A National Perspective of the Risk, Presentation, and Outcomes of Pediatric Thyroid Cancer

Trends and predictors of positive surgical margins in pediatric thyroid cancer

OBJECTIVE

To understand trends in positive margin rates in pediatric thyroid cancer over time and investigate predictors of positive margins.

STUDY DESIGN AND SETTING

Retrospective analysis of deidentified National Cancer Database (NCDB) records from 2004 to 2020.

METHODS

The study cohort included pediatric patients (age 18 or younger) with thyroid cancer with available records in the NCDB. The positive margin rate was calculated by year of diagnosis. Multivariable regression was used to assess for predictors of positive margins. Survival analysis was performed stratified by margin status.

RESULTS

We identified 6240 patients who met inclusion criteria. The overall positive margin rate was 15.5 % and did not change significantly over the study period. Positive margins were independently associated with younger age, male gender, total thyroidectomy, papillary histology, and positive lymph node status on multivariable logistic regression models. Hospital volume was not a predictor of positive margin rate. Margin status did not impact overall survival.

CONCLUSION

Positive margins in pediatric thyroid cancer are more likely in younger patients, male patients, those undergoing total thyroidectomy, those with lymph node metastasis, and those with papillary thyroid carcinoma. Hospital volume is not associated with positive margin rate. Positive margins do not impact overall survival in this patient population.

Thyroid surgery in pediatric age: a 10-year experience at a single center and literature review

OBJECTIVES

Surgery interventions for thyroid disorders are rare in pediatric population. This study aims to present our institution's 10-year experience regarding the surgical treatment and outcomes of thyroid pathologies in children and review the literature.

METHODS

All pediatric patients who underwent thyroid surgery at our institution from April 2013 to October 2023 were retrospectively reviewed.

RESULTS

The study included 57 patients with a median age of 15 years. 38 patients (66.6 %) were female, and 19 patients (33.3 %) were male. The most common indication for thyroid surgery was a nodule (71.9 %), followed by Graves' disease (10.5 %), multinodular goiter (8.7 %), and familial multiple endocrine neoplasia syndrome (8.7 %). Of the 57 patients, 36 (63.2 %) were diagnosed with thyroid neoplasia, with 28 (77.8 %) having papillary thyroid carcinoma (PTC), three (8.3 %) having medullary thyroid carcinoma (MTC), two (5.6 %) having follicular thyroid carcinoma (FTC). Temporary unilateral vocal cord paralysis and permanent unilateral vocal cord paralysis were seen in three patients (5.3 %) and in two patients (3.5 %) respectively. Persistent hypocalcemia and permanent hypoparathyroidism were noted in two patients (3.5 %), while transient hypocalcemia was observed in 13 patients (22.8 %). The presence of neoplasm did not appear to be associated with the incidence of hypocalcemia or vocal cord paralysis (p=0.115 and 0.652, respectively).

CONCLUSIONS

Thyroid pathologies in pediatric patients necessitate a multidisciplinary approach. Surgical management should be carefully evaluated in accordance with pediatric guidelines. Complication rate significantly decreases when surgery is performed by experienced surgeon.

Pathologic Characteristics and Surgical Outcomes of Pediatric Versus Adult Well-Differentiated Thyroid Cancer

OBJECTIVE

Despite the rising incidence of pediatric differentiated thyroid cancer (DTC), postoperative outcomes for such tumors have not been well-characterized. The objective of this study was to compare pathologic tumor characteristics and treatment outcomes for pediatric and adult patients with DTC.

STUDY DESIGN

Retrospective case-control study.

SETTING

National database.

METHODS

Pediatric (<18 years old) and adult (≥18 years old) patients who underwent surgery for DTC in the National Cancer Database (2004-2020) were included. Multivariable logistic, negative binomial, and linear regressions were used to compare pathologic tumor characteristics, treatment characteristics, and short-term surgical outcomes.

RESULTS

337,864 patients with DTC met the study eligibility criteria; 3584 (1.1%) were pediatric patients and 334,280 (98.9%) were adults. After adjustment, pediatric patients were found to have higher rates of pathologic T upstaging (adjusted odds ratio [ORadj]: 1.40, 95% confidence interval [CI]: 1.23-1.59), N upstaging (ORadj: 2.53, 95% CI: 2.23-2.88), and extrathyroidal extension (ORadj: 1.58, 95% CI: 1.29-1.94), compared to adult patients. Pediatric patients were also more likely to receive neck dissection (ORadj: 2.80, 95% CI: 2.55-3.07) and radioactive iodine (ORadj: 1.42, 95% CI: 1.30-1.55). Pediatric patients had higher rates of positive surgical margins (ORadj: 1.25, 95% CI: 1.11-1.41) and 30-day readmissions (ORadj: 1.26, 95% CI: 1.00-1.58) than adult patients.

CONCLUSION

These findings demonstrate that pediatric DTC is associated with more aggressive disease presentations, more radical treatment, and worse short-term surgical outcomes compared to DTC in adults. Pediatric DTC should be considered a unique clinical entity that requires personalized evaluation and multidisciplinary treatment by specialized providers.

Surgical management of iSGS in pregnant patients: Survey among North American expertise centers

OBJECTIVE

To identify, group and document the surgical management of idiopathic subglottic stenosis (iSGS) in pregnant women among North American centers with expertise in the treatment of airway stenosis.

BACKGROUND

Idiopathic subglottic stenosis is a rare airway disease that primarily affects women in their third to fifth decade of life. Symptoms of iSGS often worsen during pregnancy and can present as a threat to optimal maternal and fetal health; however there is a lack of evidence addressing the management of iSGS in pregnancy.

STUDY DESIGN

Cross-Sectional Survey Study.

METHODS

A twenty-four question survey was designed to query the surgical management, ventilation, and perioperative considerations for pregnant patients with iSGS. Twenty-nine North American academic tertiary care centers with airway surgery expertise were identified. A designated surrogate for each center was contacted by email to distribute and obtain results of the survey.

RESULTS

17 centers responded. Most centers include differences in perioperative assessment such as frequency of consultation with a maternal/fetal medicine specialist. There is occasional use of a tocometer and rarely a non-stress test. Ventilation with intermittent jet ventilation or high-flow nasal cannula is favored. The surgical protocols include positional modifications, with pregnant patients in the left lateral decubitus position. The preferred timing for intervention is in the second or third trimester.

CONCLUSION

This is the first national survey describing surgical and perioperative considerations for the pregnant patient with iSGS among centers with airway expertise in the United States and Canada.

Changing Clinical Presentation of Pediatric Differentiated Thyroid Cancer in Poland: A Retrospective Cohort Study Spanning 45 Years

Background: Differentiated thyroid carcinoma (DTC) in children is uncommon; clinical presentation over recent decades is incompletely characterized. Methods: This retrospective cohort study analyzed demographic and disease characteristics of consecutive juveniles with DTC treated from 1970 to 2015 at Poland's largest pediatric DTC referral center, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice, who had available records. Sex, age, histopathological characteristics, and DTC stage were documented. We aimed to identify changes in these variables over time and independent risk factors for lymph node or distant metastases. Trends in these variables were assessed using the Cochran-Armitage test and Spearman correlation. Multivariable logistic regression was performed to identify risk factors associated with lymph node or distant metastases. Results: 475 of 479 patients (99.2%) were included in the analysis; roughly half were age ≥15 years, 10%, <10 years. Papillary thyroid carcinoma (PTC) represented 88% of cases and follicular thyroid carcinoma (FTC) 11%. Tumors ≤2 cm constituted 56% of cases with relevant data; those >4 cm accounted for 12%. Multifocality was observed in 37% and extrathyroidal invasion in 22%. Lymph node metastases were noted in 59% and distant metastases in 16%. Over the observation period, significant trends among new cases included: increased proportion of adolescents >15 years; increased frequency of tumors ≤2 cm, decreased multifocality rates, and increased proportion of PTC versus FTC. Extrathyroidal invasion rates remained appreciable throughout, ranging from 17 to 28% during the 5-year study subperiods after 1990. Lymph node metastases significantly increased in frequency in the central neck, remaining consistently common in lateral sites; presence of distant metastases significantly decreased. In multivariable analysis, multifocality, extrathyroidal invasion, and tumor size were independently associated with lateral lymph node metastases and multifocality, larger tumor size, and N1b metastases with distant spread. Conclusions: Our observations of a rising proportion of diagnoses in adolescence, reductions in primary tumor size, and decreased frequency of multifocality and distant metastases may reflect increased detection of patients with less aggressive DTC at earlier disease stages. Nonetheless, we found persistently substantial rates of locoregionally advanced disease features (multifocality, extrathyroidal invasion, and lymph node metastases), which multivariable analyses suggested have significant associations with lateral lymph node and/or distant metastases.

Prediction model for lateral lymph node metastasis of papillary thyroid carcinoma in children and adolescents based on ultrasound imaging and clinical features: a retrospective study

BACKGROUND

The presence of lateral lymph node metastases (LNM) in paediatric patients with papillary thyroid cancer (PTC) is an independent risk factor for recurrence. We aimed to identify risk factors and establish a prediction model for lateral LNM before surgery in children and adolescents with PTC.

METHODS

We developed a prediction model based on data obtained from 63 minors with PTC between January 2014 and June 2023. We collected and analysed clinical factors, ultrasound (US) features of the primary tumour, and pathology records of the patients. Multivariate logistic regression analysis was used to determine independent predictors and build a prediction model. We evaluated the predictive performance of risk factors and the prediction model using the area under the receiver operating characteristic (ROC) curve. We assessed the clinical usefulness of the predicting model using decision curve analysis.

RESULTS

Among the minors with PTC, 21 had lateral LNM (33.3%). Logistic regression revealed that independent risk factors for lateral LNM were multifocality, tumour size, sex, and age. The area under the ROC curve for multifocality, tumour size, sex, and age was 0.62 (p = 0.049), 0.61 (p = 0.023), 0.66 (p = 0.003), and 0.58 (p = 0.013), respectively. Compared to a single risk factor, the combined predictors had a significantly higher area under the ROC curve (0.842), with a sensitivity and specificity of 71.4% and 81.0%, respectively (cutoff value = 0.524). Decision curve analysis showed that the prediction model was clinically useful, with threshold probabilities between 2% and 99%.

CONCLUSIONS

The independent risk factors for lateral LNM in paediatric PTC patients were multifocality and tumour size on US imaging, as well as sex and age. Our model outperformed US imaging and clinical features alone in predicting the status of lateral LNM.

Practice Patterns in the Operative Management of Pediatric Thyroid Disease Across Surgical Specializations

BACKGROUND

Multiple surgical specializations are involved in the operative management of pediatric thyroid disease, but current practice patterns remain unknown. The objective of this study was to examine current practice patterns in the operative management of pediatric thyroid disease, specifically comparing practices across different surgical specializations including pediatric surgery, pediatric otolaryngology, general surgery, adult otolaryngology, and endocrine-focused general surgery.

METHODS

Children 0-18 years-old undergoing thyroid surgery from 2015 to 2019 were identified using the Healthcare Cost and Utilization Project State Inpatient Databases and State Ambulatory Surgery and Services Databases across 6 states. Surgeon specialization was determined for all included surgeons. Patient and hospital characteristics were compared across surgical specializations. Clinical outcomes including hypocalcemia/hypoparathyroidism, recurrent laryngeal nerve injury, hematoma, and wound infection were assessed.

RESULTS

A total of 1241 pediatric thyroidectomies performed by 363 surgeons were included. Procedures were most frequently performed by pediatric surgeons (34.9%). Only 7.2% of procedures were performed by adult general surgeons. There were statistically significant differences in patient age, sociodemographics, surgical indications, and type of procedure performed between specializations (p < 0.05). Endocrine-focused general surgeons had the highest average annual thyroid procedure volume with 78.2 cases/year, and pediatric surgeons and pediatric otolaryngologists had the lowest volumes with 0.7 and 0.6 cases/year, respectively. Overall complication rates were low.

CONCLUSIONS

Operative management of pediatric thyroid disease was most frequently performed by pediatric surgery. Pediatric specializations are more likely to operate on low-income, minority children with public insurance and patients with Graves' disease. Overall complications were low.

LEVEL OF EVIDENCE

III.

The impact of the initial operation of PTC in children on recurrence: 9-year experience in a single center

PURPOSE

To summarize the treatment experience of single-center children with PTC and to explore the influence of initial surgery on the recurrence/metastasis of papillary thyroid carcinoma (PTC) in children.

METHODS

A retrospective analysis of PTC case data of children (≤ 18 years old) who were admitted to and received surgical treatment in the First Affiliated Hospital of Kunming Medical University from January 2012 to December 2020.

RESULTS

A total of 64 children with PTC were included, including 45 cases (70.31%) with a single lesion, and 19 cases (29.69%) with multiple lesions (≥ 2 lesions). Fifteen patients relapsed. Univariate analysis found that gender, thyroidectomy scope, central lymph node dissection, and lateral lymph node dissection were risk factors affecting reoperation; multi-factor analysis showed that central lymph node dissection was an independent risk factor affecting reoperation. According to Kaplan-Meier analysis, central lymph node dissection, total thyroidectomy (TT), lobectomy (LT), and disease-free survival (DFS) were statistically significant (p = 0.000, p = 0.000).

CONCLUSION

At the time of diagnosis of PTC in children, the rate of lymph node metastasis in the central and lateral cervical regions is high. The vast majority of children with PTC should be treated with TT, and LT is chosen for a small number of patients. CND should be routinely lined.

Short-term pediatric thyroidectomy outcome: Analysis of the Pediatric Health Information System (PHIS) database

OBJECTIVE

Thyroidectomy is the most commonly performed pediatric endocrine surgery. Our objective is to measure the short-term outcome of pediatric thyroidectomies, and report on factors associated with postoperative complications.

METHODS

This is a retrospective cohort study, performed using the Pediatric Health Information System (PHIS) database on patients ≤18 years of age, from 47 children's hospitals across the United States, who underwent partial or total thyroidectomy from January 1, 2009 to December 31, 2019.

RESULTS

A total of 6405 patients were included, mostly female (76.8%), and 46.9% were 15-18 years-old. Age <1 year, Hispanic and Black race, comorbidity with complex chronic conditions were associated with more complications. The overall short-term complication rate was 27.7%, with hypocalcemia accounting for the majority (15.6%). Complication rates were lower in benign or non-specific thyroid nodules as compared with malignancy and Graves' disease. Complication rates were significantly lower for partial thyroidectomy versus total thyroidectomy and both neck dissections and parathyroid re-implantations were associated with increased risk of complications. The mean length of stay was 1.4 days. Complications were associated with prolonged hospital stay (2.4 vs. 1.2 days) and increased cost ($19441 vs. $11232) (p < 0.001), but not associated with hospital volume (p = 0.36).

CONCLUSION

Endocrine-related complications accounts for the majority of surgical morbidity following pediatric thyroidectomies performed at pediatric hospitals, and complications does not appear to be correlate with surgical volume. The calculated Achievable Benchmarks of Care (ABC) pooled complication rates from the top performing hospitals may serve as a goal for improvement.

Health-Related Quality of Life at Diagnosis for Pediatric Thyroid Cancer Patients

CONTEXT

Pediatric thyroid cancer (TC) incidence rates are increasing, yet TC has one of the highest survival rates. Despite increased prevalence, little is known about youth adjustment to TC, particularly compared to other pediatric cancers.

OBJECTIVE

The current study sought to describe health-related quality of life (HRQoL) in pediatric TC patients early after diagnosis compared to other pediatric cancer patients and healthy youth and examine predictors of HRQoL.

DESIGN

Patients completed psychosocial questionnaires as part of a clinic-based screening program around time of surgery. TC HRQoL was compared to other pediatric cancer and healthy youth reported norms. Clinical and demographic data extracted from the medical record were examined for predictors of HRQoL.

SETTING

Pediatric Thyroid Center.

PATIENTS AND OTHER PARTICIPANTS

Pediatric TC patients (ages 8.5-23.4 years) and their caregivers.

MAIN OUTCOME MEASURES

Pediatric Quality of Life Inventory (HRQoL) and distress thermometer.

RESULTS

Findings evidenced significantly higher HRQoL for TC patients than other pediatric cancers for all but emotional and school functioning. Compared to healthy youth, TC patients reported significantly lower functioning, except comparable social functioning. No significant differences in HRQoL were identified based on disease severity, thyroid disease history, or treatment. Patient distress was associated with HRQoL.

CONCLUSIONS

The findings suggest general resilience in TC patients compared to youth with other cancers, yet worse HRQoL than peers. Early universal screening is warranted due to a short TC treatment regimen. If administrative barriers preclude comprehensive screening, the single-item distress thermometer may identify patients for further comprehensive screening.

Thyroid cancers in children and adolescents in France: Incidence, survival and clinical management over the 2000-2018 period

INTRODUCTION

Thyroid cancer is the first cause of endocrine malignancy among children. Over the past decades, an increase in the incidence rates (IR) has been observed around the world. Our study aimed to describe epidemiology, therapeutic management and survival rates of children and adolescents with thyroid cancer in France.

METHODS

A population-based study was conducted between 2000 and 2018 in children and adolescents less than 17 years with a diagnostic of thyroid cancer.

RESULTS

A total of 774 thyroid cancers were included: 579 papillary (PTC), 83 follicular (FTC), and 111 medullary carcinomas (MTC). PTC are more frequent in females and in adolescents whereas MTC mainly concerned children, mostly with a familial predisposition. Almost all patients underwent thyroidectomy, completed for most patients with PTC and FTC by radioiodine therapy. Cervical dissection was performed more frequently in patients having PTC and MTC compared to those with FTC. Between 2000 and 2018, thyroid cancers IR in children fluctuated between 1.3 and 3.2 per million, without any significant trend. The median follow-up time was 11.3 years in children, and 5.7 years in adolescents. The 5year-OS was greater than 98.5%.

CONCLUSIONS

Population-based studies are crucial for better understanding and delineation of best management of rare diseases as thyroid cancers in pediatric and adolescent population. Considering the very favorable survival, a stratification should be proposed between cases at low risk and cases at high risk of relapse, in order to consider a strategy of therapeutic de-escalation in the most favorable cases.

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.

Risk factors for lateral lymph node metastasis of papillary thyroid carcinoma in children

INTRODUCTION

Lateral cervical lymph node metastases (LNM) for pediatric patients with papillary thyroid cancer (PTC) is a poor prognostic factor. We aimed to identify risk factors for lateral LNM.

METHODS

This retrospective study had included 48 pediatric patients with papillary thyroid cancer underwent total thyroidectomy and central cervical lymphadenectomy at K hospital from 2016 to 2020.

RESULTS

The number of patients in each T stage was as follows: 24 (50.0%) in stage 1, 9 (18.7%) in Stage 2, 8 (16.7%) in Stage 3, and 7 (14.6%) in Stage 4. Most of the patients had LNM with N1a and N1b rates of 83.3% and 62.5%, respectively. Lung metastases were observed at presentation in three patients (6.3%). Univariate analysis revealed that age (p = 0.021), male (p = 0.011), tumor size > 10 mm (p = 0.002), multifocality (p < 0.001), extrathyroidal extension (p = 0.001) and central LNM (p < 0.001) were factors that increase the risk of metastasis to lateral LNM.

CONCLUSION

Approximately 62.5% of pediatric patients with PTC exhibited lateral LNM at the time of diagnosis. Our study confirmed that multifocality, maximum tumor diameter, extrathyroidal extension and central LNM were independent risk factors for lateral LNM in pediatric PTC.

LEVEL OF EVIDENCE

Level IV.

Perioperative outcomes of thyroid cancer surgery in children and adults: a nationwide inpatient database study in Japan

BACKGROUND

Little is known about perioperative outcomes after pediatric thyroidectomy. This study was performed to compare perioperative outcomes between children and adults undergoing thyroid cancer surgery using a nationwide inpatient database in Japan.

METHODS

Using the Japanese Diagnosis Procedure Combination database, we identified patients aged 0 to 40 years with thyroid cancer who underwent thyroidectomy from July 2010 to March 2020. To compare the occurrence of in-hospital morbidities including local complications (e.g., recurrent laryngeal nerve paralysis, postoperative bleeding), duration of anesthesia, postoperative length of stay, and total hospitalization costs between children (0-18 years) and adults (19-40 years), we used multivariable logistic regression analysis for the occurrence of in-hospital morbidities and linear regression for other outcomes.

RESULTS

For 16,016 eligible patients (666 children vs. 15,350 adults), no significant differences between the two groups were found in any in-hospital morbidity (5.4% vs. 5.9%; adjusted odds ratio [OR], 0.80; 95% confidence interval [CI], 0.57-1.14; P = 0.23), local complications (5.0% vs. 5.5%; OR, 0.80; 95% CI, 0.55-1.15; P = 0.22), recurrent laryngeal nerve paralysis (2.1% vs. 2.4%; OR, 0.78; 95% CI, 0.45-1.35; P = 0.37), or postoperative bleeding (1.7% vs. 1.4%; OR, 0.99; 95% CI, 0.53-1.87; P = 0.98). Children showed a longer duration of anesthesia (difference, 20 minutes; 95% CI, 13-27; P < 0.001) and higher total costs (difference, 445 US dollars; 95% CI, 239-651; P < 0.001) than adults.

CONCLUSION

This large nationwide cohort study showed no significant difference in perioperative complications between children and adults undergoing thyroid cancer surgery.

Effect of surgeon volume on pediatric thyroid surgery outcomes: A systematic review

BACKGROUND

Pediatric thyroidectomy has been identified as a surgical procedure that may benefit from concentrating cases to high-volume surgeons. This systematic review aimed to address the definition of "high-volume surgeon" for pediatric thyroidectomy and to examine the relationship between surgeon volume and outcomes.

METHODS

PubMed, Embase, Cochrane Library, Scopus, Web of Science, ClinicalTrials.gov, and OpenGrey databases were searched for through February 2020 for studies which reported on pediatric thyroidectomy and specified surgeon volume and surgical outcomes.

RESULTS

Ten studies, encompassing 6430 patients, were included in the review. Five single-center retrospective studies reported only on high-volume surgeons, one single center retrospective study reported on only low-volume surgeons, and four national database studies (2 cross sectional, 2 retrospective reviews) reported outcomes for both high-volume and low-volume surgeons. Majority of patients underwent total thyroidectomy (54.9%); common indications for surgery were malignancy (41.7%) and hyperthyroidism/thyroiditis (40.5%). Rates of transient hypocalcemia (11.4% - 74.2%), transient recurrent laryngeal nerve injury (0% - 9.7%), and bleeding (0.5% - 4.3%) varied across studies. Definitions for high-volume pediatric thyroid surgeons ranged from ≥9 annual pediatric thyroid operations to >200 annual thyroid operations (with >30 pediatric cases). Four studies reported significantly better outcomes, including lower post-operative complications and shorter length of hospital stay, for patients treated by high-volume surgeons.

CONCLUSIONS

Despite significant variation in caseloads to define volume, pediatric thyroid patients have generally better outcomes when operated on by higher volume surgeons. Concentration thyroidectomy cases to a smaller cohort of surgeons within pediatric practices may confer improved outcomes.

LEVEL OF EVIDENCE

Systematic Reviews and Meta-Analyses; Level IV.

Prophylactic Central Neck Dissection to Improve Disease-Free Survival in Pediatric Papillary Thyroid Cancer

Background

Pediatric PTC is a rare disease. Although, the prognosis is excellent and the mortality rate is low, the role of prophylactic central neck dissection is still the subject of debate. The aim was to evaluate both the role and safety of prophylactic central neck dissection (CND) in managing pediatric papillary thyroid cancer (PTC), especially in respect of disease-free survival (DFS).

Patients and Methods

In this retrospective study, we collected 54 pediatric cN0 PTC patients (≤ 18 years of age) who were treated from January 2014 to January 2021 at a high-volume thyroid surgery center. Patients were divided into two groups based on the status of prophylactic CND. We analyzed the factors related to the clinicopathological features and recurrence of PTC in children.

Results

Of the 54 cN0 patients, 35 underwent prophylactic CND and 19 patients did not undergo prophylactic CND. The two groups were similar in clinical and pathologic features, such as age, gender, tumor size, multifocal status, and follow-up time. The average DFS was 84.4 ± 2.7 months. Log-rank tests on Kaplan-Meier curves revealed that age, gender, tumor size, multifocality, and extrathyroid extension did not relate to DFS time. Furthermore, DFS time was not affected by the extent of thyroidectomy (p=0.07) or RAI treatment (p=0.21). Prophylactic CND was found to increase DFS time for pediatric patients with cN0 PTC (p = 0.003). There was no statistically significant difference in complications such as transient hypocalcemia (p=0.15) and transient recurrent laryngeal nerve injury (p=0.37) between the prophylactic CND group and the no-prophylactic CND group.

Conclusion

Prophylactic CND was found to be associated with increased DFS and not with increased rates of complications after surgery.

Surgical outcomes in survivors of childhood cancer undergoing thyroidectomy: A single-institution experience

BACKGROUND

Childhood cancer survivors (CCS) are at increased risk for thyroid disease, and many require definitive management with thyroid surgery. Despite this, there is limited evidence on surgical outcomes among CCS. We sought to evaluate postoperative outcomes at our institution among CCS undergoing thyroid surgery compared to patients without a history of primary childhood malignancy.

PROCEDURE

Medical records were reviewed for 638 patients treated at the Children's Hospital of Philadelphia Pediatric Thyroid Center between 2009 and 2020. Rates of surgical complications, including recurrent laryngeal nerve (RLN) paralysis and hypoparathyroidism, among CCS were compared to patients with sporadic/familial thyroid cancer, Graves' disease, and other benign thyroid conditions. Operative time and intraoperative parathyroid hormone levels were also evaluated.

RESULTS

There were no significant differences in long-term surgical complication rates, such as permanent RLN paralysis and hypoparathyroidism, between CCS and patients without a history of primary childhood malignancy (all p > .05). For all surgical outcomes, there were no significant differences in complication rates when CCS were compared to those undergoing surgery for sporadic/familial thyroid cancer or Graves' disease (all p > .05). CCS with benign final pathology had significantly higher rates of transient hypoparathyroidism compared to patients with benign thyroid conditions (p < .001).

CONCLUSIONS

Our study suggests that CCS are not at higher risk of long-term complications from thyroid surgery when treated by high-volume surgeons within a multidisciplinary team.

The clinical aspect of NTRK-fusions in pediatric papillary thyroid cancer

Although adult and pediatric papillary thyroid cancer (PTC) share similar oncogenic drivers, they differ in the pathological features and outcomes of the disease. In adults with PTC, the most frequent genetic alterations are mutually exclusive point mutations in BRAFV600E or the RAS family with BRAFV600E commonly associated with invasive disease and decreased response to radioiodine therapy. In pediatric PTC, fusion oncogenes involving chromosomal translocations in tyrosine kinase (TK) receptors, most commonly RET and NTRK, are often found in patients with lateral neck and distant metastases. This brief report reviews clinical data from a single-institute's cohort of NTRK-driven pediatric PTC cases with an updated review of the literature and comparison to adult NTRK-driven PTC.

Thyroidectomy practice in pediatric population: a national perspective

PURPOSE

To examine presentations and outcomes of pediatric patients underoing thyroidectomy.

MATERIALS AND METHODS

A retrospective cross-sectional analysis of the Nationwide Readmissions Database, 2010-2014, was performed. Study population included pediatric (<18 years) inpatients undergoing thyroidectomy.

RESULTS

A total of 361 patients were included. Mean age was 13.5 ± 0.2 years, and 79.8% were female. Thyroid diseases included: (i) 19.0% thyroid cancer, (ii) 5.4% Multiple Endocrine Neoplasia type II, (iii) 33.6% toxic nodular disease, and (iv) 42.0% non-toxic benign disease. Total thyroidectomy was performed in 67.7% of the patients, and 3.2% of the patients who had initial lobectomy were readmitted within 3 months for completion thyroidectomy. Postoperative complications were reported in 14.2% of the sample, and hypocalcemia was the most common complication (98.2%). Risk of hypocalcemia was significantly higher in patients who had thyroid cancer (risk = 20.9%, p = 0.011) or toxic thyroid diseases (risk = 19.8%, p = 0.033). Of the study population, 25.6% were managed exclusively in children's hospitals. Management in children's hospitals was not associated with improved outcomes or shorter hospital stay; however, it was associated with a significantly higher cost of health services [US $19,4575.0 ± 195.49 vs. US $13,788.00 ± 238.51, p < 0.001].

CONCLUSIONS

This study reports a national perspective on thyroidectomy in the pediatric population. Most thyroid surgeries performed in the pediatric population are performed for benign conditions. Most pediatric thyroidectomies are performed at low-volume centers. Surgeries performed in children's hospitals are significantly higher in cost without any associated improvement in outcomes or length of hospital stay.

The Impact of Hospital Surgical Volume on Healthcare Utilization Outcomes After Pediatric Thyroidectomy

BACKGROUND

A positive relationship between an individual surgeon's operative volume and clinical outcomes after pediatric and adult thyroidectomy is well-established. The impact of a hospital's pediatric operative volume on surgical outcomes and healthcare utilization, however, are infrequently reported. We investigated associations between hospital volume and healthcare utilization outcomes following pediatric thyroidectomy in Canada's largest province, Ontario.

METHODS

Retrospective analysis of administrative and health-related population-level data from 1993 to 2017. A cohort of 1908 pediatric (<18 years) index thyroidectomies was established. Hospital volume was defined per-case as thyroidectomies performed in the preceding year. Healthcare utilization outcomes: length of stay (LOS), same day surgery (SDS), readmission, and emergency department (ED) visits were measured. Multivariate analysis adjusted for patient-level, disease and hospital-level co-variates.

RESULTS

Hospitals with the lowest volume of pediatric thyroidectomies, accounted for 30% of thyroidectomies province-wide and performed 0-1 thyroidectomies/year. The highest-volume hospitals performed 19-60 cases/year. LOS was 0.64 days longer in the highest, versus the lowest quartile. SDS was 83% less likely at the highest, versus the lowest quartile. Hospital volume was not associated with rate of readmission or ED visits. Increased ED visits were, however, associated with male sex, increased material deprivation, and rurality.

CONCLUSIONS

Increased hospital pediatric surgical volume was associated with increased LOS and lower likelihood of SDS. This may reflect patient complexity at such centers. In this cohort, low-volume hospitals were not associated with poorer healthcare utilization outcomes. Further study of groups disproportionately accessing the ED post-operatively may help direct resources to these populations.

Late Recovery of Parathyroid Function after Total Thyroidectomy in Children and Adults: Is There a Difference?

BACKGROUND

Parathyroid failure after total thyroidectomy is the commonest adverse event amongst both children and adults. The phenomenon of late recovery of parathyroid function, especially in young patients with persistent hypoparathyroidism, is not well understood. This study investigated differences in rates of parathyroid recovery in children and adults and factors influencing this.

METHODS

A joint dual-centre database of patients who underwent a total thyroidectomy between 1998 and 2018 was searched for patients with persistent hypoparathyroidism, defined as dependence on oral calcium and vitamin D supplementation at 6 months. Demographic, surgical, pathological, and biochemical data were collected and analysed. <F00_Regular>Parathyroid Glands Remaining</F00_Regular> in Situ (PGRIS) score was calculated.

RESULTS

Out of 960 patients who had total thyroidectomy, 94 (9.8%) had persistent hypoparathyroidism at 6 months, 23 (24.5%) children with a median [range] age 10 [0-17], and 71 (75.5%) adults aged 55 [25-82] years, respectively. Both groups were comparable regarding sex, indication, extent of surgery, and PGRIS score. After a median follow-up of 20 months, the parathyroid recovery rate was identical for children and adults (11 [47.8%] vs. 34 [47.9%]; p = 0.92). Sex, extent, and indication for surgery had no effect on recovery (all p > 0.05). PGRIS score = 4 (HR = 0.48) and serum calcium >2.25 mmol/L (HR = 0.24) at 1 month were associated with a decreased risk of persistent hypoparathyroidism on multivariate analysis (p < 0.05).

CONCLUSION

Almost half of patients recovered from persistent hypoparathyroidism after 6 months; therefore, the term persistent instead of permanent hypoparathyroidism should be used. Recovery rates of parathyroid function in children and adults were similar. Regardless of age, predictive factors for recovery were PGRIS score = 4 and a serum calcium >2.25 mmol/L at 1 month.

Surgical management of parotid non-tuberculous mycobacteria lymphadenitis in children: A pediatric tertiary-care hospital's experience

OBJECTIVE

Non-tuberculous mycobacteria (NTM) represents an important etiology of cervicofacial lymphadenitis (CFL) and skin/soft tissue infections in children. It can also affect the salivary glands, including the parotid gland, which is unique due to the presence of intra-salivary lymph nodes. There are no established guidelines for treatment of NTM CFL. NTM lymphadenitis was historically surgically treated; recently the literature supports initial medical treatment. Treatment decisions have been dependent on the extent of disease, preference of providers, and risk of surgical complications. The goal is to report our experience in surgical outcomes of NTM CFL with involvement of the parotid gland after pre-operative medical management.

METHODS

A retrospective case series of patients with NTM affecting the parotid gland at a tertiary care pediatric hospital between 2004 and 2020.

RESULTS

Seventy-two patients were referred for surgical evaluation of possible parotid NTM. Thirty-three patients underwent surgical excision. Fifteen patients were identified with presumed NTM infection involving the parotid gland. There were twelve females and three males with a mean age of 2.0 years (SD 1.55; range 1-6 days) at the time of surgery. All underwent surgical excision with parotidectomy. The most common pre-operative antimycobacterial therapy used was a combination of clarithromycin and rifampin. All 15 patients had pathological findings consistent with NTM infection (granulomatous lymphadenitis). Forty percent (n = 6) of patients had positive stains with acid-fast bacilli (AFB), with Mycobacterium avium as the most common species (n = 5). The majority of patients, 86.67% (n = 13), had complete resolution of infection after surgery. Clarithromycin and rifampin were the most common post-operative antimycobacterial treatment (mean 81.5 days, SD 110.14, range 2-411 days). The most common complication experienced was acute (<3 months) lower facial nerve paresis (40%, n = 6), but no patient had permanent facial paralysis.

CONCLUSION AND RELEVANCE

Parotidectomy is a safe and efficacious treatment in patients with NTM CFL affecting the parotid gland after incomplete resolution with antimycobacterial therapy. Further investigation to optimize duration of antimycobacterial treatment is necessary. We highlight the experience of a high-volume tertiary care pediatric hospital with surgical management of this disease.

Rate of Incidental Parathyroidectomy in a Pediatric Population

Objective

Incidental parathyroidectomy is a relatively common occurrence in thyroid surgery, which may lead to hypoparathyroidism and postoperative hypocalcemia, but it is not well studied in children. The objectives of this study were to determine the rate of incidental parathyroidectomy, identify potential risk factors, and investigate postoperative complications in children undergoing thyroidectomy.

Study Design

Retrospective cohort study.

Setting

Patients who underwent thyroidectomy over a 10-year period at a tertiary children’s hospital.

Methods

Pathology reports were reviewed to determine incidental parathyroid gland tissue. Additional data collected included patient demographics, type of procedure, underlying thyroid pathology, as well as immediate and long-term postoperative clinical outcomes.

Results

Of 209 patients, 65 (31%) had incidental parathyroidectomy. Several variables were associated with incidental parathyroidectomy on univariable analysis. However, in the final multivariable model, only thyroidectomy with lymph node dissection was associated with increased odds of having incidental parathyroidectomy (odds ratio, 3.3; P = .04; 95% CI, 1.1-9.8). After a median follow up of 1 year, a significantly higher percentage of patients with incidental parathyroidectomy had evidence of long-term hypoparathyroidism (9/62 [15%] vs 3/144 [2%], P = .001).

Conclusion

Incidental parathyroidectomy was relatively common in our pediatric thyroidectomy population, which may be a result of several anatomic, clinical, and surgeon-related factors. Close attention to parathyroid preservation with meticulous surgical technique is the most practical method of preventing long-term hypoparathyroidism and hypocalcemia.

Clinical and Molecular Characterizations of Papillary Thyroid Cancer in Children and Young Adults: A Multicenter Retrospective Study

Background: Papillary thyroid carcinoma (PTC) is a rare malignancy in children and young adults (CAYA). It often presents with aggressive disease patterns and advanced stages, which are clinically distinct from those in adult patients. In this study, we sought to characterize and better understand the clinical variants of PTC in CAYA and explore the underlying mechanisms. Methods: CAYA patients (age ≤18 years) diagnosed with PTC between June 2006 and June 2018 were retrospectively recruited from five hospitals. Demographic information, pathological data, and follow-up status were recorded. Tumor samples obtained from 20 children (mean age 15.15 years) and 10 adults (mean age 38.80 years) underwent comprehensive whole transcriptome sequencing. Differentially expressed genes (DEGs), mutational landscape, and immune infiltration were analyzed. Results: A total of 217 CAYA-PTC patients (162 females and 55 males) with an average age of 14.38 ± 3.53 years (range 2-18) were included. Lymph node metastasis (LNM) was observed in 85.71%, of which 57.60% were in the lateral cervical compartment. Disease recurred in 28 of 217 (12.90%) patients with a median follow-up of 4.76 years. Multivariate logistic regression analysis revealed that age, bilateral disease, extrathyroidal extension, and coexisting Hashimoto's thyroiditis (co-HT) were independent risk factors for LNM, while co-HT was the only risk factor for recurrence. Using whole transcriptome sequencing of PTC tissues, we identified 301 DEGs. Gene Ontology and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analyses showed that differences in immune mediators played important roles, based on the distributions of mutation frequencies, types, and expression levels between CAYA and adult patients. Based on the integrated data sets, we identified significantly mutated immune genes, cluster of differentiation 24 (CD24), coagulation factor 12 (F12), coagulation factor 5 (F5), integrin subunit alpha 3 (ITGA3), and retinoic acid early transcript 1L (RAET1L), which were then verified by immunohistochemistry. Furthermore, resting mast cells, resting natural killer cells, plasma cells, and regulatory T cells were different in the CAYA-PTC group and correlated with the expression of immune checkpoints. Conclusions: There are considerable variabilities that may contribute to the different clinical presentations between CAYA and adult PTC patients, among which the decrease in protective immune cells may be a factor. Collectively, our results add to the possible biological mechanisms involved in CAYA-PTC.

Thyroid Lobectomy for T1 Papillary Thyroid Carcinoma in Pediatric Patients

Importance

The current recommendation for pediatric patients with papillary thyroid cancer (PTC) is a total thyroidectomy. This recommendation applies to all stages of PTC, including papillary thyroid microcarcinoma (≤1 cm, T1a) tumors.

Objective

To evaluate the characteristics of American Joint Committee on Cancer T1 PTC tumors in a large pediatric population and to identify a subgroup of patients who may benefit from a thyroid lobectomy instead of a total thyroidectomy.

Design, Setting, and Participants

This retrospective cohort study was conducted from January 1, 2009, to May 31, 2020. The study took place at a tertiary care medical center and included 102 patients who were surgically treated for T1 PTC: 52 with stage T1a (≤1 cm) tumors and 50 with stage T1b (>1 cm but ≤2 cm) tumors.

Main Outcomes and Measures

Primary outcomes included the presence of bilateral disease and lymph node metastasis.

Results

A total of 102 patients (mean age, 15.3 years [range, 9.7-18.9 years]; 84 girls [82.4%]) were included in the analysis. Among 52 patients with T1a tumors, 10 (19.2%) had bilateral disease, and 15 (28.8%) had central neck lymph node (N1a) metastasis. Among 50 patients with T1b tumors, 10 (20%) had bilateral and 13 (26%) had N1a disease. Of those with T1a, unilateral multifocality was associated with bilateral disease (odds ratio [OR], 2.1; 95% CI, 1.3-3.4) and N1a disease (OR, 5.1; 95% CI, 1.5-17.6). Both N1a disease (OR, 20.0; 95% CI, 3.5-115.0) and ≥4 positive lymph nodes (OR, 8.6; 95% CI, 1.2-60.9) were associated with bilateral disease. In patients with no pathologic evidence of lymph node metastasis (N0), there was a 95% rate of unilateral PTC. In patients with T1b tumors, unilateral multifocality was also associated with bilateral disease (OR, 1.8; 95% CI, 1.3-2.7). Patients with T1b tumors had an increased risk of lateral (N1b) neck lymph node metastasis when compared with those with T1a tumors (OR, 3.7; 95% CI, 1.0-14.5).

Conclusions and Relevance

The findings of this cohort study suggest that, in patients with unifocal T1a PTC without clinically evident nodal disease on preoperative ultrasonography, a thyroid lobectomy and central neck dissection may be considered. If there is no evidence of unilateral multifocality or if there are fewer than 4 positive lymph nodes on postoperative pathology, then close observation may be considered. These findings have substantial clinical implications and may result in practice changes regarding the extent of thyroid surgery on low-stage pediatric PTC.

Pediatric Thyroid Cancer: To Whom Do You Send the Referral?

Simple Summary

Pediatric thyroidectomies are performed by pediatric and adult general surgeons as well as pediatric and adult otolaryngologists. Surgeons may be high or low-volume thyroid surgeons. In this review, we discuss the roles of surgical subspecialty, surgeon volume, and institution volume as they relate to pediatric thyroidectomy outcomes. We also present institutional approaches to multidisciplinary treatment of pediatric thyroid cancer.

Abstract

Pediatric thyroid cancer is rare, but increasing in annual incidence. Differentiated thyroid cancer in pediatric patients is treated surgically. Pediatric thyroidectomies are performed by general surgeons, otolaryngologists, general pediatric surgeons, and pediatric otolaryngologists. In a comprehensive literature review, we discuss the evidence supporting the importance of surgeon subspecialty and surgeon volume on outcomes for pediatric thyroid cancer patients. Pediatric general surgeons and pediatric otolaryngologists perform most pediatric thyroidectomies. Certain subpopulations specifically benefit from a combined approach of a pediatric surgeon and a high-volume thyroid surgeon. The correlation between high-volume surgeons and lower complication rates in adult thyroid surgery applies to the pediatric population; however, the definition of high-volume for pediatric thyroidectomies requires further investigation. The development of dedicated pediatric thyroid malignancy centers and multidisciplinary or dual-surgeon approaches are advantageous.

Association of same-day discharge with hospital readmission after pediatric thyroidectomy

BACKGROUND

Studies have demonstrated that same-day discharge (SDD) following thyroid resection is safe and feasible in adults but there are no similar studies in the pediatric age group. The purpose of this study is to evaluate the influence of SDD on 30-day readmission rates following thyroid surgery in pediatric patients.

METHODS

This retrospective cohort study used the American College of Surgeons National Surgical Quality Improvement Program-Pediatric database to evaluate 30-day readmission rates among patients < 19 years of age who underwent thyroid resection between 2012 and 2017. Patients excluded were those discharged more than 2 days after surgery. The main exposure variable was SDD and the primary outcome was 30-day readmission. Secondary outcomes included wound complications, unplanned reoperation and death. Patient characteristics were compared using chi-squared testing and odds ratios for readmission were calculated using multivariate logistic regression.

RESULTS

Of the 1125 patients (79% female, median age 15 years), 122 (11%) were discharged on the day of surgery. Total or near-total thyroidectomy represented the majority of operations (714, 63.5%) and patients undergoing these operations were less likely to be discharged on the same day as surgery compared to those undergoing thyroid lobectomy (4.3 vs. 22.1%, P < 0.001). Twenty-nine patients were readmitted within 30 days (3 in the same day group, 26 in the later group). There was no difference in the odds of readmission between the two groups (adjusted odds ratio in SDD compared to later discharge 1.04 [95% CI 0.29-3.75, P = 0.96; readmission rate, 2.46 vs. 2.59%). Wound complications were reported in two patients, both in the later discharge group.

CONCLUSION

Same-day discharge in pediatric patients undergoing thyroidectomy is not associated with an increase in 30-day readmissions or wound complications when compared to patients discharged 1 or 2 days after surgery. In selected patients, SDD may be an appropriate alternative to traditional overnight stay.

The Use of the Bethesda System for Reporting Thyroid Cytopathology in Pediatric Thyroid Nodules: A Meta-Analysis

Background: Little is known about the application of the Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) in pediatric thyroid nodules. This meta-analysis was aimed to investigate the use of TBSRTC in the pediatric population. Methods: Relevant articles were searched in PubMed and Web of Science. Meta-analysis of proportion and its 95% confidence interval (CI) were computed utilizing the random-effect model. We used subgroup analyses and meta-regression to explore the sources of heterogeneities. Egger's regression test and funnel plot visualization were used to examine publication bias. Results: We included 17 articles comprising of 3687 pediatric thyroid nodules for meta-analyses. TBSRTC outputs including frequency and risk of malignancy (ROM) for the majority of categories were not statistically different from recently published meta-analysis of 145,066 thyroid nodules in adult patients. The resection rate (RR) in the pediatric group was significantly higher in most of the categories compared with published adult data: benign, 23.2% [CI = 18.6-27.9] vs. 13.0% [CI = 9.5-16.5]; atypia of undetermined significance/follicular lesion of undetermined significance, 62.6% [CI = 50.3-74.9] vs. 36.2% [CI = 29.9-42.5]; follicular neoplasm/suspicious for follicular neoplasm, 84.3% [CI = 75.2-93.4] vs. 60.5% [CI = 54.5-66.5]; and suspicious for malignancy, 93.8% [CI = 90.1-97.6] vs. 69.7% [CI = 64.0-75.5]. Conclusion: TBSRTC is a valuable tool to make clinical decisions for pediatric patients with thyroid nodules. Pediatric patients with benign and indeterminate thyroid nodules had a higher RR than adult counterpart, but ROM of these categories in adults and children was not statistically different suggesting a potential risk of overtreatment in pediatric patients. Determining the best treatment guidelines and additional tools for risk stratification must be a top priority to precisely identify the target patient groups for surgical intervention.

Differentiated Thyroid Cancer in Children and Adolescents: Long Term Outcome and Risk Factors for Persistent Disease

Simple Summary

Despite their excellent prognosis, pediatric differentiated thyroid cancers (P-DTC) often undergo aggressive treatment due to the advanced disease presentation. Reliable risk stratification tools to guide management are needed; unfortunately, the current American Thyroid Association (ATA) classification for P-DTC lacks an unequivocal definition of the three risk categories. In line with previous work, our data confirm a favorable long-term outcome in P-DTC including cases with distant metastases. We propose a modified ATA pediatric risk stratification using a cut-off of five lymph nodes as proposed by the 2015 ATA guidelines for adult DTC. The modified pediatric ATA risk class independently predicted short- and long-term outcome. The utility of applying dynamic risk classification was also confirmed as P-DTC with an excellent response seldom experiences relapse.

Abstract

Background: Pediatric differentiated thyroid cancer (P-DTC) frequently presents with advanced disease. The study aim was to evaluate the outcome of P-DTC and a modified 2015 American Thyroid Association risk classification (ATA-R). Methods: A retrospective study of consecutive P-DTC patients was performed. The ATA-R for P-DTC was used with a cut-off of ≤ 5 N1a for low-risk. The outcome could be excellent response (ER) (thyroglobulin < 1 ng/mL and no evidence of disease (EoD) at imaging), biochemical incomplete response (BIR) (thyroglobulin ≥ 1 ng/mL and no EoD at imaging) or structural incomplete response (SIR) (EoD at imaging). Results: We studied 260 P-DTC (70% females; median age at diagnosis 14 years; 93% total thyroidectomy and 82% lymph node dissection). The ATA-R was low in 30% cases, intermediate in 15% and high in 55%, including 31.5% with distant metastases. Radioiodine treatment was administered in 218 (83.8%), and further radioiodine and surgery was performed in 113 (52%) and 76 (29%) patients, respectively. After a median follow-up of 8.2 years, the outcome was ER in 193 (74.3%), BIR in 17 (6.5%) and SIR in 50 (19.2%). Independent predictors of SIR or BIR at first and last visits were ATA-R intermediate or high. Conclusion: P-DTC has an excellent prognosis. Modified ATA-R is a useful prognostic tool in P-DTC to guide management.

Thyroid and parathyroid surgeon case volume influences patient outcomes: A systematic review

BACKGROUND

The study aim was to systematically review literature evaluating surgeon volume-outcome relationships for thyroid and parathyroid operations in order to inform surgical quality improvement initiatives. Current literature suggests surgeons who perform a high volume of thyroid and/or parathyroid operations have better outcomes than low volume surgeons, though specific volume definition are not standardized.

METHODS

Eligible studies were selected through a literature search focused on the effect of surgeon volume on thyroid and parathyroid surgery patient outcomes. The literature search was conducted in accordance with the PRISMA guidelines. Publication dates extended from January 1998 to February 2021, and were limited to articles published in English.

RESULTS

A total of 33 studies were included: 25 studies evaluating thyroid surgery outcomes, 4 studies evaluating parathyroid surgery outcomes, and 4 studies evaluating both thyroid and parathyroid (mixed) surgery outcomes. Higher volume thyroid and parathyroid surgeons were found to be associated with fewer surgical and medical complications, shorter length of hospital stay, and reduced total cost when compared to lower volume surgeons. This volume-outcome relationship was also found to specifically affect the complication and recurrence rates for thyroid cancer patients undergoing surgery, especially for individuals with advanced stage disease.

CONCLUSION

The heterogeneity in cut-offs used for characterizing surgeons as high versus low volume, and also in subsequent patient outcome measures, limited direct study comparisons. The trend of improved patient outcomes with higher surgeon volume for both thyroid and parathyroid surgeries was consistently present in all studies reviewed.

Initial outcomes at a nascent tertiary pediatric thyroid surgical center

OBJECTIVES

Previous studies on pediatric thyroid surgical complications suggest that high-volume centers achieve improved outcomes. We hypothesize that initial outcomes from a nascent pediatric surgical practice may be comparable to higher volume centers. Furthermore, we determine whether a low-volume center can safely transition to an intermediate or high-volume center.

METHODS

A retrospective chart review was performed for all pediatric patients undergoing thyroid surgery at a single institution from 2014 to 2020. Surgeries were performed by two pediatric otolaryngologists. All patients were managed postoperatively by a multidisciplinary team of physicians that included pediatric otolaryngologists and endocrinologists. Data collection focused on patient demographics and postoperative complications, including rates of recurrent laryngeal nerve injury and permanent hypoparathyroidism.

RESULTS

From 2014 to 2020, a total of 31 patients underwent thyroid surgery at our pediatric thyroid surgery center, 9 of whom underwent neck dissection. The mean age of our cohort was 14.4 ± 3.9 years (range 8 months-20 years). Postoperative pathology results revealed that 15 patients (46.9%) were diagnosed with PTC, 6 (18.8%) with follicular adenoma, and 4 (15.6%) with benign thyroid tissue. One (2.0%) patient had permanent unilateral recurrent laryngeal nerve paralysis and one patient experienced permanent hypoparathyroidism (2.7%).

CONCLUSIONS

Our initial low complication rate as a nascent pediatric thyroid surgery center suggests that favorable outcomes can be achieved at lower volume surgery centers. In order to increase patient access to high-volume pediatric thyroid surgery centers, new centers must start with lower volumes before ultimately becoming high-volume centers. Our study shows that this can be safely achieved.

LEVEL OF EVIDENCE

IV.

Trends and Outcomes of Surgical Management of Primary Papillary Carcinoma in the Pediatric Population

BACKGROUND

Childhood papillary thyroid cancer is more aggressive than carcinomas in adults. Current American Thyroid Association pediatric guidelines recommend a total or near-total thyroidectomy for all pediatric patients without gross evidence of lymph node metastases. Our objective is to analyze trends in the surgical management of pediatric papillary thyroid cancer and assess how well the guidelines are implemented.

METHODS

A retrospective cohort study of pediatric patients (ages 19 y and under) who underwent a thyroidectomy was conducted using the Surveillance, Epidemiology, and End Results database 2006-2017. Procedure type was classified as lobectomy or less and subtotal or total thyroidectomy. Descriptive statistics to illustrate patient and tumor characteristics as well as chi-square analysis to evaluate frequency of treatment with total thyroidectomies versus lobectomy or less were performed. Logistic regression analysis controlling for age, sex, size of tumor, rural versus urban institutions, and surgery year was conducted to identify factors predictive of procedure type.

RESULTS

A total of 2271 children underwent surgical management of papillary thyroid cancer between 2006 and 2017. Most patients received a subtotal or total thyroidectomy as surgical management (n = 2,085, 91.8%). One hundred eighty-six patients (8.2%) received a lobectomy or less. The number of lobectomies or less increased with time, with 41 (6.6%) patients between 2006 and 2009, 98 (8.0%) between 2009 and 2015, and 47 (11.1%) between 2016 and 2017 (P = 0.03). Mortality rates were low (n = 15, 0.7%). On logistic regression analysis, later stages, larger sizes, and earlier operative years were predictive of a near-total or total thyroidectomy.

CONCLUSIONS

Despite the American Thyroid Association Guidelines recommending a total thyroidectomy for pediatric well-differentiated thyroid cancer, the results of this study demonstrate that thyroid lobectomies are being performed in increasing frequency for smaller tumors in earlier stages of disease. Further investigation of whether this trend actually affects the outcomes in this patient cohort is needed.

A quality improvement project for managing hypocalcemia after pediatric total thyroidectomy

Objectives Hypocalcemia following total thyroidectomy (TT) is relatively common. It may result in significant morbidity, prolonged hospital stay, and increased costs. Treatment with intravenous (IV) calcium gluconate may also carry significant risks. In pediatrics, management consensus guidelines are lacking. Methods At Phoenix Children's Hospital, a team of pediatric endocrinologists, surgeons and otolaryngologists developed a clinical pathway for patients undergoing TT. It was a Quality Improvement (QI) project with the primary aim of decreasing IV calcium gluconate use from a baseline of 68% to less than 40% over 15 months. Secondary aims included reducing hypocalcemia and length of hospitalization. Interventions included sending weekly pathway reminder emails, starting pre-operative calcium, and pathway implementation into the electronic health record. Results Twenty-seven patients underwent TT over 15 months. IV calcium gluconate use dropped to 48%. Hypocalcemia and length of hospitalization were 96% and 52.7 h (range 21.1-115.7) respectively. Pathway adherence improved after targeted interventions. Eleven (73%) of the 15 patients whose post-operative parathyroid hormone (PTH) nadir was below 15 pg/mL required IV calcium gluconate vs. two (17%) out of 12 with levels above this threshold. Conclusions Standardizing care allowed for objective outcome analysis. We learned that post-operative serum PTH level was the main risk factor for requiring IV calcium gluconate. Implementing the pathway as a QI project allows for revisions based on outcomes, ultimately resulting in a pathway that best utilizes our infrastructure to optimize care. Other pediatric institutions may face similar challenges and can potentially learn from our experience.

Extrathyroidal Extension is an Important Predictor of Regional Lymph Node Metastasis in Pediatric Differentiated Thyroid Cancer

Introduction: The American Joint Committee Cancer (AJCC) TNM system predicts survival in patients with differentiated thyroid cancer (DTC). In the eighth edition of the AJCC TNM, microscopic extrathyroidal extension (microETE) was removed and tumor size >4 cm was maintained in the definition of T3 disease to reduce unnecessarily aggressive therapy for adults at low risk of death from DTC. In pediatric patients where DTC survival rates are high, the AJCC TNM is used to identify patients at increased risk of persistent, postsurgical disease, to identify patients who benefit from radioactive iodine therapy. The aim of this study was to assess the correlation of microETE with cervical lymph node (LN) metastasis in pediatric patients and to determine if tumor size or microETE is more informative in predicting regional LN disease. Methods: Patients with DTC <19 years of age at the time of thyroidectomy with AJCC T3 tumors (seventh edition) and the presence of LNs on the surgical specimen were included in this retrospective chart review. Pathological findings were confirmed by pathologist review. Results: Forty-five patients with AJCC T3 designation were included, 34 with microETE and 11 without microETE. Of those with microETE, 32 (94.1%) demonstrated regional LN metastasis compared with 5/11 patients (45.5%) without microETE (p = 0.001). In addition, microETE was associated with lateral neck LN metastasis (p = 0.004), bilateral disease (p = 0.001), and tumor multifocality (p = 0.003). Patients with microETE had smaller tumors (median = 2.5 cm, interquartile range [IQR]: 1.6-4.5) compared with patients without microETE (median = 5 cm, IQR: 4.2-5.4; p = 0.02). No increased association was found between microETE and vascular invasion, distant metastasis, or persistent/recurrent disease. Conclusions: In pediatric patients with DTC, microETE is a strong predictor of LN metastasis when compared with tumor size. For patients who do not undergo prophylactic central neck LN dissection, the presence of microETE predicts an increased risk of postsurgical disease and should be included in future revisions of the American Thyroid Association pediatric risk stratification categories.

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.

Bilateral papillary thyroid cancer in children: Risk factors and frequency of postoperative diagnosis

BACKGROUND

The recommendation for children with papillary thyroid cancer (PTC) is total thyroidectomy (TT) based on the incidence of bilateral disease. Evaluating this assumption, we reviewed the characteristics of bilateral PTC in a large cohort of children.

METHODS

A retrospective chart review for patients surgically treated for PTC from 2009 to 2018 analyzing preoperative risk factors, ultrasound findings, and pathology results was performed. Bilateral disease was defined as pathologic PTC in the contralateral lobe, including microscopic disease.

RESULTS

Of the 172 patients included, 38.4% had bilateral disease with 23% diagnosed postoperatively. Multifocal disease on ultrasound was associated with bilateral disease (OR 2.9, 95% CI 1.5-5.9, p = 0.002). Nodule dimension >2 cm was associated with increased risk for postoperative bilateral disease (OR 3.5, 95% CI 1.6-7.4, p = 0.001). Patients with bilateral disease were more likely to have extrathyroidal extension, lymphovascular invasion, positive central lymph nodes, and extranodal extension (p < 0.001 for all). Diffuse-sclerosing variant PTC was also associated with bilateral disease.

CONCLUSION

Thirty-eight percent of children were diagnosed with PTC demonstrate bilateral disease. Nearly one in four have occult bilateral disease. The features that predicted bilateral disease were multifocality, widely invasive PTC on ultrasound, and the presence of lymphadenopathy. Thus, TT is the appropriate surgical approach for pediatric patients with PTC.

TYPE OF STUDY

Clinical Research, Retrospective Review.

LEVEL OF EVIDENCE

Level IV.

Surgical management of benign thyroid disease in children

Benign thyroid disease in children represents a wide spectrum of disease. While most benign thyroid disorders may be either monitored or managed medically, surgery is an important treatment, particularly for Graves' disease or large multinodular goiters. Multidisciplinary teams including specialists in pediatric endocrinology, genetics, radiology, pathology and surgery at high volume centers offer the safest and most effective management.

Pediatric thyroid cancer: Risk factors for central lymph node metastasis in patients with cN0 papillary carcinoma

INTRODUCTION

Prophylactic central neck node dissection (CND) for pediatric patients with papillary thyroid cancer (PTC) is still controversial. We aimed to identify the incidence and the predictive parameters of the central lymph node metastasis (CLN) in pediatric patients with cN0 PTC.

METHODS

This retrospective study had included 32 pediatric patients with cN0 PTC who underwent total thyroidectomy and prophylactic CND from 2015 to 2019.

RESULTS

The proportion of CLN metastasis was 75.0%. Univariate logistic regression demonstrated that CLN metastasis was associated with age (≤15 years; p = 0.028), tumour size > 1 cm (p = 0.008), multifocality (p = 0.028) and external extension (p = 0.041) Multivariate logistic regression revealed that age (≤15 years), multifocality, tumour size (>1 cm) and external extension were independent risk factors of CLN metastasis in pediatric patients.

CONCLUSIONS

In summary, central lymph node metastasis occurred in 75% of cN0 pediatric patient and were more common in larger tumour size (>1 cm), multifocal tumours, extrathyroidal extension, and younger age.

Metabolomics as a potential method for predicting thyroid malignancy in children and adolescents

PURPOSE

To identify potential metabolic biomarkers for distinguishing malignant and benign thyroid nodules in children and adolescents using a metabolomics approach.

METHODS

A total of 96 consecutive patients (median age 14.29 ± 2.31 years, range 9-18 years) who underwent thyroidectomy and 40 healthy controls were enrolled. Patients were assigned to the papillary thyroid carcinoma and benign thyroid adenoma groups according to postoperative pathologic biopsy. Plasma samples were preoperatively collected, and multivariate analysis was performed to identify differential metabolites.

RESULTS

Papillary thyroid carcinoma could be distinguished not only from healthy serum but also from benign thyroid adenoma according to the metabolic profiles. A total of 17 metabolites were identified. Compared with those from benign thyroid adenoma patients and healthy controls, the metabolites from papillary thyroid carcinoma patients, including leucine, lactate, alanine, glycine, acetate, lysine and choline, were increased, while glucose was decreased.

CONCLUSION

The metabolomics method based on proton nuclear magnetic resonance has great potential for identifying papillary thyroid carcinoma in children and adolescents. Lactate and glycine may be used as potential serum markers for the diagnosis of papillary thyroid carcinoma.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level IV.

The utility of intact parathyroid hormone level in managing hypocalcemia after thyroidectomy in children

INTRODUCTION

Hypocalcemia is a common complication after thyroidectomy. Intact parathyroid hormone (PTH) has been successfully used as a predictive indicator for hypocalcemia in adults during the postoperative period. We aim to demonstrate the utility of PTH in predicting and managing postoperative hypocalcemia following thyroidectomy in pediatrics.

METHODS

The study is a retrospective case series including 38 patients up to 18 years of age who underwent total or completion thyroidectomy from 1/1/2010 to 12/31/2016 at a tertiary pediatric academic center. Patient demographics, pathology, postoperative PTH, serum calcium, and length of stay were analyzed.

RESULTS

The median age was 14.3 years (range of 4.3-18.4 years) with 84.2% being female. Thyroid malignancy was noted in 25 patients, and 13 had benign pathology including 8 patients with multinodular goiter and 5 with Grave's disease. In this serie, 63.2% (24/38) developed hypocalcemia (serum calcium <8.5 mg/dL) postoperatively. The median PTH of 15.8 pg/mL in the hypocalcemic group was significantly lower than the median PTH of 41.6 pg/mL in the normocalcemic group (p < 0.001). Using a PTH threshold of 26 pg/mL, hypocalcemia was predicted with a sensitivity of 75%, and specificity of 100%. Six patients with calcium <7.5 mg/dL received teriparatide injections to avoid intravenous calcium replacement. The length of hospital stay for normocalcemic patients was 1.7 ± 0.8 days vs. 2.9 ± 1.4 days for hypocalcemic patients (p = 0.002). We found no correlation between the incidence of hypocalcemia and pathologic indication for surgery. Completion thyroidectomy was associated with a lower risk of hypocalcemia when compared to total thyroidectomy (p = 0.01) and neck dissections carried an increased risk of postoperative hypocalcemia (p = 0.04).

CONCLUSION

Postoperative PTH level has an excellent specificity in predicting hypocalcemia in this pediatric cohort using a threshold of PTH ≤ 26 pg/mL. Those with PTH >26 pg/mL may avoid hypocalcemia by oral calcium replacement with outpatient follow-up. We did not identify a reliable PTH cutoff value above which pediatric patients may be safely discharged immediately following surgery. Adult guideline or pathways that advocate for outpatient thyroidectomy surgery based on normal PTH ≥10 pg/mL in the recovery room may not apply to children.

Relationship between BRAF V600E and clinical features in papillary thyroid carcinoma

OBJECTIVE

To investigate the mutant status of BRAF gene and analyze its relationship to epidemiological risk factors and clinical outcomes among patients with papillary thyroid cancer (PTC) in the largest, single-institution Chinese cohort to date.

METHODS

The medical records of 2048 PTC patients were reviewed in this retrospective study. Single-factor and multiple logistic regression analyses were applied to identify risk factors for BRAF V600E mutation. Survival outcomes including distant metastatic and persistent or recurrent PTC were examined, with a mean follow-up time of 23.4 (5-47) months.

RESULTS

The BRAF V600E mutation was present in 83.7% of patients (1715 of 2048). Correlation was found between BRAF V600E mutation and several epidemiological features, including age, concomitant hypertension and Hashimoto thyroiditis (HT). For the clinicopathological features, BRAF V600E was significantly associated with bilateral multifocality (odds ratio (OR) 1.233, 95% confidence interval (CI) 1.063-1.431, P < 0.01) and less lateral lymph node metastases (OR 0.496, 95% CI 0.357-0.689, P < 0.01). Smaller tumor size and advanced disease stage were significant in single-factor analyses but became insignificant after multivariate adjustment. No association was found between BRAF V600E mutation and extrathyroidal invasion, distant metastatic and disease persistence or recurrence.

CONCLUSION

Part of epidemiological features are independent risk or protective factors for BRAF V600E mutation. The presence of BRAF V600E mutation is not an aggressive prognosis on poor clinical outcomes in PTC. However, the high prevalence of BRAF V600E may provide guidance for surgery strategy and opportunity for targeted treatment in recurrent and advanced stage disease.

The relationships of surgeon volume and specialty with outcomes following pediatric thyroidectomy

BACKGROUND

Previous studies of pediatric thyroidectomies suggest a volume-outcome relationship, but none have focused exclusively on pediatric surgical specialists. Our objective was to examine the effects of pediatric surgeon volume and specialty on post-thyroidectomy outcomes.

METHODS

The Pediatric Health Information System was queried for patients ≤21 years who underwent partial or total thyroidectomy between 2005 and 2016. Multivariable logistic regression with propensity score weighting was used to assess the relationships between surgeon volume or specialty and 90-day thyroidectomy-specific complications. High-volume surgeons/hospitals were defined as those in the top tertile of annual thyroidectomies.

RESULTS

The inclusion criteria were met by 3149 patients. Patients treated by higher-volume surgeons had significantly fewer complications than those treated by lower-volume surgeons (15.0% vs. 19.2%, p = 0.01). Patients with thyroid cancer also had less morbidity when treated by higher-volume surgeons compared to lower-volume surgeons (25.0% vs. 35.1%, p = 0.03), as did children with Graves' disease (19.8% vs. 29.3%, p = 0.007). Patients managed by pediatric surgeons had fewer complications than those managed by pediatric otolaryngologists across all patients (14.0% vs. 22.5%, p < 0.001) and among cancer (25.3% vs. 42.1%, p < 0.001) and Graves' patients (20.1% vs. 37.3%, p < 0.001) specifically.

CONCLUSIONS

Morbidity following pediatric thyroidectomy is associated with surgeon volume.

TYPE OF STUDY

Prognostic Study.

LEVEL OF EVIDENCE

Level II.

Pediatric thyroidectomy: Favorable outcomes can be achieved by a multidisciplinary team of pediatric providers

AIM OF THE STUDY

Recent publications suggest pediatric surgeons may not be well suited to perform thyroid surgeries unless considered high volume. We sought to assess the outcome of thyroidectomies performed by pediatric surgeons in an academic setting.

METHODS

We reviewed charts of patients younger than 18 years who underwent thyroid surgeries at a free standing children's hospital between April 2006 and October 2015.

MAIN RESULTS

The analysis included 118 surgeries in 98 patients (mean age 11.8 years). Most surgeries were performed by a single pediatric surgeon (average 10 thyroidectomies per year). The commonest indication for resection was thyroid nodule (64%). 80% of patients had a single surgery; the remainder had two, including 13 completion hemithyroidectomies. Cancer was found in 37% of specimens, with papillary subtype being most common (72%). Seven patients had locoregional metastases and one had pulmonary metastases. Among the 17 malignant cases that had a second intervention, 6 had malignancy in the resected specimen. There were no deaths in the follow up period (mean 2.7 years). Two patients had permanent hypocalcemia, and three had persistent unilateral recurrent laryngeal nerve injuries causing dysphonia for a total permanent complication rate of 4.2%.

CONCLUSIONS

We conclude that pediatric thyroidectomy is a safe procedure when performed by pediatric surgeons. Our rate of complications is comparable to those reported in the literature. Our data highlight the need for a vigilant and multidisciplinary approach for children with thyroid pathology.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

IV.

Understanding Malignancies of the Thyroid Gland: Institutional Experience

To study the epidemiological, pathological characters and determine survival in patients diagnosed of having thyroid gland malignancies. Retrospective chart review of patients having thyroid gland malignancies, which were managed by the two senior authors at our tertiary care institute from January 2000 to December 2006, were performed and evaluated in terms of various clinical, operative and histological parameters. Patients in which follow up of at least 10 years are available were included in the study. Survival was enquired telephonically in those patients who got cured and did not consent to come for follow up. Slides were reviewed. Statistical analysis was done using SPSS statistical software. Kaplan-Meier method was used for calculating survival. A total of 182 patients were included in the study. Papillary carcinoma was the commonest malignant lesion with a frequency of 87.91% followed by follicular carcinoma (7.69%), medullary carcinoma (3.29%) and anaplastic carcinoma (1.09%). Female predominance was seen (F:M-5.06:1). The 5 year and 10 year survival rates were 89% and 73% respectively. The most common postoperative squeal was transient hypocalcaemia, seen in (27/182) 15% patients which was followed by permanent hypocalcaemia 16/182 (8.79%), transient recurrent laryngeal nerve paresis 12/182 (6.59%) and permanent recurrent laryngeal nerve palsy 8/182 (4.39%). Thyroid malignancies affect all age groups and have good long term prognosis. Management yields promising results and hence early and adequate treatment is emphasized.

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.

Risk factors for hypocalcemia and hypoparathyroidism following thyroidectomy: a retrospective Chinese population study

Background

Hypocalcemia is one of the most common postoperative complications following thyroid surgery in clinical practice. The occurrence of hypocalcemia is mainly attributed to hypoparathyroidism when parathyroid glands are devascularized, injured, or dissected during the surgery. The aim of this study was to analyze the risk factors for hypocalcemia and hypoparathyroidism following thyroidectomy.

Patients and methods

A total of 278 patients who underwent thyroid surgery were analyzed retrospectively. Univariate analysis and multivariable logistic regression were performed to discover the risk factors for hypocalcemia and hypoparathyroidism.

Results

Postoperative hypocalcemia occurred in 76 (27.3%) patients and hypoparathyroidism occurred in 42 (15.1%) patients. Seven factors were significantly related to the presence of postoperative hypocalcemia, namely, age (P=0.049), gender (P=0.015), lateral lymph node dissection (P=0.017), operation type (P<0.001), preoperative parathyroid hormone (PTH) level (P=0.035), operation time (P=0.001), and applying carbon nanoparticles (CNs; P=0.007). Our result revealed that gender (P=0.014), lateral lymph node dissection (P=0.038), operation type (P<0.001), operative time (P<0.001), and applying CNs (P=0.001) had a significant correlation with postoperative hypoparathyroidism.

Conclusion

These findings were crucial for guiding surgeons to prevent the occurrence of hypocalcemia and hypoparathyroidism.