Thyroid carcinoma in children and adolescents-systematic review of the literature

The U-Shaped association between age and distant metastasis in patients with papillary thyroid carcinoma

PURPOSE

To investigate the association between age distribution and synchronous distant metastasis of papillary thyroid carcinoma.

METHOD

Patients with PTC who were treated from January 2013 to December 2018 at a single institute in a cancer referral center in China were retrospectively reviewed. A logistic regression model with restricted cubic splines (RCS) was used to examine the association between age at diagnosis and synchronous distant metastasis.

RESULTS

A total of 111 patients (0.7%) were diagnosed with distant metastasis. The logistic regression model with RCS revealed a "U-shape" association between age and distant metastasis. The RCS curve suggested a U-shaped pattern. The multivariable regression analysis showed that patients in the age groups ≤21 years (OR 2.33, 95% CI 1.09-4.68, P = 0.022) and >55 years (OR 3.32, 95% CI 1.99-5.46, P < 0.001) had a significantly higher incidence of distant metastasis than patients in the age group of 22 to 55 years.

CONCLUSIONS

A U-shaped association was observed between age at diagnosis and synchronous distant metastasis in papillary thyroid carcinoma patients.

Papillary thyroid carcinoma in an 8-year-old Ethiopian child: A case report with literature review

Thyroid nodular disease can present in different forms, such as a solitary nodule, multinodular goiter, nodular goiter caused by autoimmune goiter, and nonpalpable thyroid nodules. Among children, thyroid cancer is the most common type of endocrine cancer. Pediatric thyroid cancer is usually detected as a neck mass without any symptoms, leading to variable stages of progression when diagnosed. Papillary thyroid carcinoma is the most common type of thyroid cancer in children with thyroid nodules. We are presenting a case of an 8-year-old male child who was referred to Jimma Medical Center after he developed swelling on the right side of his neck. On examination, multiple, matted 8 × 6 cm, firm to hard, non-tender right lateral neck masses were found, which moved with swallowing. Thyroid function tests were normal. An ultrasound diagnosis of thyroid carcinoma and a cytologic diagnosis of suspicion for papillary thyroid carcinoma (Bethesda V) was made, and an excisional biopsy was advised. A total thyroidectomy was done. A histopathology diagnosis of Papillary thyroid carcinoma (Classic variant) was made. This is an unusual case of Papillary thyroid carcinoma in an Ethiopian child, with plenty of examples previously recorded in the literature but no such report of its occurrence in our setup to our knowledge. When children under 10 have cervical masses, thyroid cancer should be considered. The evaluation of a palpable thyroid mass typically begins with a blood test to check thyroid function, along with ultrasound and fine-needle aspiration biopsy. Currently, fine-needle aspiration biopsy is the most reliable way to diagnose malignancy and determine the appropriate surgical approach. In most cases, treatment will involve a total thyroidectomy. Lymph node dissection is necessary only if lymph node disease is detected during preoperative evaluation.

Case Series of Surgical Treatment in Pediatric Thyroid Carcinoma in a Single Institution

Introduction

The prevalence of thyroid carcinoma (TC) among pediatric and adolescent populations is infrequent, yet its global occurrence is escalating. Insufficient information pertaining to TC in the pediatric populace of Indonesia presents issues in the identification and management of patients with this condition. The objective of this study is to provide a detailed account of a collection of pediatric TC cases that were recorded at a tertiary care center throughout an extended interval of eight years.

Presentation of Cases

The present study conducted a retrospective data analysis of ten patients who received a diagnosis of TC during the period spanning from 2014 to 2022. The present study focused on analyzing the clinical manifestation, diagnostic measures, treatment modalities, and immediate postoperative consequences of TC. All patients diagnosed with thyroid cancer exhibited the presence of neck lump. Nine patients underwent total thyroidectomy, while one patient underwent isthmolobectomy. The histopathologic evaluation confirmed the diagnosis of thyroid cancer in every individual. There were a significant number of patients, up to 50%, who encountered complications after undergoing surgery. Two patients reported the hoarseness of voice, whereas two other patients experienced the signs of hypocalcemia. Only one patient exhibited both these symptoms simultaneously.

Discussion

The implementation of total thyroidectomy as a surgical intervention in pediatric patients poses a notable challenge. Postoperative monitoring for potential complications following surgery for total thyroidectomy is imperative.

Conclusions

The current study provides evidence that the utilization of total thyroidectomy in combination with lymph node dissection as indicated in patients with lymph node metastases in pediatric patients with thyroid carcinoma leads to a significant reduction in the probability of recurrence of lymph node enlargement. During the performance of surgical procedures, meticulous observation plays a key role in mitigating the risk of postoperative complications, such as hypoparathyroidism, hypocalcemia, and injury to the recurrent laryngeal nerve. Thus, it is imperative to conduct follow-up procedures for post-surgical interventions among pediatric patients diagnosed with TC.

Long-term Treatment of Pediatric Metastatic Papillary Thyroid Cancer With Lenvatinib

Papillary thyroid carcinoma (PTC) is the most common pediatric thyroid malignancy and incidence is increasing. Standard treatment for PTC in pediatric patients includes surgical intervention, suppression of TSH with levothyroxine, and radioactive iodine therapy (RAI) in select patients. In the setting of metastatic PTC or PTC refractory to RAI therapy, tyrosine kinase inhibitors (TKIs), such as lenvatinib, may be used. Until recently, experience with these targeted agents were largely limited to adult patients with progressive or refractory PTC. More recently, increased experience with TKI therapy has been reported in the pediatric population, with case reports and small series describing short-term TKI use. We report the case of a 15-year-old girl with RAI-refractory metastatic PTC who achieved stable disease with long-term lenvatinib treatment for more than 5.5 years. Prospective, longitudinal studies of TKIs in RAI-refractory pediatric PTC are needed.

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.

An Autobiographical Case Report on Papillary Thyroid Carcinoma with Positive Antithyroid Antibodies: Coincidence or Correlated?

The relationship between autoimmunity and cancer has been a gray area, with many theories but no solid proof so far. Hashimoto's thyroiditis is an autoimmune disorder and a major cause of hypothyroidism, while papillary thyroid carcinoma is the most common thyroid malignancy generally found in patients younger than 45 years of age. The literature on the correlation between these two disorders is somewhat based on potentially biased histopathological examination from pre-operative fine needle aspiration and post-thyroidectomy samples. Although recent studies are evaluating a possible holistic molecular, hormonal, and histopathological foundation for this correlation, a clear causal relationship has not been established yet. This report illustrates the author's case presentation, treatment, and eventual outcome of the disease when she was diagnosed with papillary thyroid cancer at the age of 25 years, with positive antithyroid peroxidase and antithyroglobulin antibodies.

Differentiated Thyroid Cancer in Children and Adolescents: Clinicopathological Characteristics of 32 Patients Followed up in our Pediatric Endocrinology Unit

Objectives

This study aims to investigate the clinical and pathological features of patients with differentiated thyroid cancer (DTC) treated at our tertiary care institution.

Methods

Thirty-two children and adolescents followed up with the diagnosis of DTC between 2001 and 2017 were enrolled. We classified patients with DTC into two groups as below and above 10 years of age, and compared their clinical and pathological features.

Results

The mean age at presentation was 11.2±4 years. The female/male ratio was 7 (28:4). The diagnosis was papillary thyroid cancer (PTC) in 90.6% (n=29). The frequencies of lymph node and pulmonary metastases were 53.1% and 21.8%, respectively. The groups were comparable in terms of gender, initial clinical signs and tumor histopathology. The mean tumor size was greater in the younger age group (p=0.008). However, there was no difference between the two groups in terms of lymph node and pulmonary metastases. The pathological parameters associated with tumor aggressiveness were also similar between the groups, except lymphovascular invasion. Lymphovascular invasion was more frequent in the younger age group (p=0.01). Patients with lymph node and pulmonary metastases were more likely to have extrathyroidal extension and lymphovascular invasion.

Conclusion

PTC was the most common type of DTC and presented with considerable rates of lymph node and pulmonary metastases. Tumor size was greater and lymphovascular invasion was more common in younger patients. Overall prognosis was favorable despite high rates of lymph node and pulmonary metastases.

Multi-Omics and Management of Follicular Carcinoma of the Thyroid

Follicular thyroid carcinoma (FTC) is the second most common cancer of the thyroid gland, accounting for up to 20% of all primary malignant tumors in iodine-replete areas. The diagnostic work-up, staging, risk stratification, management, and follow-up strategies in patients who have FTC are modeled after those of papillary thyroid carcinoma (PTC), even though FTC is more aggressive. FTC has a greater propensity for haematogenous metastasis than PTC. Furthermore, FTC is a phenotypically and genotypically heterogeneous disease. The diagnosis and identification of markers of an aggressive FTC depend on the expertise and thoroughness of pathologists during histopathological analysis. An untreated or metastatic FTC is likely to de-differentiate and become poorly differentiated or undifferentiated and resistant to standard treatment. While thyroid lobectomy is adequate for the treatment of selected patients who have low-risk FTC, it is not advisable for patients whose tumor is larger than 4 cm in diameter or has extensive extra-thyroidal extension. Lobectomy is also not adequate for tumors that have aggressive mutations. Although the prognosis for over 80% of PTC and FTC is good, nearly 20% of the tumors behave aggressively. The introduction of radiomics, pathomics, genomics, transcriptomics, metabolomics, and liquid biopsy have led to improvements in the understanding of tumorigenesis, progression, treatment response, and prognostication of thyroid cancer. The article reviews the challenges that are encountered during the diagnostic work-up, staging, risk stratification, management, and follow-up of patients who have FTC. How the application of multi-omics can strengthen decision-making during the management of follicular carcinoma is also discussed.

Characteristics of PTEN Mutation in Thyroid Tumours: A Retrospective Chart Review

While some studies suggest that PTEN mutations correlate with a low-risk phenotype in pediatric thyroid nodules, the relationship between the mutation and malignancy in the adult populations is abstruse. This study investigated whether PTEN mutations result in thyroid malignancy, and whether these malignancies are aggressive. This multicenter study involved 316 patients who underwent preoperative molecular testing, and subsequent lobectomy or total thyroidectomy at two quaternary care hospitals. A four-year retrospective review was performed on the 16 charts of patients that opted for surgery following a positive PTEN mutation on molecular testing results from January 2018 to December 2021. Of the total 16 patients, 37.5% (n = 6) had malignant tumours, 18.75% (n = 3) had non-invasive follicular thyroid neoplasms with papillary-like nuclear features (NIFTPs), and 43.75% (n = 7) had benign disease. Aggressive features were detected in 33.33% of the malignant tumours. Malignant tumours were found to have a statistically significant higher allele frequency (AF). The aggressive nodules were all poorly differentiated thyroid carcinomas (PDTCs) with copy number alterations (CNAs) and the highest AFs.

Thyroid tumor ratio: Improving the assessment of the impact of size in pediatric thyroid cancer

BACKGROUND

The impact of thyroid nodule size is less useful in children who have smaller thyroid volumes than in adults. We investigate using a novel thyroid tumor ratio measurement in children with thyroid cancer.

METHODS

Patient and pathologic characteristics were investigated via Student's t-test in a univariate analysis for any correlation with the log-transformed tumor ratio, followed by a multivariate linear regression.

RESULTS

Of 75 patients with malignancy and tumor ratio information, mean ratio decreased with increasing age (p = 0.04). Out of several clinical factors, patients with lymph node metastases and those treated with postoperative radioactive iodine had significantly higher mean tumor ratios on multivariate analysis (p = 0.04 for both factors).

CONCLUSIONS

Our study is the first to describe thyroid tumor volume in pediatric thyroid cancer and shows that increased tumor ratio was associated with indicators of more advanced disease such as lymph node metastases and use of radioactive iodine.

Puberty and sex in pediatric thyroid cancer: could expression of estrogen and progesterone receptors affect prognosis?

OBJECTIVE

A sharp increase in pediatric thyroid cancer incidence is observed during adolescence, driven mainly by girls. Differences in disease presentation across sexual maturity stages raise the question of whether sex steroids have a role in the heterogeneity. The aims of this study were to analyze the influence of puberty and sex on clinical presentation and prognosis and to evaluate the correlation between the expression of sex hormone receptors.

DESIGN AND METHODS

Clinical records and immunohistochemical of specimens from 79 patients were analyzed. Puberty was analyzed by two criteria: end of puberty and beginning, in which the age of 10 was the cutoff.

RESULTS

Postpubertal were more frequently classified as having low-risk disease and a lower frequency of persistent disease, especially when the completion of puberty was used as the criteria. Male sex was associated with a higher risk of persistent disease at the end of the observation period. Estrogen receptor α positivity was low in the entire sample, while progesterone receptor positivity was positive in 30% of the cases. Female hormone receptor expression was not associated with sex, American Thyroid Association risk score, persistent structural disease, or pubertal status.

CONCLUSION

Our study showed that the completion of puberty correlated best with the clinical behaviour of pediatric thyroid cancer. It was also shown that postpubertal patients have a less aggressive initial presentation and better outcomes. However, this observation could not be explained by the expression of estrogen and progesterone receptors in the primary tumors.

Clinicopathological Profile of Thyroid Carcinoma in Young Patients: An Indonesian Single-Center Study

Introduction

Thyroid cancer is the third most common cancer that occurs in children and adolescents. Papillary thyroid carcinoma (PTC) is the most common type of thyroid malignancy. Although the mortality rate of thyroid malignancy in children is usually low, the disease recurrence is higher in children with more severe clinical presentation than in adults. This study aimed to determine the demographic and clinicopathological characteristics and outcome of pediatric and adolescent patients with thyroid malignancy in Indonesia.

Methods

The retrospective study included all patients diagnosed with thyroid carcinoma aged <20 years, from January 1, 2015, to December 31, 2019. Twenty-nine subjects fulfilled the inclusion and exclusion criteria. We retrieved baseline characteristics, pathology features, TSH and fT4 status, radioactive iodine therapy data, and patients' outcomes. Then, data were analyzed using the chi-square or Fisher's exact method.

Results

We identified 29 eligible subjects, including 3 boys and 26 girls. The most common type of thyroid carcinoma was PTC (96.5%), and follicular type (31%) was the predominant variant of PTC. Lymph node involvement occurred in 24% of patients, while distant metastasis occurred in 17.2% of patients with PTC. Twenty-four (82.7%) patients had stage 1 disease. Disease recurrence was recorded in 31% of patients during the study period with a median follow-up time of 24 months.

Conclusion

PTC is the most frequent type of thyroid carcinoma among children and adolescents. This malignancy has a low mortality rate, but the recurrence rate remains high among younger patients than adults even during a short-term follow-up analysis. Distant metastasis and lymph node involvement are commonly found in this age group.

Papillary thyroid carcinoma in a 5-year old child, mimicking lymphoma in presentation

Thyroid cancer is very rare in children and papillary thyroid carcinoma (PTC) represents the most common type. Patients are frequently in the second decade of life and complain of painless enlargement of the gland. Pediatric PTC has unique clinicopathologic characteristics that make it different from the adult counterpart. The biologic behavior tends to be aggressive and patients frequently present with advanced disease. Herein, we report a case with an unusual presentation. A 5-year-old child manifested with fever, night sweats, cervical lymphadenopathy, and weight loss for 2 months. He also complained of mild cough and shortness of breath. Clinical suspicion of tuberculosis or lymphoma was raised, but laboratory workup was unremarkable. Cervical lymph node excision was done, and the histopathologic examination showed metastatic PTC. The patient underwent surgical and radioactive therapy and remained in complete remission for 5 years. Unfortunately, the disease ultimately relapsed with disseminated metastasis and the patient passed away.

Well-Differentiated Thyroid Cancer Invading the Trachea in a Pediatric Patient

Objectives

Pediatric thyroid cancer is rare. Most cases are well-differentiated thyroid cancers (WDTCs). However, gross laryngotracheal invasion of WDTCs is unusual. This report details the first case in English medical literature of a pediatric WDTC invading the trachea.

Methods

Thyroid stimulating hormone, free triiodothyronine, free thyroxine, thyroglobulin, parathyroid hormone, calcitonin, thyroglobulin antibody, chest magnetic resonance imaging, neck ultrasound, neck computed tomography, and fine needle aspiration were performed.

Results

A 9-year-old boy with moderate persistent asthma presented with increasing upper respiratory symptoms. Spirometry suggested a fixed upper airway obstruction. Chest x-ray revealed a left tracheal shift, and chest magnetic resonance imaging identified a right thyroid mass. Thyroglobulin level was 809 ng/mL (normal, ≤33 ng/mL). Results of thyroid stimulating hormone, free triiodothyronine, free thyroxine, parathyroid hormone, calcitonin, and thyroglobulin antibody were normal. Neck ultrasound revealed 2 right thyroid lobe nodules. Neck computed tomography revealed tracheal compression. Fine needle aspiration of the largest nodule yielded atypia of undetermined significance. Bronchoscopy findings at his local hospital were concerning for tracheal invasion. He underwent total thyroidectomy, cricotracheal resection, reconstruction, and radioactive iodine therapy (220 mCi). Pathology demonstrated a well-differentiated papillary thyroid carcinoma without solid or diffuse sclerosing subtype components. Tumor cytogenetic and single nucleotide polymorphism microarray studies showed normal findings. One year postoperatively, neck ultrasound demonstrated no recurrence, and thyroglobulin levels were undetectable while on levothyroxine therapy.

Conclusion

Pediatric WDTC invading the trachea has not been reported.

Differentiated Thyroid Cancer in Children in the Last 20 Years: A Regional Study in Romania

Pediatric thyroid carcinoma is a current area of interest, because there are few studies in this field; the current classification and treatment guidelines are extrapolated from adults, sometimes leading to overly aggressive treatments or incomplete treatment of the disease. The purpose of this retrospective study is to analyze the presentation, diagnosis, treatment, complications, and outcome of children diagnosed with thyroid cancer in the last two decades (2000–2018) at the Oncological Institute “Prof. Dr. Ion Chiricuță” Cluj-Napoca (IOCN) Romania, a tertiary center in a region with environmental influences from both the nuclear fallout of the Chernobyl accident and from iodine deficiency. The results were compared with those obtained in a previous study carried out in the same institution between 1991–2010, and with those obtained in a similar study carried out in Netherlands between 1970–2013, a cohort of children not exposed to the post-Chernobyl fallout. We statistically analyzed 62 patients. Papillary form was present in the majority of cases, and we highlighted the occurrence of thyroid microcarcinoma in children. A total of 85.4% of patients received radioiodine, the total activity being significantly lower compared with the data from literature. In our study, the prognosis of the disease was excellent, with 100% overall survival.

Genetic Landscape of Papillary Thyroid Carcinoma and Nuclear Architecture: An Overview Comparing Pediatric and Adult Populations

Thyroid cancer is a rare malignancy in the pediatric population that is highly associated with disease aggressiveness and advanced disease stages when compared to adult population. The biological and molecular features underlying pediatric and adult thyroid cancer pathogenesis could be responsible for differences in the clinical presentation and prognosis. Despite this, the clinical assessment and treatments used in pediatric thyroid cancer are the same as those implemented for adults and specific personalized target treatments are not used in clinical practice. In this review, we focus on papillary thyroid carcinoma (PTC), which represents 80-90% of all differentiated thyroid carcinomas. PTC has a high rate of gene fusions and mutations, which can influence the histologic subtypes in both children and adults. This review also highlights telomere-related genomic instability and changes in nuclear organization as novel biomarkers for thyroid cancers.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Overdiagnosis of Juvenile Thyroid Cancer

Overdiagnosis is the detection of a disease that does not do any harm to the patient throughout the lifetime. Thyroid cancer in children is a rare disease; however, since 2011, many children in Fukushima, Japan, have been diagnosed with it, and the number has shown a steady increase to over 200 cases at present. Some experts have stated that this phenomenon is due to overdiagnosis caused by thyroid ultrasound (US)-based thyroid screening detecting self-limiting thyroid cancer, which will not lead to clinical symptoms in the future. Harm caused by overdiagnosis of thyroid cancer is more serious in the young, since it is difficult to perform active surveillance and children diagnosed with cancer are likely to suffer from stigma. Thus, overdiagnosis of thyroid cancer in the young is not only a health problem but also a problem of human rights. Conflicts of interest among people related to screening programs and some experts with incomplete knowledge on overdiagnosis help to spread misleading opinions together with fear of radiation exposure among residents, which has led to their erroneous understanding of the nature of US-based thyroid screening. Scientific and honest discussions among experts to enhance education of residents and consideration of medical ethics are crucial to prevent the expansion of overdiagnosis.

Multifocal papillary thyroid cancer in children and adolescents: 12-year experience in a single center

Background

Thyroid cancer is the most common endocrine malignant disease in children and adolescents. There is a trend of more conservative strategies including lobectomy and less radioactive iodine therapy (RAI) in multifocal papillary thyroid cancer (PTC) for its good survival outcome. The aim of our study was to define long-time outcome of a large cohort of multifocal PTC patients less than 20 years old treated at our institution.

Methods

Data were collected from 276 cases who were initially diagnosis of PTC under the age of 20 from January 2006 to December 2015 at Fudan University Shanghai Cancer Center. All patients received total/near total thyroidectomy or lobectomy. Therapeutic central-compartment (level VI) and lateral neck lymph node dissection performed for patients with clinically involved neck nodes. RAI therapy used in selected patients. No patients received chemotherapy or kinase inhibitor therapy. Thyroid-stimulating hormone (TSH) suppression therapy was performed in all patients for at least 5 years.

Results

Ninety among 276 were multifocal PTC patients and included in this study. The median follow-up time was 54.28 months, ranging from 6.10 to 141.27 months. Fifteen patients had tumor recurrence during the follow-up. On Kaplan-Meier survival curves, lymphovascular invasion and extrathyroidal extension was associated with a decline in recurrence-free survival. However, there was no difference in recurrence-free survival curves in patients no matter which treatment they had received, either lobectomy or total thyroidectomy, RAI or not.

Conclusions

More conservative strategies including lobectomy and less RAI in multifocal PTC among children and adolescents are safe and effective.

[Clinical and morphological characteristics of thyroid tumors in children of the Chelyabinsk Region]

OBJECTIVE

To carry out a clinical and morphological analysis of thyroid cancer cases in the children of the Chelyabinsk Region.

SUBJECT AND METHODS

Thyroid tumor pathology was verified in 50 of the 196 patients aged 7-17 years, who had been operated on in 2000-2016. Clinical and morphological features, including immunohistochemical and ultrastructural characteristics of thyroid cancer, were studied.

RESULTS

Over the past 17 years, there has been a decline in the number of children with surgical thyroid diseases, including thyroid carcinomas. There is a predominance of papillary carcinoma (70%) that is characterized by more aggressive clinical and morphological signs than follicular and medullary thyroid carcinoma. The immunophenotype of follicular cell tumors in children is characterized by the expression of growth factors (TTF-1, EGFR-384) and malignancy markers (mesothelial cell, AMACR (P504S), S 100).

CONCLUSION

The vector change (decrease) in the long-term unfavorable trend toward an increasing incidence of thyroid cancer in children of the Chelyabinsk Region is currently accompanied by the pathomorphism of thyroid carcinoma.

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.

Primary thyroid Burkitt lymphoma in a 15-year-old boy

In children, primary thyroid Burkitt lymphoma (PTBL) is an extremely rare pathologic entity of thyroid malignant tumor. Here we describe a case of PTBL in a 15-year-old boy, who developed a rapidly enlarging neck mass that showed signs of compression. The color Doppler ultrasound revealed diffuse swelling of the thyroid gland, with a solid and irregular mass from the left to the isthmus, which was about 8 × 7 × 5 cm in size. Computed tomography showed Irregular masses were seen in the left thyroid with a range of about 7.1 × 5.4 × 8.0 cm, and a beaded slightly enlarged lymph node with a maximum of 1.6 × 0.8 cm was discovered in the left neck. Postoperative pathologic examination also found the specific starry-sky phenomenon of Burkitt lymphoma. Moreover, immunohistochemistry also indicated that the related cellular immunophenotypic expression was also positive or negative. In particular, the proliferation rate by ki67 was almost 100% and C-MYC was also positive. After thyroidectomy, patient underwent four cycles of CHOP regimen chemotherapy. Unfortunately, the patient died as a result of the deterioration of his condition. This report provides an opportunity to review an uncommon type of PTBL in children.

Association between BRAF (V600E) mutation and clinicopathological features of papillary thyroid carcinoma: a Brazilian single-centre case series

OBJECTIVES

We aimed to investigate the prevalence of the BRAF (V600E) mutation in consecutive cases of papillary thyroid carcinoma (PTC) in patients diagnosed and treated at the Hospital Sao Rafael (Salvador, BA, Brazil) and evaluate its association with clinical and pathological characteristics of PTC.

SUBJECTS AND METHODS

We retrospectively enrolled in the study a total of 43 consecutive PTC patients who underwent total thyroidectomy. We performed DNA extraction from formalin-fixed paraffin-embedded (FFPE) tumour tissue samples. Polymerase chain reaction (PCR) and direct sequencing were used to determine BRAF (V600E) mutation status. Univariate and multivariate logistic regression analyses were employed to identify independent associations.

RESULTS

The prevalence of BRAF (V600E) mutation was 65.1% (28/43). A high frequency of older patients (p value: 0.004) was observed among the BRAF-mutated PTC group and, in contrast, a low frequency of concurrent Hashimoto's thyroiditis (HT) (p value: 0.011) was noted. Multivariate analysis confirmed that older age (OR: 1.15; 95% CI: 1.00 - 1.33; p value: 0.047) and HT (OR: 0.05; 95% CI: 0.006-0.40; p value: 0.005) were independent factors associated with BRAF (V600E) mutation.

CONCLUSION

We found a high prevalence of BRAF (V600E) mutation in PTC cases. Older age and no concurrent HT were independently associated with BRAF (V600E) mutation.

Cervical Lymph Node Metastases of Papillary Thyroid Carcinoma, in the Central and Lateral Compartments, in Children and Adolescents: Predictive Factors

PROBLEM STATEMENT

The aim of our study was to identify predictive factors for lymph node metastases (LNM) in children and adolescents with papillary thyroid carcinoma (PTC) and their impact on survival.

METHODS

The authors conducted an Italian multicentric retrospective analysis on 132 pediatric patients (0-18 years old) affected by PTC between 2000 and 2014. The investigated variables were demographic characteristics of the patients, clinicopathological features of PTCs, and persistence/recurrence of disease. The female/male ratio was 3.1:1. The median age was 14.3 ± 3.5 years (range 4-18 years). Total thyroidectomy was performed in all the patients, followed by lymph node dissection in 87 patients (65.9%). Metastatic lymph node involvement was confirmed in 73 patients (55.3%): lateral compartment (LC) in 25 patients (34.2%), central compartment (CC) in 17 patients (23.3%), and both compartments in 31 patients (42.5%).

RESULTS

Multifocality (P < .00), vascular invasion (P = .04), infiltration of the thyroid capsule (P < .00), minimal extrathyroidal extension (P < .00), diffuse sclerosing variant of PTC (P = .02), and presence of LNM in the LC (P < .00) were significantly associated with LNM in CC. Infiltration of the thyroid capsule (P < .00), massive extrathyroidal extension (P = .03), distant metastases (P = .02), PTC, not otherwise specified (P < .00), and presence of LNM in the CC (P < .00) were significantly associated with LNM in LC. Age, sex and size of PTC were not correlated with the presence of cervical LNM. Moreover, presence of LNM in CC increases the risk of persistence (P < .01) and recurrence (P < .02) of PTC in children and adolescents.

CONCLUSIONS

Most predictors, unfortunately, are only identified post-operatively by histopathologic examination: Just a small part of them can be pre-operatively detected with a low-sensitivity neck ultrasonography. In PTC patients with pre-operative predictors, we suggest an accurate pre- and intra-operative evaluation of CC and/or LC to find suspicious lymph nodes. The presence of LNM in CC has an impact on disease/progression/relapse-free survival. We suggest performing RAI therapy and an accurate follow-up for pediatric patients with only post-operative predictors.

Dynamic Risk Stratification in the Follow-Up of Children and Adolescents with Differentiated Thyroid Cancer

BACKGROUND

Risk stratification for persistent disease is an important step in pediatric differentiated thyroid cancer (DTC) management. The dynamic risk stratification (DRS) is a well validated system for adults, but not yet for children and adolescents. This study evaluated the DRS as well as other prognostic factors in pediatric DTC.

METHODS

Patients aged ≤18 years from four DTC tertiary teaching hospitals in Southern Brazil were included. Clinical characteristics were systematically retrieved, and all patients were classified according to the risk-stratification system of the 2015 American Thyroid Association pediatric DTC guidelines (ATA risk) and according to DRS (excellent, indeterminate, biochemical, or structural incomplete responses). Disease status was evaluated after initial therapy and at last follow-up visit.

RESULTS

Sixty-six patients aged 14.5 ± 3.0 years were studied of whom 54 (81.8%) were girls and 62 (93.9%) had papillary thyroid carcinomas. Tumor size was 2.3 cm (P25-75 1.6-3.5); 41 (63.1%) had cervical and 18 (27.7%) distant metastasis at diagnosis. All patients underwent total thyroidectomy, and 63 (95.5%) received radioiodine. Patients were classified according to DRS after initial therapy (n = 63) as follows: 21 (33%) excellent, 13 (21%) indeterminate, 6 (9%) biochemical, and 23 (37%) structural incomplete responses. Notably, after six years (P25-75 2.7-10.0), most patients remained in the same category. Interestingly, the cutoff analysis of stimulated postoperative thyroglobulin (sPOTg) through receiver operating characteristic curve showed that the value of 37.8 ng/mL showed 81% sensitivity and 100% specificity to predict an excellent response. Prognostic factors associated with persistent disease in the univariate analysis were TNM, ATA risk, DRS, and sPOTg.

CONCLUSION

DRS after initial therapy and sPOTg are strong predictors of disease outcome and might be helpful for defining follow-up strategies in pediatric DTC.

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.

Sorafenib treatment for papillary thyroid carcinoma with diffuse lung metastases in a child with autism spectrum disorder: a case report

BACKGROUND

Pediatric papillary thyroid carcinoma frequently presents with lymph node involvement and distant metastases. Sorafenib, an oral multikinase inhibitor, has been used to treat radioactive iodine (RAI) therapy-refractory thyroid carcinoma in adults; however, pediatric experience is limited. Medical procedures and hospitalization for children with autism spectrum disorder may be challenging.

CASE PRESENTATION

An 11-year-old boy with autism spectrum disorder and moderate intellectual impairment presented with dyspnea on exertion with thyroid carcinoma and diffuses lung metastases. Total thyroidectomy and adjuvant RAI therapy is the standard treatment; however, the latter therapy was impractical because of his respiratory status and challenging behaviors. He was therefore started on sorafenib 200 mg/day (150 mg/m²/day) and this dosage was increased to 400 mg/day (300 mg/m²/day). The adverse effects were mild and tolerable. After administration of medication, his dyspnea improved and surgery was performed. We attempted to administer RAI therapy after surgery; however, we abandoned it because he had difficulty taking care of himself according to isolation room rules. Thyrotropin suppression therapy was therefore started and sorafenib treatment (400 mg/day) resumed. Follow-up imaging showed regression of pulmonary metastases. The metastases have remained stable for over 24 months on continuous sorafenib treatment without serious adverse events.

CONCLUSION

We inevitably used sorafenib as an alternative to standard therapy because of the patient's specific circumstances. Individualized strategies for pediatric cancer patients with autism spectrum disorder are needed.

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.

Thirty-Five Years of Thyroid Cancer Experience in a Paediatric Population: Incidence Trends in Lithuania between 1980 and 2014

BACKGROUND

Thyroid cancer (TC) is a rare condition in children. It may be associated with radiation, iodine deficiency or familial inheritance.

AIMS

The objectives of this study were to analyse the prevalence and incidence trends over 3 decades and clinical features of TC in the paediatric population in Lithuania.

METHODS

We reviewed all TC cases diagnosed in children aged less than 18 years during the period 1980-2014 using medical records from 3 main hospitals in Lithuania where such TC cases are managed.

RESULTS

During the 35-year period (1980-2014) there were 57 cases (45 females) of TC in children in Lithuania. The mean age at the time of diagnosis was 14.51 ± 0.52 years. The crude incidence rate of TC ranged from 0 to 0.93 cases per 100,000 children per year and the mean annual increase was 5.26% (p < 0.001). Papillary carcinoma was the most common histological type (73.7%). No association was found between the incidence of TC and the reported areas of radioactive contamination after the Chernobyl accident. In total, 8.8% of patients had secondary TC after initial radiotherapy of a primary oncologic disease.

CONCLUSION

The incidence of TC in the Lithuanian paediatric population between 1980 and 2014 ranged from 0 to 0.93 cases per 100,000 children per year and there was a 5.26% annual increase (p < 0.001), most probably related to the increased use of ultrasound testing.

Single Point Mutations in Pediatric Differentiated Thyroid Cancer

PURPOSE

Differentiated thyroid cancer (DTC) is rare in children. Previous studies have suggested that it has different clinicopathologic features and mutation profiles compared with adult DTC. However, those studies focused on a single or limited number of gene mutations. This study comprehensively investigated a large series of pediatric DTC for single point mutations in BRAF, HRAS, KRAS, NRAS, PIK3CA, PTEN, and TERT. It also analyzed associations between clinicopathologic features and the BRAF^V600E mutation.

PATIENTS AND METHODS

Eighty-nine consecutive cases seen in children and adolescents (≤18 years) during 1998-2015 were identified. Rare variants of DTC were excluded, and the study focused on 72 (91.1%) classical papillary thyroid carcinoma (PTC) and seven (8.9%) follicular variant PTC. These included 68 (86.1%) females and 11 (13.9%) males, with a median age of 15.5 years (range 8-18 years). The clinical and histopathological data were obtained from medical records. DNA was extracted from paraffin-embedded tumor tissue, and was PCR-amplified and directly sequenced.

RESULTS

Mutations detected included BRAF^V600E in 19/72 (26.4%) classical PTC samples, and in none of seven follicular variant PTC. Other mutations included: 1/78 (1.3%) successfully amplified tumor samples with TERT^C228T; 2/79 (2.5%) NRAS 61 (c.181C>A and c.182A>G); 1/73 (1.4%) PIK3CA exon 9 (c.1589A>G and c.1598C>T in one tumor); 1/79 (1.3%) PIK3CA exon 20 (c.2951G>A); and 1/74 (1.4%) PTEN exon 5 (c.295G>A). No mutation was found in HRAS, KRAS, NRAS12, PTEN exons 6, 7, and 8, and TERT^C250T. No significant association was found between BRAF^V600E mutation and sex, extrathyroidal invasion, tumor multifocality, vascular invasion, lymph node or distant metastases, and persistent/recurrent disease.

CONCLUSIONS

In pediatric DTC, the prevalence of the BRAF^V600E mutation is significantly less common compared with adult DTC, and there is no association between this mutation and the histopathological features and outcome of PTC. PIK3CA, PTEN, NRAS 61, and TERT^C228T mutations are rare.

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.

Classical V600E and other non-hotspot BRAF mutations in adult differentiated thyroid cancer

BACKGROUND

BRAF is the most frequently mutated gene in differentiated thyroid cancer (DTC). Previous studies on DTC have well documented high rates of the BRAF (V600E) mutation in patients of mixed ages. Previous studies either included a mix of pediatric and adult patients or pediatric patients only. However, the prevalence of hotspot and non-hotspot BRAF mutations and its significance in pure adult DTCs is not yet well determined. In this study we determine the frequency of this classical BRAF mutation and other rare BRAF mutations in pure adult DTCs.

METHODS

A total of 204 adult DTC samples (Age >18 years) were analyzed for mutations in exon 15 of the BRAF gene by performing polymerase chain reaction (PCR) amplification of tumor genomic DNAs and direct sequencing of amplicons using Sanger sequencing. Obtained results were correlated to clinical and pathological characteristics of DTCs. Statistical analyses were performed using SPSS (The Statistical Package for Social Sciences) version 20 software.

RESULTS

Overall, BRAF mutations were identified in 48.5 % (99/204) of adult DTCs. Three rare non-hotspot mutations (T599I, T599dup and K601E) were detected in four tumor samples (2 %). One (K601E) of these non-hotspot mutations occurred in conventional papillary thyroid cancer (CPTC) and other three (T599I, T599dup and K601E) were found in follicular variant PTC. We found significant association between BRAF (V600E) mutation and age (P < 0.0001), extrathyroidal invasion (P = 0.017), lymph node metastasis (P = 0.038) and TNM stage III/IV (P = 0.001).

CONCLUSIONS

Our study is the first to report BRAF mutations in a pure adult sample of DTCs of Saudi Arabian ethnicity. Our results show a high rate and a strong prognostic role of the classical BRAF (V600E) mutation and also suggest a common occurrence of non-hot spot mutations in adult DTC from this highly inbred population.

Syndrome-Associated Tumors by Organ System

Certain tumors suggest the possibility of a patient harboring a genetic syndrome, particularly in children. Syndrome-associated tumors of the gastrointestinal tract, genitourinary tract, gynecologic tract, heart, lungs, brain, eye, endocrine organs, and hematopoietic system will be briefly discussed.

Comparison of differentiated thyroid cancer in children and adolescents (≤20 years) with young adults

CONTEXT

Age is a major prognostic factor in differentiated thyroid cancer (DTC). It is not clear if paediatric DTC has a different histopathological profile and outcome than DTC in adult patients <45 years of age.

OBJECTIVE

To assess whether DTC in children and adolescents differs from young age group by comparing paediatric DTC (age ≤ 20) with DTC in patients >20 to <45 years of age.

PATIENTS AND METHODS

We studied all cases of paediatric DTC seen during the period 1998-2011. We compared this group with a large sample of 213 consecutive adult patients in the age group >20 to <45 years seen during the period 1998-1999 in terms of their pathological features, extent of the disease and long-term outcome. Both groups were managed by the same team at a single institution.

RESULTS

A total of 310 DTC were studied including 97 paediatric patients [median age 17 years (range, 8-20)] and 213 young adult patients [median age 33 years (range, 20·5-44·9)]. There was no difference in gender distribution, tumour subtypes, size and tumour multifocality, but there was a significantly higher rate of extrathyroidal extension [40/75 (53·3%) vs 81/213 (38·0%), P = 0·03], lymph node [57/73 (78%) vs 102/183 (55·7%), P < 0·0001] and distant metastases [16/97 (16·5%) vs 8/213 (3·8%), P < 0·0001] in the paediatric than the adult groups. Kaplan-Meier analysis showed a higher risk of persistent/recurrent disease in the paediatric group than adults (log-rank test 0·03). However, there was no mortality secondary to DTC in both groups.

CONCLUSION

Paediatric DTC is distinct from DTC in the young adults (age >20 to <45 years). It is characterized by a higher rate of extrathyroidal extension, lymph node and distant metastases and a higher risk of persistent/recurrent DTC.

Uncommon TERT Promoter Mutations in Pediatric Thyroid Cancer

PURPOSE

The aim of this study was to determine the rate and significance of TERT promoter mutations that have been recently described in adult thyroid cancer (TC) but not yet in the uncommonly occurring pediatric TC. Furthermore, the role of the BRAF(V600E) mutation in the clinical outcome of pediatric TC is unknown.

METHOD

The study included 55 pediatric (median age 16 years, range 9-18 years; 46 females) and 210 adult TC patients (median age 40 years, range 20-75 years; 155 females) seen during the same time period. DNA was isolated from TC tissues and subjected to direct sequencing. Genetic-clinicopathological correlations were analyzed.

RESULTS

Only one case of pediatric TC was found to harbor the C228T TERT promoter mutation (1.8%). The C250T mutation was not detected in any of the 55 pediatric TC. In contrast, there was a significantly higher rate of TERT promoter mutations in the adult patients (15.7%, 33/210) compared with the pediatric patients (p = 0.003). In addition, persistent/recurrent TC was seen in 8/12 (66.7%) pediatric patients harboring the BRAF(V600E) mutation versus 14/41 (34.1%) patients harboring the wild type BRAF (p = 0.05), and when only conventional papillary TC was examined, in 7/9 (77.8%) cases harboring BRAF(V600E) mutation versus 11/33 (33.3%) cases harboring wild type BRAF (p = 0.025).

CONCLUSIONS

This is the first study on TERT promoter mutations in pediatric TC, which revealed an exceedingly low prevalence, suggesting a limited role of these mutations in pediatric TC. This study also for the first time demonstrates an association of the BRAF(V600E) mutation with TC recurrence in pediatric patients.

Long-Term Quality of Life and Pregnancy Outcomes of Differentiated Thyroid Cancer Survivors Treated by Total Thyroidectomy and I(131) during Adolescence and Young Adulthood

Introduction. Differentiated thyroid cancer (DTC) is rare and confers good prognosis. Long-term health related quality of life (HRQoL) and pregnancy outcomes are not well known in subjects treated during adolescence and young adulthood. Methods. Cross-sectional analysis of HRQoL and global self-esteem, using SF-36 and ISP-25 surveys, and of pregnancy outcomes in female survivors of DTC treated by total thyroidectomy and I(131) before age of 25 years. Results. Forty-five of 61 patients (74%) responded to the survey. Cumulative I(131) activity was ≤3.85 GBq in 18 subjects and >3.85 GBq in 27 subjects. Mean time from diagnosis was 7.6 ± 5.2 years for the group ≤ 3.85 GBq versus 16.9 ± 11.6 years for the group > 3.85 GBq (P < 0.05). No significant alteration in long-term HRQoL and global self-esteem was observed. Thirty pregnancies after I(131) were noted in patients from the group > 3.85 GBq and 10 in patients from the group ≤ 3.85 GBq. Frequency of miscarriages was of 17% (group > 3.85 GBq) and 10% (group ≤ 3.85 GBq) with 9 and 24 live births, respectively. No congenital malformations or first year mortality was noted. Conclusion. Long-term HRQoL, global self-esteem, and pregnancy outcomes are not affected in young female survivors of DTC.

An analysis of trends of incidence and cytohistological correlation of papillary carcinoma of the thyroid gland with evaluation of discordant cases

Background:

The role of fine-needle aspiration cytology (FNAC) in thyroid nodules has been well-studied but there is a paucity of studies solely involving papillary thyroid carcinoma (PTC). The diagnostic criteria for PTC are established but still there is a worrisome possibility of false positive and false-negative results, which can have a serious impact on patient care. This article correlates the cytological and histological diagnosis of PTC with an eventual aim of analyzing the cause of false positive and false negative results in order to prevent misdiagnosis. An increase in the incidence of PTC in the younger population has been noted.

Aims:

To analyze the epidemiological trends and cytohistological correlation of PTC and evaluate the discordant cases and pitfalls of FNAC.

Materials and Methods:

Seventy-two cases who had undergone both FNAC and histopathological examination (HPE) of the thyroid gland were selected. Age and sex distribution as well as cytohistological correlation were done for all the cases.

Results:

Cytohistological correlation was 81.94%. False positives were 5.56% and the false negative rate was 13.2%. Sensitivity was 86.7% and the positive predictive value was 93.6%. The peak age was 31-40 years among females and 41-60 years among males. Seven of our patients were <20 years of age (10%).

Conclusion:

FNAC is an indispensible tool for the early diagnosis of PTC. However, certain conditions of the thyroid gland can cause diagnostic dilemma. Awareness of pathologists regarding these pitfalls can prevent misdiagnosis and provide better patient care. Increasing the incidence of PTC with a more striking increase in the younger population makes early diagnosis all the more important owing to better prognosis 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.

Nuclear Medicine in Thyroid Diseases in Pediatric and Adolescent Patients

Both benign and malignant diseases of the thyroid are rare in the pediatric and adolescent population, except congenital hypothyroidism. Nuclear medicine plays a major role, both in the diagnosis and therapy of thyroid pathologies. Use of radioactivity in pediatric population is strictly controlled due to possible side effects such as secondary cancers; therefore, management of pediatric patients requires detailed literature knowledge. This article aims to overview current algorithms in the management of thyroid diseases and use of radionuclide therapy in pediatric and adolescent population.

Radiation exposure and the risk of pediatric thyroid cancer

It has been more than three years since the unprecedentedly massive earthquake and tsunami struck eastern Japan on March 11, 2011, and the large accident occurred at the Fukushima Daiichi Nuclear Power Plant. To investigate the influence of radiation exposure, thyroid ultrasonography has been provided preliminarily for 360,000 children who lived in Fukushima Prefecture at the time of the accident. As of September 2013, 59 children had been diagnosed with thyroid cancer by fine-needle aspiration cytology, and 34 children had been treated surgically and ultimately diagnosed with papillary thyroid cancer. Here, I would like to describe the characteristics of pediatric thyroid cancer and typical thyroid images obtained by ultrasonography.

Thyroid Follicular Carcinoma in a Fourteen-year-old Girl with Graves' Disease

Here we present the case of a 14-yr-old girl who developed thyroid follicular carcinoma accompanied by Graves’ disease. She was diagnosed with Graves’ disease at 10 yr of age and soon achieved a euthyroid state after starting treatment. When she was 13 yr of age, her hyperthyroidism and goiter worsened despite medical therapy. Multiple nodules were found in her enlarged thyroid gland by ultrasonography. Her serum Tg level seemed within the normal range. She underwent near-total thyroidectomy for control of thyroid function. Histopathological study demonstrated that multiple oxyphilic follicular neoplasms were surrounded by the thyroid tissue compatible with Graves’ disease. Capsular invasion was identified in one of the nodules, and thus the histological diagnosis was minimally invasive follicular carcinoma. She did not have signs suggesting metastasis, and has had no relapse for 18 mo after the operation. Although some previous studies showed a high prevalence of thyroid cancer with an aggressive nature in adult patients with Graves’ disease, few reports about thyroid cancer accompanied by Graves’ disease are available in children. The present case, however, suggests that careful investigation is needed when we detect thyroid nodules or progressive thyroid enlargement, especially in children with Graves’ disease.

Long-term survival in young women: hazards and competing risks after thyroid cancer

Background. Differentiated thyroid cancers (DTCs) are one of the most common and survivable cancers diagnosed in women. We examine factors associated with long-term survival and competing risks of death in women diagnosed with DTC under the age of 40 (<40) and aged 40 and older (40+). Methods. SEER data was used to identify DTCs diagnosed in women from 1975 to 2009. We examined overall (OS), disease-specific (DSS), other cancer (OCS), and non-cancer-related (NCS) survival using multivariate Cox proportional hazards modeling. Results. Observed survival was 97.2% for <40 (n = 14,540) and 82.5% for 40+ (n = 20,513). Distant stage (HR = 1.96, 95% CI 1.23–3.07), non-Hispanic Black (HR = 2.04, 95% CI 1.45–2.87), being unmarried (HR = 1.26, 95% 1.03–1.54), and subsequent primary cancers (HR = 4.63, 95% CI 3.76–5.71) were significant for OS in women <40. Age was an effect modifier for all survival outcomes. Racial disparities in NCS were most pronounced for young non-Hispanic black women (HR = 3.36, 95% CI 2.17–5.22). Women in both age groups were more likely to die from other causes. Conclusions. Age at diagnosis remains one of the strongest prognostic factors for thyroid cancer survival. More directed efforts to ensure effective care for comorbid conditions are needed to reduce mortality from other causes.