persistent disease occurred in 43 (31.6%) patients. The multivariable analysis showed that age and LNR were the independent factors predictive of persistent disease. Patients with a LNR >0.34 exhibited a threefold higher risk of persistent disease after initial therapy than the counterparts (P = .02).

CONCLUSION

Our findings suggest that LNR was an independent determinant predictive of persistent disease after initial therapy in children and adolescents with papillary thyroid cancer.

The Efficacy and Short- and Long-Term Side Effects of Radioactive Iodine Treatment in Pediatric Graves' Disease: A Systematic Review

BACKGROUND

Graves's disease (GD) is the most common cause of hyperthyroidism. Maximal 30% of pediatric GD patients achieve remission with antithyroid drugs. The majority of patients therefore require definitive treatment. Both thyroidectomy and radioactive iodine (RAI) are often used as definitive treatment for GD. However, data on efficacy and short- and long-term side effects of RAI treatment for pediatric GD are relatively scarce.

METHODS

A systematic review of the literature (PubMed and Embase) was performed to identify studies reporting the efficacy or short- and long-term side effects of RAI treatment in pediatric GD.

RESULTS

Twenty-three studies evaluating 1,283 children and adolescents treated with RAI for GD were included. The treatment goal of RAI treatment changed over time, from trying to achieve euthyroidism in the past to aiming at complete thyroid destruction and subsequent hypothyroidism in the last 3 decades. The reported efficacy of a first RAI treatment when aiming at hypothyroidism ranged from 42.8 to 97.5%, depending on the activity administered. The efficacy seems to increase with higher RAI activities. When aiming at hypothyroidism, both short- and long-term side effects of treatment are very rare. Long-term side effects were mainly seen in patients in whom treatment aimed at achieving euthyroidism.

CONCLUSION

RAI is a safe definitive treatment option for pediatric GD when aiming at complete thyroid destruction. When aiming at hypothyroidism, the efficacy of treatment seems to increase with a higher RAI activity. Prospective studies are needed to determine the optimal RAI dosing regimen in pediatric GD.

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

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

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

Background:

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

Methods:

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

Results:

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

Conclusions:

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

Long-term scintigraphic and clinical follow up in patients with differentiated thyroid cancer and iodine avid bone metastases

AIM

The aim of this study was to evaluate the long-term overall therapy outcomes and clinicopathological risk factors in patients with differentiated thyroid cancer (DTC) and iodine avid bone metastases.

METHODS

Our study included 93 patients [female to male ratio (2:1)]. All patients were subjected to clinical examination, laboratory assessment, I-131 whole body scan, and neck ultrasound. Iodine avid metastases were treated with successive radioactive iodine-131 (RAI-131) doses. The overall response was defined as complete response (CR), incomplete response (IR) [partial response (PR) and stable disease (SD)], and progressive disease (PD).

RESULTS

Fifty-four patients had follicular carcinoma and 39 with papillary type. Isolated bone metastases, bone and lung metastases, and multi-organ metastases were found in 45, 34, and 14 patients, respectively. The overall CR, PR, SD, and PD were found in 8.6%, 28%, 46.2%, and 17.2% patients, respectively. Adjunctive radiotherapy resulted in more CR, IR, and low PD rates compared to RAI-131 therapy (9.0%, 78.3%, 12.7% vs. 7.9%, 56.8%, and 23.7%, respectively) (P = 0.03). The overall survival rate was 88.2% and median follow-up period was 123 months. Female patients, papillary carcinoma, and single focal lesion had better overall response rate. Males, extrathyroidal extension, vascular invasion, and lymph nodes metastases had increased PD and decreased global response rates.

CONCLUSION

Despite of low CR rate (8.6%), most patients with DTC and iodine avid bone metastases had SD (46.2%) and long lived (88.2%). Adjunctive radiotherapy reduced PD and improved outcome. Males, extra thyroid extension and vascular invasion were bad prognostic factors.

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

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.

Long-term follow-up of differentiated thyroid carcinoma in children and adolescents

Objectives The aims were to analyze the clinical features, response to treatment, prognostic factors and long-term follow-up of children and adolescents with differentiated thyroid carcinoma (DTC). Methods Eighty patients with DTC were studied retrospectively. All underwent total or near-total thyroidectomy, and in 75 cases, ablative iodine therapy was recommended. Patients were assessed periodically by tests for serum thyroglobulin levels and whole-body iodine scans. Age, gender, initial clinical presentation, histology, tumor stage, postoperative complications, radioiodine treatment protocol, treatment response, thyroglobulin (Tg), recurrence and long-term disease progression were evaluated. Results Seventy patients completed >2 years of follow-up (23 males, 47 females; median age: 14 years; range: 3-18 years). Sixty-two patients showed papillary DTC and eight, follicular DTC. Sixty-five percent presented nodal metastasis and 16%, pulmonary metastasis at diagnosis. Six months after first radioiodine treatment, 36.2% of patients were free of disease. Seven recurrences were documented. At the end of follow-up, overall survival was 100%, and 87.2% of patients were in complete remission. Nine patients had persistent disease. We found a significant association between stage 4 and persistent disease. Hundred percent of patients with negative Tg values at 6 months posttreatment were documented free of disease at the end of the follow-up. The analysis of disease-free survival based on radioiodine treatment protocols used showed no statistically significant differences. Conclusions DTC in children and adolescents is frequently associated with presence of advanced disease at diagnosis. Despite this, complete remission was documented after treatment in most cases, with a good prognosis in the long-term follow-up. Negative posttreatment thyroglobulin and stage 4 at diagnosis were significant prognostic variables.

Practice Patterns and Outcomes of Pediatric Thyroid Surgery: An NSQIP Analysis

BACKGROUND

Pediatric thyroid cancer rates are rising. The aim of this study was to determine the state of current practice and outcomes for pediatric thyroidectomies using the pediatric National Surgical Quality Improvement Program (NSQIP-P) with specific attention to differences based on surgeon type/specialty.

METHODS

All cases of pediatric thyroidectomies and neck dissections within the NSQIP-P database were identified from 2015 to 2017. Patient, disease, and treatment-related factors affecting 30-day outcomes were analyzed using univariate and multivariate analyses.

RESULTS

A total of 1300 cases were identified. Mean age at time of surgery was 14.0 (SD 3.5) years. The majority of patients were female (78%) and Caucasian (72%). Pediatric general surgeons performed the largest proportion of cases (42%) followed by pediatric otolaryngologists (33%). Malignancies were present in 29% of cases. The overall rate of complications was 3.0%. On multivariate analysis, non-pediatric surgeons were more likely to operate on Caucasian children, malignant pathology, and perform modified radical neck dissections. Pediatric surgeons were more likely to have longer operative times, have specialized in otolaryngology, and operate on sicker children (ASA>2). There were no differences in length of stay or overall complications rates.

CONCLUSIONS

This study shows that pediatric surgeons currently perform the majority of thyroid surgeries in children. While unable to assess surgeon volume, our data show that thyroid surgery is being safely performed at NSQIP-affiliated hospitals by both non-pediatric and pediatric surgeons. Further studies are needed to determine if there are differences in specific procedure-related complications and long-term outcomes between surgeon types.

Recurrence and Complications in Pediatric and Adolescent Papillary Thyroid Cancer in a High-Volume Practice

BACKGROUND

Treatment approaches for pediatric papillary thyroid cancer (PTC) are historically extrapolated from adult experience. However, pediatric PTC demonstrates a greater propensity for lymph node involvement, early metastases, and recurrence, highlighting the need for pediatric-specific treatment paradigms.

MATERIALS AND METHODS

A retrospective review included patients with PTC aged ≤21 y, with ≥18 mo of follow-up, treated between 2002 and 2015. Fisher's exact test and Cox proportional hazard were used to estimate the effect of risk factors on disease recurrence.

RESULTS

Seventy-two cases of PTC were identified with median age of 17.0 y and median follow-up of 64.1 mo. Disease recurred at a median of 24.6 mo (range 7.8-78.1) in 7 of 51 (13.7%) of patients with disease limited to the thyroid or central neck, 7 of 18 (39%) patients with lateral neck disease at presentation who underwent a compartment-based resection, and three of three patients (100%) with lateral neck disease who sought care after non-compartment-based resection. There were no deaths from disease. Univariate predictors of recurrence included tumor size >2 cm (P = 0.005), lateral neck disease (P = 0.004), lymphovascular invasion (P = 0.017), extracapsular invasion (P < 0.0001), multifocality (P = 0.03), and non-Caucasian race (P = 0.05). Multivariate analysis identified race (P = 0.05) as an independent predictor of recurrence. In patients without lateral neck disease, there was a trend toward lower recurrence in patients undergoing thyroidectomy with central neck dissection compared with thyroidectomy alone (P = 0.07).

CONCLUSIONS

Pediatric PTC is associated with excellent survival, although recurrence is common in patients with lateral node involvement. Predictors of recurrence are multifactorial and may be influenced by extent of disease, patient or tumor biology, and aggressiveness of resection.

LEVEL OF EVIDENCE

Prognosis study, level IV, retrospective case series.

Differentiated thyroid carcinoma in children: Clinical characteristics and long-term follow-up

Differentiated thyroid cancer (DTC) is rare in children, but it still remains the most common endocrine malignancy in children. The aim of this study was to analyze treatment response to radioactive iodine (RAI) therapy, clinical outcomes, recurrences, survival analysis, and long-term follow-up. We retrospectively reviewed the medical records of 43 pediatric patients (≤17 years of age) with DTC diagnosis after thyroidectomy who were treated with RAI. The follow-up protocol consisted of detailed clinical examination, testing of thyroid function, determination of serum thyroglobulin (Tg), and anti-Tg antibodies, and neck ultrasonography application. Forty-three pediatric patients (34 females and 9 males) treated with RAI for DTC in our institute. The median follow-up period was 54 months. The histologic classification was papillary thyroid cancer in 41 patients and the remaining 2 patients had follicular thyroid cancer. After the long-term follow-up, complete remission, partial remission, and recurrent-persistent disease were observed in 37 patients, 3 patients, and 3 patients, respectively. Among the series, 1 death occurred due to multiple metastases. The mortality rate is 2.56%. Total thyroidectomy followed by RAI appears to be the most effective treatment for patients with pediatric DTC in terms of reducing the rate of relapse and improving surveillance for recurrent disease.

Initial treatment of pediatric differentiated thyroid cancer: a review of the current risk-adaptive approach

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.

Performance of the American Thyroid Association Risk Classification in a Single Center Cohort of Pediatric Patients with Differentiated Thyroid Cancer: A Retrospective Study

Introduction

Differentiated thyroid cancer (DTC) is the most common endocrine malignancy in children. Retrospective studies show conflicting results regarding predictors of persistent and recurrent disease after initial therapy. In 2015, the American Thyroid Association (ATA) proposed a clinical classification system to identify pediatric thyroid cancer patients at risk for persistent/recurrent disease.

Material and Methods

We retrospectively included all patients in our registry diagnosed with papillary DTC at ≤ 18 years of age. We analyzed the prognostic performance of the ATA classification and other risk factors for predicting response to initial treatment and final outcome in pediatric DTC.

Results

We included 41 patients, 34 females and 7 males, diagnosed with papillary DTC at a mean (SD) age of 16.2 (1.8) years. Based on the ATA pediatric risk classification, patients were categorized as low (61%), intermediate (10%), or high risk (29%). The median follow-up period was 7.3 (1-41) years. After initial treatment, disease free status was achieved in 92%, 50%, and 42% of the low, intermediate, and high risk groups, respectively (P <0.01). At the last visit, persistent disease was present in 12%, 25%, and 33% (P=0.27). Assessing other risk factors, only the presence of distant metastases at diagnosis resulted in increased presence of persistent disease at last follow-up (P=0.03).

Conclusion

This study supports the clinical relevance of the ATA risk classification for predicting the response to initial treatment. There was no clear prediction of long-term outcome, but this may be due to limited power caused by the small number of patients.

Effects of Radioactive Iodine Therapy on Ovarian Reserve: A Prospective Pilot Study

Background: Thyroid carcinoma is the most common endocrine malignancy. Surgery is the standard therapeutic approach for patients with differentiated thyroid carcinoma (DTC), followed by radioiodine (RAI) therapy if indicated. For women with DTC, the effects of RAI therapy on gonadal and reproductive function are an important consideration. This study aimed to evaluate the effects of RAI therapy on ovarian function. Methods: A total of 33 premenopausal women were enrolled in this study. Serum follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol, and anti-Müllerian hormone (AMH) levels during the early follicular phase were measured before and 3, 6, and 12 months after RAI therapy. The Friedman and Wilcoxon tests were used to detect changes in FSH, AMH, LH, and estradiol levels induced by RAI therapy over time. Results: The patients' ages ranged from 21 to 38 years, with a mean age of 31.15 ± 4.83 years. The median follow-up was 19 months (range 4-26 months). The median AMH levels were 3.25 ng/mL (range 0.32-17.42 ng/mL), 1 ng/mL (range 0.01-3.93 ng/mL), 1.13 ng/mL (range 0.08-6.12 ng/mL), and 1.37 ng/mL (range 0.09-6.1 ng/mL) before and at 3, 6, and 12 months after RAI therapy, respectively. The median FSH levels were 6.6 mIU/mL (range 3.78-15.5 mIU/mL), 5.83 mIU/mL (range 4.19-35.36 mIU/mL), 7.71 mIU/mL (range 4.24-16.25 mIU/mL), and 7.04 mIU/mL (range 4.93-19.96 mIU/mL) before and at 3, 6, and 12 months after RAI therapy, respectively. The AMH levels were higher before than after RAI therapy (p = 0.001). The AMH levels did not differ significantly between the three time points (p > 0.05). The FSH, LH, and estradiol levels were similar before and after RAI therapy (p > 0.05). Conclusion: AMH is considered an important marker of ovarian reserve. Ovarian reserve decreased after RAI therapy. More attention may be needed when considering RAI therapy for patients with reduced ovarian reserve.

Management outcomes of pediatric and adolescent papillary thyroid cancers with a brief review of literature

Background

Papillary carcinoma of thyroid (PTC) is a rare disease in children and adolescents and contributes to about 1.5%-3% of all pediatric malignancies. To date, no randomized trial has ever been performed in the pediatric population and management of these patients has been extrapolated from adult practice.

Materials and Methods

Retrospective analysis of the patients treated for PTC in the age <21 years, between the years 1998-2013 at a tertiary cancer center from India.

Results

Sixty-seven patients were treated in the above said period with a male:female ratio of 1:1.6 and a median age of 18 years. Fifty-two (77.6%) patients clinically presented as a thyroid swelling with or without nodal swelling while 13 (19.4%) presented with isolated nodal swelling. Surgery was performed in 30 patients at a nononcological hospital and was subsequently referred to our center; more than half of them needed a completion surgery at our center. Pathologically, multifocal tumors were found in close to a quarter of the patients. Among the pathological variants, classical, follicular, and tall cell variants comprised 65.7%, 28.4%, and 5.9% of the cases, respectively. Nodal positivity was noted 71.6% of the cases of which 14.5% were N1a disease and the vast majority (85.5%) harboring N1b disease. The median follow-up period of the study cohort was 104 months during which there were 3 local, 6 nodal, and 2 systemic recurrences. The 5- and 10-year disease-free survival were found to be 85.9% and 81.4%, respectively. Univariate and multivariate analysis has shown no significant clinical and pathological feature defining the disease outcomes except for the T-stage. Logistic regression revealed extrathyroidal invasion and the age ≤ 15 years correlated with nodal positivity.

Conclusion

Being a rare malignancy, pediatric and adolescent PTCs tend to behave differently from adult PTC with a seemingly aggressive clinical presentation; however, they are associated with excellent survival outcomes.

Treatment outcomes in pediatric differentiated thyroid carcinoma

Background Until the American Thyroid Association (ATA) guidelines on management of pediatric differentiated thyroid carcinoma (DTC) became available in 2015, all children with DTC were treated like adults. This study aims to investigate the outcome of pediatric DTC and factors predicting the response to therapy in pediatric DTC managed according to adult guidelines. Methods Clinical records of 41 children less than 18 years of age diagnosed with DTC followed from 2007 in a single center were reviewed. According to the new ATA classification for pediatric DTC, five had low-risk, 28 had intermediate-risk and eight had high-risk disease at presentation. Results There was no mortality or recurrence in this cohort of pediatric DTC patients and the cure rate was 46% during a mean follow-up of 44 months when they were managed according to adult guidelines. Neither the new ATA risk classification nor any clinicopathological character was identified which could predict the response to therapy. The new ATA guidelines would have avoided 27% of the radioiodine therapies given. Conclusions This study showed that DTC in children managed according to adult guidelines had a good cure rate. The new ATA guidelines on pediatric DTC might have drastically reduced the number of radioiodine therapies in the affected children. Long term prospective studies are needed to validate the benefits and risks of both these approaches.

Differentiated thyroid cancer in children: Heterogeneity of predictive risk factors

OBJECTIVE

To correlate clinical and pathological characteristics at diagnosis with patient long-term outcomes and to evaluate ongoing risk stratifications in a large series of paediatric differentiated thyroid cancers (DTC).

STUDY DESIGN

Retrospective analysis of clinical and pathological prognostic factors of 124 paediatric patients with DTC (age at diagnosis <19 years) followed up for 10.4 ± 8.4 years. Patients with a follow-up >3 years (n = 104) were re-classified 18 months after surgery on the basis of their response to therapy (ongoing risk stratification).

RESULTS

Most patients had a papillary histotype (96.0%), were older than 15 years (75.0%) and were diagnosed because of clinical local symptoms (63.7%). Persistent/recurrent disease was present in 31.5% of cases during follow-up, but at the last evaluation, only 12.9% had biochemical or structural disease. The presence of metastases in the lymph nodes of the lateral compartment (OR 3.2, 95% CI, 1.28-7.16, P = 0.01) was the only independent factor associated with recurrent/persistent disease during follow-up. At the last evaluation, biochemical/structural disease was associated with node metastases (N1a, N1b) by univariate but not multivariate analysis. Ongoing risk stratification compared to the initial risk classification method better identified patients with a lower probability of persistent/recurrent disease (NPV = 100%).

CONCLUSIONS

In spite of the aggressive presentations at diagnosis, paediatric patients with DTC show an excellent response to treatment and often a favourable outcome. N1b status should be considered a strong predictor of persistent/recurrent disease which, as in adults, is better predicted by ongoing risk stratification.

Anti-Müllerian hormone in pre-menopausal females after ablative radioiodine treatment for differentiated thyroid cancer

PURPOSE

In recent years, anti-Mullerian hormone (AMH) has been considered a reliable index of ovarian reserve. There are few data on AMH values in thyroid cancer. The aim of this study was to evaluate AMH levels in pre-menopausal women with a history of low-risk thyroid cancer.

METHODS

Thirty-four women (aged 40.7 ± 6.7 years) were studied 7.1 ± 0.9 years after surgery and at least one RAI treatment. A group of 23 thyroid cancer women (41.6 ± 7.4 years) who had undergone only thyroidectomy served as controls. AMH, follicle-stimulating hormone (FSH) and estradiol were assayed on days 2-3, and prolactin and progesterone levels on days 21-24 of the menstrual cycle.

RESULTS

Pregnancy (RAI group 62%; control group 61%) and miscarriage rates (18% and 26%) were similar. AMH levels were similar in the RAI (10.7 ± 1.7 pmol/l) and control (17.5 ± 4.7 pmol/l) groups. Regular menses were reported in 41% and 52% of RAI and control subjects, respectively. Non-ovulatory cycles were noted in 26% and 35% of RAI and control women, respectively. AMH levels were found to be negatively correlated with age (RAI group P = 0.0003; control group P = 0.0001) and FSH, and positively correlated with progesterone, but not with the other hormonal parameters.

CONCLUSIONS

AMH should replace FSH in the evaluation of gonadal reserve in pre-menopausal thyroid cancer women. At present, age is the only predictor of AMH levels. About one out of two women with a history of thyroid cancer suffers from menstrual dysregulation, but infertility must be considered a low risk.

Clinical characteristics and treatment of thyroid cancer in children and adolescents: a retrospective analysis of 83 patients

OBJECTIVE

To study the clinical characteristics, treatment, and prognosis of thyroid cancer in children and adolescents.

METHODS

We performed a retrospective analysis of clinical data from 83 cases of thyroid cancer in children and adolescents from January 1990 to December 2010. We compared extra-thyroid extension, lymph node metastasis, distant metastasis, and prognosis between pediatric patients ≤12 years of age (27 cases) and those >12 years of age (56 cases). All the patients agreed to undergo thyroidectomy and endocrine therapy, and the consent was obtained from parents or guardians.

RESULTS

Histopathology included papillary carcinoma in 67 cases, papillary carcinoma with partial follicular growth pattern in 1 case, papillary carcinoma with squamous metaplasia in 4 cases, follicular carcinoma in 7 cases, medullary carcinoma in 3 cases, and poorly differentiated carcinoma in 1 case. The total lymph node metastasis rate was 78.31%. Patients ≤12 years of age showed a higher rate of lymph node metastasis than the older group (92.59% vs. 71.43%, P=0.028). The incidence rate in females in the older group was higher than that in the younger group (80.36% vs. 59.26%, P=0.041). There were no significant differences in extra-thyroid extension, distant metastasis, survival rate, or recurrent disease between the two groups.

CONCLUSIONS

The lymph node metastasis of thyroid cancer is higher in patients ≤12 years of age than in those >12 years of age; the incidence rate is higher in females than in males. Childhood thyroid cancer has a good prognosis, surgery being the most effective treatment. Choosing a reasonable surgery method and comprehensive postoperative treatment can achieve a cure and satisfactory survival rate.

Practical Initial Risk Stratification Based on Lymph Node Metastases in Pediatric and Adolescent Differentiated Thyroid Cancer

BACKGROUND

Data on the risk stratification of pediatric differentiated thyroid cancer (DTC) remain scarce. This study aimed to evaluate the predictors of structural persistent/recurrent disease and revise an initial risk-stratification system in pediatric DTC patients.

METHODS

This retrospective cohort study included 203 patients (aged <20 years) from two tertiary referral centers in Korea. The extent of cervical lymph node (LN) metastasis was classified based on the location or number of metastatic LNs.

RESULTS

During a median follow-up duration of 5.5 years, structural persistent/recurrent disease was observed in 51 (25%) patients, including 22 (11%) with distant metastases. The presence of extrathyroidal extension (ETE) and lateral cervical LN metastases or more than five metastatic LNs were independent predictors for structural persistent/recurrent disease. The presence of bilateral lateral cervical LN metastases or >10 metastatic LNs were independent predictors for distant metastasis. A total of 67 (33%), 72 (35%), and 64 (32%) patients were classified into the low-, intermediate-, and high-risk groups, respectively, based on the presence of ETE and the extent of cervical LN metastases. Compared to the low-risk group, the intermediate- and high-risk groups had a significantly greater risk of structural persistent/recurrent disease (hazard ratio = 7.32, p = 0.008, and hazard ratio = 24.28, p < 0.001, respectively).

CONCLUSIONS

This revised initial risk-stratification system based on the presence of ETE and the extent of cervical LN metastasis is useful for predicting the clinical outcomes of pediatric DTC patients. The findings could facilitate the practical use of a risk-stratification system.

Pediatric differentiated thyroid carcinoma: trends in practice and outcomes over 40 years at a single tertiary care institution

BACKGROUND

This study aims to analyze changes in characteristics, practice and outcomes of pediatric differentiated thyroid cancer (DTC) at our tertiary care institution.

METHODS

Patients <21 years of age diagnosed between 1973 and 2013 were identified. Clinicopathological data, treatment and outcomes were obtained by a retrospective review.

RESULTS

Thirteen males and 68 females were divided into Group A (n=35, diagnosed before July 1993) and Group B (n=46, diagnosed after July 1993). Group B was more likely to undergo neck ultrasound (US) (70% vs. 23%, p<0.0001) and fine-needle aspiration (FNA) biopsy (80% vs. 26%, p<0.0001). Patients in Group B more often underwent total thyroidectomy as a definitive surgical treatment (87% vs. 69%, p=0.04). There was no difference in radioactive iodine use. Recurrence-free survival was similar.

CONCLUSIONS

Increased use of US and FNA has affected initial surgical management in the latter part of the study, possibly due to extension of adult DTC guidelines. The effects of the new pediatric DTC guidelines need further study.

Validation of dynamic risk stratification in pediatric differentiated thyroid cancer

PURPOSE

There has been increasing interest in a risk-adopted management strategy known as dynamic risk stratification following the revised American Thyroid Association guidelines for differentiated thyroid cancer. We aimed to evaluate the usefulness of dynamic risk stratification for predicting structural disease in pediatric differentiated thyroid cancer patients.

METHODS

We retrospectively reviewed 130 pediatric differentiated thyroid cancer patients (≤19 years) who were treated between 1996 and 2015 at Samsung Medical Center. Patients were stratified according to three American Thyroid Association initial risk group (low, intermediate, or high risk) and four dynamic risk stratification group (excellent, indeterminate, biochemical incomplete, or structural incomplete).

RESULTS

Based on dynamic risk stratification strategy, structural disease was identified 3.9% in the excellent group, 9.7% in the indeterminate group, 76.9% in the biochemical incomplete group, and 100% in the structural incomplete group. The hazard ratios of the structural disease were 18.10 (P < 0.001) in the biochemical incomplete group, and 19.583 (P < 0.001) in the structural incomplete group compared to the excellent group. The prevalence of structural disease also increased as American Thyroid Association initial risk classification increased (5.9% in the low-risk group, 13.6% in the intermediate-risk group, and 45% in the high-risk group). The hazard ratios of structural disease in the high-risk group was 10.296 (P < 0.001) in compared to the low-risk group.

CONCLUSION

Dynamic risk stratification based on patient responses to initial therapy was able to effectively predict the risk of structural disease in a pediatric population, and as a follow-up strategy, may work as well in pediatric differentiated thyroid cancer patients as it does in adult differentiated thyroid cancer patients.

Role of Postoperative Stimulated Thyroglobulin as Prognostic Factor for Differentiated Thyroid Cancer in Children and Adolescents

BACKGROUND

Prognostic factors are essential for risk stratification in patients with differentiated thyroid carcinoma (DTC). The role of stimulated postoperative thyroglobulin (sPOTg) has been well established in adult DTC population, but it remains unclear in children and adolescents. This study aimed to evaluate potential prognostic factors in children and adolescents with DTC, with special emphasis on sPOTg analysis.

METHODS

Individuals aged ≤18 years at diagnosis were selected from a cohort of DTC patients attending the thyroid clinic of a tertiary university-based hospital. Baseline clinical and oncological characteristics, interventions, disease status, and outcomes were obtained from medical records. Clinical variables included in the univariate analysis were sex, age at diagnosis, tumor size, the presence of lymph node and distant metastasis, and sPOTg. Additionally, sPOTg was evaluated using the area under the receiver operating characteristic curve analysis.

RESULTS

Thirty-two children and adolescents with DTC (28 girls, 87.5%; the mean age at diagnosis = 14.7 ± 3.2 years) were included in this study. Thirty-one (96.9%) patients had papillary thyroid carcinoma. The median tumor size was 2.0 cm (P25-75 = 1.6-3.5), 22 patients (68.8%) had lymph node disease, and 5 (15.6%) had distant metastasis at diagnosis. All patients underwent total thyroidectomy, and 29 (90.6%) received radioactive iodine therapy. After a median follow-up of 5.0 years (P25-75 = 2.0-10.0), disease status was available for 27 patients: 15 (55.6%) patients were disease free, six (22.5%) had biochemical disease, and six (22.2%) had persistent structural disease (two cervical and four distant metastasis). Prognostic factors associated with persistent disease in the univariate analysis were lymph node and distant metastasis at diagnosis and sPOTg. According to the receiver operating curve analysis (n = 17 patients), the best sPOTg cutoff to predict disease-free status was 31.5 ng/mL, with a sensitivity and specificity of 100%.

CONCLUSION

The data demonstrate that sPOTg displayed high accuracy in predicting the risk of persistent disease in young patients with DTC.

Predictors of nodal metastasis in pediatric differentiated thyroid cancer

BACKGROUND/PURPOSE

There are limited data identifying risk factors for nodal metastasis in children with differentiated thyroid cancer.

METHODS

The 1998-2011 Surveillance, Epidemiology, and End Results Program database was queried for patients ≤18years of age diagnosed with differentiated thyroid cancer who underwent nodal examination. Patients were grouped by absence or presence of nodal metastasis. Multivariable logistic regression methods were used to identify independent risk factors for nodal metastasis.

RESULTS

In total, 1075 children met study criteria: 734 (68%) had nodal metastases, while 341 (32%) did not. After adjustment, risk factors for nodal metastasis included larger tumor size (1.1-2cm: odds ratio [OR] 2.02, 95% confidence interval [CI] 1.22-3.34, p=0.006; 2.1-4cm: OR 3.37, 95% CI 2.03-5.60, p<0.001; > 4cm: OR 3.39, 95% CI 1.69-6.81, p=0.001), extrathyroidal extension (OR 7.28, 95% CI 4.07-13.01, p<0.001), and multifocal disease (OR 1.94, 95% CI 1.33-2.84, p=0.001).

CONCLUSIONS

Increasing tumor size, extrathyroidal extension, and multifocal disease are independent factors associated with nodal metastases in pediatric differentiated thyroid cancer. If these risk factors are present, children with differentiated thyroid cancer should undergo careful preoperative evaluation for evidence of lateral cervical lymph node metastases, and the central compartment should be evaluated intraoperatively, with consideration of central lymphadenectomy.

LEVEL OF EVIDENCE

Level III.

Pediatric papillary thyroid cancer: current management challenges

Although with a standardized incidence of 0.54 cases per 100,000 persons, differentiated thyroid cancer (DTC) is a rare disease in children and adolescents, it nonetheless concerns ~1.4% of all pediatric malignancies. Furthermore, its incidence is rising. Due to the rarity and long survival of pediatric DTC patients, in most areas of treatment little evidence exists. Treatment of pediatric DTC is therefore littered with controversies, many questions therefore remain open regarding the optimal management of pediatric papillary thyroid cancer (PTC), and many challenges remain unsolved. In the present review, we aim to provide an overview of these challenging areas of patient and disease management in pediatric PTC patients. Data on diagnosis, surgery, radionuclide, and endocrine therapy are discussed, and the controversies therein are highlighted.

Prognostic Factors for Early and Long-Term Remission in Pediatric Differentiated Thyroid Carcinoma: The Role of Sex, Age, Clinical Presentation, and the Newly Proposed American Thyroid Association Risk Stratification System

BACKGROUND

The incidence of pediatric differentiated thyroid carcinoma (DTC) has been rising in recent years, and the main risk factors for recurrence are lymph node and distant metastasis at diagnosis. Other clinical features remain unclear, such as the impact of age, sex, and puberty. Furthermore, until now, this population has been treated using the same strategies used to treat adults. In 2015, the American Thyroid Association (ATA) published the first guidelines targeted at this age group. The aims of this study were to investigate the prognostic factors for early and long-term remission and also to validate the ATA risk stratification proposal in a population outside the United States.

METHODS

Clinical records from 118 patients <18 years old followed in two referral centers were reviewed. The median age was 12 years (range 4-18 years), and 20.3% (24 patients) were <10 years old at diagnosis. The median follow-up was 9.1 years. The majority were female (72%) and received total thyroidectomy and radioiodine therapy (RAI), and 61.8% were treated with more than one dose of RAI. The majority were classified as high risk (48.3%) by the new ATA pediatric guidelines due to distant metastasis (30 patients) or extensive lymph node involvement (27 patients). The remained were classified as low risk (31.3%) and intermediate risk (20.4%).

RESULTS

Females with no lymph node or distant metastasis and low ATA pediatric risk were more likely to have no evidence of disease (p < 0.05) within the first year and also in the long term. In this study, age did not significantly predict outcomes. Furthermore, patients also benefitted from multiple doses of RAI, but when the cumulative activity was >400 mCi, this benefit was diminished.

CONCLUSIONS

This study shows that the ATA risk stratification proposal for pediatric patients is useful in predicting early and long-term outcomes in pediatric patients with DTC. In addition, it shows that sex and metastatic disease are important prognostic factors in pediatric populations.

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.

Recombinant human thyrotropin preparation for adjuvant radioiodine treatment in children and adolescents with differentiated thyroid cancer

AIM

Although recombinant human thyrotropin (rhTSH) is widely used in treating differentiated thyroid cancer (DTC), almost all clinical investigation has been in adults. The aim of our retrospective study was to evaluate outcomes of adjuvant, rhTSH-aided radioiodine treatment in children/adolescents with DTC and to compare them to (131)I therapy during l-thyroxin withdrawal (THW).

METHODS

Patients with the diagnosis of DTC who were ≤18 years of age and had no signs of persistent disease at the time of (131)I treatment were included; 48 patients were treated after rhTSH (rhTSH group) and 82 after THW group. The median time of follow-up after therapy was 67 months and was longer in the THW group (99 vs 43 months, P<0.05).

RESULTS

On the day of (131)I administration, all but one patient had TSH levels above 25 μIU/ml. Peak TSH concentration was significantly higher in the rhTSH group (152 μIU/ml vs 91 μIU/ml). Similarly, the thyroglobulin concentration was higher in the rhTSH group (9.7 ng/ml vs 1.8 ng/ml). No side effects requiring medical intervention were recorded after rhTSH administration. The evaluation of disease outcomes during TSH stimulation (6-18 months after (131)I treatment) revealed equal rates of thyroid ablation (71%) in both groups. During subsequent follow-up, five patients showed recurrence (P>0.05).

CONCLUSIONS

In children/adolescents, rhTSH-aided adjuvant radioiodine treatment is associated with rates of remnant ablation and short-term recurrence similar to THW. As this preparation has several advantages over THW, rhTSH may become the preferred method of TSH stimulation once studies of long-term outcomes show non-inferiority to THW in this age group.

"Clinicopathological features and treatment outcomes of differentiated thyroid cancer in Saudi children and adults"

Introduction

Age is an important prognostic factor in differentiated thyroid cancer (DTC). Our aim was to evaluate differences in clinicopathological features and treatment outcomes among children and adult patients with DTC.

Materials and methods

We studied 27 children (below 18 years) with DTC treated during the period 2000–2012 and were compared with (a) 78 adults aged 19–25 years and (b) 52 adults aged 26–30 years treated during the same period in terms of their clinicopathological features and long term treatment outcomes. Locoregional recurrence (LRR), locoregional control (LRC), distant metastasis (DM), distant metastasis control (DMC), disease free survival (DFS) and overall survival (OS) rates were evaluated.

Results

Mean age of children was 13.5 years (range: 5–18), while mean age of adults was 24.6 years (range: 19–30). In children, female: male ratio was 2.85:1, and in adults female: male ratio was 7.1:1 (P = 0.041). No significant difference in tumor size was seen between the two groups (P = 0.653). According to American Thyroid Association (ATA) risk stratification classification, the children (85.2 %) were found to have at high risk as compared to adults P = 0.001. Post-thyroidectomy complications and RAI induced toxicities were observed more in children than adults (P = 0.043 and P = 0.041 respectively). LRR occurred in 6 (22.2 %), 9 (11.5 %) and 3 (5.8 %) in age groups of <18 years, 19–25 years and 26–30 years respectively (P = 0.032); while DM was seen in 10 (37.0 %), 9 (10.3 %) and 5 (9.6 %) in age groups of <18 years, 19–25 years and 26–30 years respectively (P = 0.002). Ten year DFS rates were 67.3 % in age group below 18 years, 82.4 % in age group of 19–25 years and 90.1 % in age group of 26–30 years (P = 0.021).

Conclusion

At the time of diagnosis, children with DTC were found to have more aggressive clinicopathological characteristics. Comparatively lower LRC, DMC and DFS rates in children warrants further multi-institutional studies.

Determinants of successful ablation and complete remission after total thyroidectomy and ¹³¹I therapy of paediatric differentiated thyroid cancer

PURPOSE

In adult differentiated thyroid cancer (DTC) patients, successful ablation and the number of (131)I therapies needed carry a prognostic significance. The goal was to assess the prognosis of DTC in children and adolescents treated in our centre in relation to the number of treatments needed and to establish the determinants of both complete remission (CR) and successful ablation.

METHODS

Seventy-six DTC patients <21 years of age at diagnosis were included. Recurrence and death rates, rates of CR (=negative stimulated thyroglobulin, negative neck ultrasound and negative (131)I whole-body scintigraphy) and successful ablation (=CR after initial (131)I therapy) were studied.

RESULTS

No patients died of DTC. Seven patients were treated by surgery alone and did not show signs of recurrence during follow-up. Of the 69 patients also treated with (131)I therapy, 47 patients achieved CR, 25 of whom had successful ablation. In multivariate analysis, female gender and the absence of distant metastases were independent determinants of a higher CR rate. Female gender, lower T stage and higher (131)I activity (successful ablation, median activity 3.1 GBq, unsuccessful ablation 2.6 GBq) were determinants of a higher rate of successful ablation. After (131)I therapy no patient showed recurrence after reaching CR or disease progression if CR was not reached.

CONCLUSION

In our paediatric DTC population prognosis is extremely good with no deaths or recurrences occurring regardless of the number of (131)I therapies needed or whether CR was reached. The determinants of CR and successful ablation can be used to optimize the chance of therapy success.

Radioactive iodine (RAI) therapy for distantly metastatic differentiated thyroid cancer (DTC) in juvenile versus adult patients

In general, juvenile differentiated thyroid carcinoma (DTC) demonstrate indolent characteristics and favorable prognosis are observed in comparison with many other carcinomas. However, recurrence is frequent, necessitating additional treatment, including radioactive iodine (RAI) therapy. In this report, the probability of recurrence, prognostic factors, treatment, and outcomes in both juvenile- and adult-onset DTC were analyzed and compared. At our institution, a total of 1552 DTC patients underwent thyroidectomy and/or lymph node dissection. The patients included 23 in their teens, 118 in their twenties, and 1412 in their thirties or older. The risk factors for distant metastases for DTC were male gender, follicular carcinoma, size of the PTC primary tumor, cervical lymph node metastases from PTC, and the presence of more than two distant metastatic foci. Patients with the highest risk underwent RAI ablation in line with institutional guidelines. Although the overall outcome in our juvenile patients was excellent, during follow-up, 4 (17.4%) of the 23 patients developed recurrent disease: 91.3% achieved complete remission, 4.35% partial remission, and 4.35% stable disease, with no disease-related deaths. Among the 118 patients in their twenties to thirties, 1 (0.8%) experienced progressive disease and disease-related death. A younger age at diagnosis and less radical primary surgery without subsequent RAI ablation are factors strongly predictive of distant metastases in patients with juvenile-onset DTC. To reduce the rate of relapse and improve surveillance for recurrent disease, total thyroidectomy followed by RAI appears to be the most beneficial initial treatment for patients with high- and intermediate-risk juvenile DTC.