The role of a more extensive surgical approach in the initial multimodality management of papillary thyroid cancer in children

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.

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.

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 treatment of pediatric and adolescent papillary thyroid cancer: a retrospective study of 54 patients in a single center

OBJECTIVE

In 2015, American Thyroid Association (ATA) issued the first version of Management Guidelines for Children with Thyroid Nodules and Differentiated Thyroid Cancer. The purpose of this study is to evaluate whether the ATA pediatric guidelines recommended surgical approach for the patient can be applied to surgical treatment of pediatric PTC in China.

METHOD

From April 2012 to December 2020, clinical data of children (≤18 years) with PTC consecutively admitted and treated with initial surgery in the study's department were retrospectively reviewed.

RESULTS

The authors found that the central lymph node metastasis (CLNM) rate was significantly higher than that in the lateral neck (83.33 % vs 62.96%, χ² = 5.704, p = 0.017) .The lymph node metastasis rate was significantly lower in cN1b (-) patients than in cN1b (+) patient (55.00% vs 100.00%, χ² = 15.263, p = 0.000); Meanwhile, the CLNM and LLNM rates of ipsilateral were significantly higher than those of contralateral central compartment (83.33༅vs 57.41༅%, χ² = 8.704, p = 0.003). Lymph nodes of 51 lateral lymph node dissection (LND) were analyzed, which revealed the LNM rate of cN1b (-) patients was significantly lower than that of cN1b (+) patients (55.00% vs. 100.00%, χ² = 15.263, p = 0.000).

CONCLUSION

Children and adolescents have a higher rate of lymph node metastasis at the time of diagnosis. TT should be conducted in the majority of children with PTC. CND should be routinely performed; therapeutic LND is recommended for children with cN1b (+).

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

Background

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

Methods

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

Results

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

Conclusions

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

Development and validation of a population-based model for predicting the regional lymph node metastasis in adolescent differentiated thyroid carcinoma

BACKGROUND

Adolescent differentiated thyroid carcinoma (DTC) is a rare type of thyroid cancer that represents a special entity of all endocrine-related cancer. This study aims to establish the first nomogram for predicting the regional (central and lateral) lymph node metastasis (LNM) in the adolescent population for better surgical management.

METHOD

We retrospectively reviewed the clinicopathology characteristics of adolescent patients with DTC in the Surveillance, Epidemiology, and End Results database between 2010 and 2015.

RESULTS

A total of 1,930 adolescent patients between the ages of 10 and 24 years from the SEER database were enrolled in this study. Six predictive factors including age, race, histology, multifocality, extrathyroidal invasion (EI) and tumor size were identified to be significantly associated with the regional LNM via univariate and multivariate logistic regression analyses. These indicators were used to construct a nomogram for predicting the regional LNM in adolescent patients with DTC. Moreover, a satisfied predictive ability of the model was determined with a C-index of 0.794, supported by an internal validation group with a C-index of 0.776. The Decision Curve Analysis and calibration curve further conducted a great agreement in our model.

CONCLUSION

The first predictive model containing multiple factors has been successfully established with good discrimination for predicting the regional LNM in adolescent patients with DTC. This nomogram could effectively help surgeons to make better individualized surgical decision intraoperatively, especially in terms of whether cervical lymph node dissection (LND) is warranted.

Accuracy of the Lymph Node Yield in Surgery for Papillary Thyroid Cancer in Children

INTRODUCTION

Our aim was to determine the accuracy of lymph node yield (LNY) for pediatric patients undergoing thyroidectomy with concurrent lymph nodes harvest for clinically node-negative (cN0) papillary thyroid cancer (PTC).

METHODS

Patients aged ≤ 18 years with cN0 PTC undergoing thyroidectomy were reviewed in the NCDB, 1998-2016. Demographic and clinical characteristics of patients with ≥ 1 LNY were compared to those without. A truncated beta-binomial distribution estimated the number of lymph nodes needed to detect pathologic nodal positivity, and LNY was calibrated for 90% sensitivity in nodal staging and stratified across clinical tumor size staging (T).

RESULTS

1,948 children with cN0 PTC underwent surgical resection; median age was 17 years; 83.2% were female; 47.6% were T1, 25.3% T2, 9.3% T3. 1,272 (65.3%) of these patients had lymph nodes resected, or ≥ 1 LNY. The median LNY was 5 nodes (interquartile range 2-12); 45.9% of patients had ≥ 1 metastatic lymph nodes. In the overall ≥ 1 LNY cohort, 12 nodes (CI 9-19) were needed to predict nodal positivity with > 90% sensitivity. Based on clinical T-stage, detecting a metastatic lymph node with > 90% sensitivity required a LNY of 14 for T1; 8 for T2; 6 for T3.

CONCLUSION

This is the first study estimating the necessary LNY for determining nodal positivity in children with cN0 PTC. The high LNY required in small T1 tumors is likely infeasible and should not be pursued. Accuracy increases with lower LNYs for higher T-stages. Our findings can help guide prognosis and treatment for pediatric patients with PTC.

Total Thyroidectomy vs Thyroid Lobectomy for Localized Papillary Thyroid Cancer in Children: A Propensity-Matched Survival Analysis

BACKGROUND

Current guidelines recommend total thyroidectomy (TT) and radioablation for most papillary thyroid cancer (PTC) in children. These guidelines have been criticized as aggressive, especially for early-stage PTC, as it likely does not influence patient survival and results in life-long thyroid hormone replacement. We sought to study whether the extent of thyroidectomy (TT vs thyroid lobectomy [TL]) influences overall and disease-specific survival in children with localized PTC.

METHODS

The National Cancer Database and the Surveillance, Epidemiology, and End Results registries were queried. Patients 18 years or younger with low-risk PTC between 2004 and 2016 were included. Using a 1:1 propensity score matching, patients who underwent TT were matched for age, sex, race, year of diagnosis, and tumor size with a similar cohort of patients who underwent TL. Primary end points were overall survival and disease-specific survival.

RESULTS

There were 3,500 patients identified as surgically treated for PTC, of which 1,325 patients met inclusion criteria for matching. Three hundred and twenty-six patients were matched. One hundred and sixty-three patients had TT; 140 were female and mean age was 16 years (interquartile range [IQR] 13 to 17 years). One hundred and sixty-three patients had TL; 140 were female and mean age was 16 years (IQR 14 to 17 years). Median follow-up was 5.0 years (IQR 2.8 to 8 years) and 8.3 years (IQR 3.6 to 14.4 years) in the National Cancer Database and Surveillance, Epidemiology, and End Results cohorts, respectively. There was no statistically significant difference in overall survival or disease-specific survival in patients with PTC < 4 cm, regardless of whether patients underwent TT or TL (p = 0.32 for National Cancer Database registry and p = 0.67 for Surveillance, Epidemiology, and End Results registry).

CONCLUSIONS

This study suggests that the extent of thyroidectomy does not influence survival for pediatric patients with early-stage PTC and that TL might be adequate in this patient population.

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.

Management of Differentiated Thyroid Carcinoma in Pediatric Patients

Differentiated thyroid carcinomas are rare in young children but represent almost 10% of all malignancies diagnosed in older adolescents. Differentiated thyroid carcinoma in children is more likely to demonstrate nodal involvement and is associated with higher recurrence rates than seen in adults. Decisions regarding extent of surgical resection are based on clinical and radiologic features, cytology, and risk assessment. Total thyroidectomy and compartment-based resection of involved lymph node basins form the cornerstone of treatment. The use of molecular genetics to inform treatment strategies and the use of targeted therapies to unresectable progressive disease is evolving.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TYPE OF STUDY

Summary review.

LEVEL OF EVIDENCE

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

Management of pediatric differentiated thyroid cancer: An overview for the pediatric oncologist

Differentiated thyroid cancer (DTC) is the most common childhood thyroid malignancy. The standard of care for pediatric DTC is total thyroidectomy followed by radioactive iodine (RAI) treatment when indicated. Molecular changes and potential therapeutic targets have been recently described in pediatric thyroid cancer. Pediatric oncologists are increasingly involved in the evaluation of thyroid nodules in childhood cancer survivors and in the management of advanced thyroid cancer. In 2015, the American Thyroid Association published management guidelines for children with DTC. We provide an overview of the current standard of care and highlight available targeted therapies for progressive or RAI refractory DTC.

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.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Prognosis study, level IV, retrospective case series.

Risk factors of post-surgery complications in children with thyroid cancer

INTRODUCTION

Thyroid cancer in children is a hot topic because of the large clinical heterogeneity and the risk of severe complications. We aimed to study 1. The frequency, 2. Etiology, and 3. Risk factors of post-surgery complications of thyroid cancer.

MATERIAL AND METHODS

A retrospective analysis including risk factors for post-surgery complications of patients treated for thyroid malignancies in years 2006-2018 was performed.

RESULTS

Over a period of 12 years 22 patients with thyroid malignancy (68% female; 12.6 ± 4.0 years of age, median follow-up 6 years) were identified. Histologically, 12 (55%) patients had papillary carcinoma. Six patients (27.3%) had multiple endocrine neoplasia type 2 (MEN2) syndrome, 3 (13.7%) patients had medullary carcinoma and 1 patient had follicular carcinoma. Neck lymph node metastases were diagnosed in 8 (36.4%), distant metastases in 6 (27.3%), and both locations were involved in 4 (18.2%) patients. Six (27.3%) children had surgical complications: 1 child had unilateral vocal cord paralysis and transient hypoparathyroidism and 5 had transient hypoparathyroidism. The higher risk of surgery complications in forward stepwise logistic regression was associated in with distant metastases (R2 = 0.584, OR 52.63, p = 0.010).

CONCLUSIONS

Postoperative complications were significantly associated with presence of distant metastases. Favorable results were observed in with children with MEN2 syndrome.

Clinical Analysis of Pediatric Thyroid Cancer: A Single Medical Institution Experience of 18 Years

OBJECTIVE

The incidence of pediatric thyroid cancer is relatively low compared to the disease in adults. This study aims to present the data in our institution on pediatric thyroid cancer patients, with particular emphasis on the risk factors of recurrence together with treatment outcomes.

SUBJECTS AND METHODS

Between January 2000 and July 2018, patients <20 years who were diagnosed with thyroid carcinoma and primarily treated with surgery at a major large-volume tertiary medical center specializing in thyroid cancer were enrolled. A total of 83 patients were eligible for this study.

RESULTS

The majority of the studied patients were girls and adolescents (age ≥13 years). Papillary thyroid carcinoma (PTC) was the most common pathology (n = 74). PTC tumors >1 cm showed higher rate of lymph node metastasis and extrathyroidal extension than tumors ≤1 cm. All patients survived with nine PTC patients who displayed treatment failure. Age, tumor size, multifocality, lateral lymph node metastasis, and postoperative thyroglobulin levels were significant prognosticators for disease recurrence.

CONCLUSION

Pediatric thyroid cancer is relatively rare and should be considered a specific disease entity with respect to the thyroid cancer in adults, since there are several distinctive characteristics.

The surgical choice for unilateral thyroid carcinoma in pediatrics: Lobectomy or total thyroidectomy?

BACKGROUND

Total thyroidectomy is no doubt the standard procedure for patients with bilateral thyroid carcinoma in pediatrics. However, for lesions confined in unilateral thyroid gland, lobectomy or radical total thyroidectomy is still controversial in pediatrics.

METHODS

Thirty-five cases of pediatric thyroid carcinoma which were confirmed by pathology were retrospectively analyzed in our hospital from 2005 to 2016. In 13 cases of unilateral lesions, 6 received lobectomy, while others underwent total thyroidectomy. Recurrence and complications were compared between 2 groups. Also, there were 20 cases of primary total thyroidectomy and 4 cases of supplementary resection of the residual gland. The short-term complications were compared.

RESULTS

There were no differences between groups of lobectomy and total thyroidectomy in size, extrathyroid extension, stage, cervical lymph nodes metastases, and distant metastases. They were the same in incidence of postoperative hypocalcemia, calcium supplement, recurrent laryngeal nerve damage, and recurrence rate and mortality, except that the length of stay in hospital was shorter in lobectomy group. Patients in supplementary resection were more likely to present the symptoms of postoperative hypocalcemia and hypokalemia, and it was difficult to identify the parathyroid gland during the operation by comparing with patients of primary total thyroidectomy.

CONCLUSIONS

Thyroid carcinoma in pediatrics is inclined to be multifocal, and even in a single focus, the volume is large. Total thyroidectomy does not bring more complications. In contrast, the morbidity increases in staged resection. Endocrine hormone supplement can satisfy the need for growth and development.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

Level III.

Management of Differentiated Thyroid Cancer in Children: Focus on the American Thyroid Association Pediatric Guidelines

First introduced in 1946, radioactive iodine (I-131) produces short-range beta radiation with a half-life of 8 days. The physical properties of I-131 combined with the high degree of uptake in the differentiated thyroid cancers (DTCs) led to the use of I-131 as a therapeutic agent for DTC in adults. There are two indications for the potential use of I-131 therapy in pediatric thyroid disorders: nonsurgical treatment of hyperthyroidism owing to Graves' disease and the treatment of children with intermediate- and high-risk DTC. However, children are not just miniature adults. Not only are children and the pediatric thyroid gland more sensitive to radiation than adults but also the biologic behavior of DTC differs between children and adults as well. As opposed to adults, children with DTC typically present with advanced disease at diagnosis; yet, they respond rapidly to therapy and have an excellent prognosis that is significantly better than that in adult counterparts with advanced disease. Unfortunately, there are also higher rates of local and distant disease recurrence in children with DTC compared with adults, mandating lifelong surveillance. Further, children have a longer life expectancy during which the adverse effects of I-131 therapy may become manifest. Recognizing the differences between adults and children with DTC, the American Thyroid Association commissioned a task force of experts who developed and recently published a guideline to address the unique issues related to the management of thyroid nodules and DTC in children. This article reviews the epidemiology, diagnosis, staging, treatment, therapy-related effects, and suggestions for surveillance in children with DTC, focusing not only on the differences between adults and children with this disease but also on the latest recommendations from the inaugural pediatric management guidelines of the American Thyroid Association.

Conservative or radical surgery for pediatric papillary thyroid carcinoma: A systematic review of the literature

BACKGROUND

Pediatric papillary thyroid carcinoma (PTC) is characterized by an aggressive clinical course. Early diagnosis is a challenge and treatment consists principally of partial or total thyroidectomy±neck dissection and radioactive iodine therapy. Due to the rarity of PTC in children, there is no consensus on optimal surgical treatment.

METHODS AND RESULTS

A literature search was carried out using PubMed, Embase, Medline, Cochrane and Web of Science. Seven studies (489 patients) investigating the outcome of surgically managed pediatric PTC were identified. No clear advantage in survival or recurrence rate was found for total thyroidectomy compared to other surgical approaches.

CONCLUSION

Despite the aggressive behavior of PTC, prognosis is good, with low mortality. After removal of disease and prevention of recurrence, reduction of iatrogenic complications are a priority in this age group. Due to the paucity of available evidence, this review cannot recommend conservative or radical surgery for pediatric papillary thyroid carcinoma. To answer this question, we recommend the establishment of a randomized controlled trial with adequately matched baseline variables.

Management Guidelines for Children with Thyroid Nodules and Differentiated Thyroid Cancer

BACKGROUND

Previous guidelines for the management of thyroid nodules and cancers were geared toward adults. Compared with thyroid neoplasms in adults, however, those in the pediatric population exhibit differences in pathophysiology, clinical presentation, and long-term outcomes. Furthermore, therapy that may be recommended for an adult may not be appropriate for a child who is at low risk for death but at higher risk for long-term harm from overly aggressive treatment. For these reasons, unique guidelines for children and adolescents with thyroid tumors are needed.

METHODS

A task force commissioned by the American Thyroid Association (ATA) developed a series of clinically relevant questions pertaining to the management of children with thyroid nodules and differentiated thyroid cancer (DTC). Using an extensive literature search, primarily focused on studies that included subjects ≤18 years of age, the task force identified and reviewed relevant articles through April 2014. Recommendations were made based upon scientific evidence and expert opinion and were graded using a modified schema from the United States Preventive Services Task Force.

RESULTS

These inaugural guidelines provide recommendations for the evaluation and management of thyroid nodules in children and adolescents, including the role and interpretation of ultrasound, fine-needle aspiration cytology, and the management of benign nodules. Recommendations for the evaluation, treatment, and follow-up of children and adolescents with DTC are outlined and include preoperative staging, surgical management, postoperative staging, the role of radioactive iodine therapy, and goals for thyrotropin suppression. Management algorithms are proposed and separate recommendations for papillary and follicular thyroid cancers are provided.

CONCLUSIONS

In response to our charge as an independent task force appointed by the ATA, we developed recommendations based on scientific evidence and expert opinion for the management of thyroid nodules and DTC in children and adolescents. In our opinion, these represent the current optimal care for children and adolescents with these conditions.

Radioiodine treatment in pediatric Graves' disease and thyroid carcinoma

Graves' disease (GD) is the most common cause of hyperthyroidism in pediatric patients. Most pediatric thyroid cancer is differentiated thyroid cancer (DTC). The two diseases can be treated using different methods, such as antithyroid drug, radioactive iodine (RAI), and surgery for GD and surgery and RAI for DTC. RAI can be used to treat pediatric GD and DTC. In the article, we reviewed the RAI application in pediatric GD and DTC.

Diagnostic utility of fine-needle aspiration cytology in pediatric differentiated thyroid cancer

BACKGROUND

Pediatric patients present with thyroid nodules less often than adults, but the rate of malignancy is much higher. This study was designed to determine the ability of fine-needle aspiration cytology (FNA) to diagnose accurately and facilitate management of thyroid neoplasms in pediatric patients.

METHODS

A retrospective study revealed 110 patients <19 years old who had undergone thyroid surgery and FNA biopsy at two academic institutions over the last 28 years. FNA sensitivity for diagnosing papillary thyroid cancer (PC) and follicular neoplasm (FN) was investigated.

RESULTS

Of 110 patients who presented for surgery, 27 had PC and 33 had a FN: 4 follicular carcinomas (FCs) and 29 follicular adenomas (FAs). Among the PCs patients, the FNA results were as follows: 1 (4%) nondiagnostic, 6 (22%) atypical, 2 (7%) benign, and 18 (67%) malignant lesions. The sensitivity of a malignant FNA was 90% for diagnosing a PC. Sensitivity of an atypical FNA was 75% for FCs and 69% for FAs, giving an overall FN sensitivity of 70%. Of the atypical FNA readings, 60% had confirmed histological atypical features, and 19% were malignant. In 95% of the malignant FNA reports, final histology confirmed PC, resulting in a positive predictive value of 95%.

CONCLUSIONS

FNA biopsy can reliably diagnose malignancy in pediatric thyroid patients and should be used as a standard technique to indicate surgical treatment. Atypical or suspicious FNA results do not predict cancer effectively, confirming the current accepted practice for adults that diagnostic excision is required to exclude malignancy in pediatric patients.

Surgical management of well-differentiated thyroid cancer: state of the art

Nonmedullary well-differentiated thyroid cancer (WDTC) comprises a group of tumors including papillary thyroid carcinoma (PTC) and follicular thyroid carcinoma (FTC), with Hürthle cell carcinoma being a subtype of follicular carcinoma. This article reviews the epidemiology, pathogenesis, preoperative and diagnostic evaluation, imaging, and staging of WDTC. Different approaches to therapy and follow-up care are discussed. The prognosis for WDTC remains good and most patients can expect to be cured of their disease.

Treatment strategy of papillary thyroid carcinoma in children and adolescents: clinical significance of the initial nodal manifestation

BACKGROUND

Risk factors and treatment strategy in younger patients with papillary thyroid carcinoma are still controversial.

METHODS

We reviewed 120 consecutive papillary thyroid carcinoma patients younger than 20 years who underwent initial surgery between 1977 and 2004 (14 male and 106 female subjects; mean age, 16.3 years; mean follow-up, 11.6 years). Outcomes were evaluated initially, and risk factors for disease-free survival (DFS) were analyzed statistically. Cox proportional multivariate analysis revealed that initial nodal manifestation (P < .001, hazard ratio 2.97) was the most statistically significant risk factor for DFS. The outcomes were then compared between four subgroups on the basis of the initial nodal manifestation and node dissection: 17 patients in group A (no lymphadenopathy, no or only prophylactic central dissection), 30 patients in group B (no lymphadenopathy, prophylactic modified neck dissection, MND), 46 patients in group C (nonpalpable lymphadenopathy detected by radiological or operative findings, therapeutic MND), and 27 patients in group D (palpable lymphadenopathy, therapeutic MND).

RESULTS

Subtotal/total thyroidectomy and radioactive iodine therapy were performed for 47.1 and 0% in group A, 33.3 and 0% in group B, 43.4 and 10.9% in group C, and 85.1 and 48.1% in group D, respectively. In groups A, B, C, and D, 0%, 3.3%, 28.3%, and 48.1% developed recurrence, respectively (P < .001). DFS Kaplan-Meier curves differed significantly among the four subgroups (P < .0005).

CONCLUSIONS

Initial nodal manifestation is useful to predict DFS in younger papillary thyroid carcinoma patients. Our findings will be beneficial to determine the treatment strategy. Conservative therapy is considered acceptable for patients without risk factors.

Total thyroidectomy for benign disease in the pediatric patient--feasible and safe

PURPOSE

Total thyroidectomy (TT) is a safe and efficacious treatment of malignant thyroid disease in children. The role of TT in benign thyroid disease is less well-defined. The goal of this study was to compare the safety of TT performed for benign and malignant disease.

METHODS

The medical records of 31 patients undergoing TT from January 2000 to June 2007 at a single center were reviewed. The benign cohort totaled 15 patients consisting of 12 with Graves' disease, 2 with hyperthyroidism, and 1 with large and symptomatic multinodular goiter. The malignant cohort totaled 16 patients consisting of 9 with malignant disease, 4 with a nodule and history of cancer or radiation exposure, and 3 with RET proto-oncogene mutations.

RESULTS

The most common complication was transient hypocalcemia observed in 7 (46%) of 15 patients with benign disease and 9 (56%) of 16 patients with malignancy (P = .72). Permanent hypocalcemia, defined as need for calcium supplement 6 months postprocedure, was observed in 1 patient with benign disease (6.67%) and 1 patient with malignancy (6.25%; P = 1.0). A single parathyroid gland was reimplanted in 2 patients with malignancy and 2 patients with benign disease (P = 1.0). One case of keloid scar was noted, and no cases of recurrent laryngeal nerve palsy, nerve paralysis, tracheal injury, tracheostomy, or wound infection were encountered in either cohort. There were no cases of relapse hyperthyroidism in the benign cohort.

CONCLUSIONS

Similar rates of postoperative complications can be expected with TT for benign thyroid disease as compared to TT for malignant disease. Total thyroidectomy is a safe treatment option for benign thyroid disease in children.

UICC-2002 TNM classification is not suitable for differentiated thyroid cancer in children and adolescents

BACKGROUND

Recently the UICC-TNM classification for differentiated thyroid cancer (DTC) was changed neglecting the special circumstances for children affected by the disease. While the 1997 TNM classification grouped tumours </=1 cm as T1, the 2002 system changed this to a margin of </=2 cm. The consequences of this change were evaluated by analysing patients enrolled in the multicentre interdisciplinary therapy study of the German Society of Paediatric Oncology and Haematology (GPOH) on malignant endocrine tumours in children and adolescents, GPOH-MET 97.

PROCEDURE

Between 1998 and 2005, 82 patients with histologically proven DTC entered the study. Patients classified according to UICC-TNM classification 1997 were reclassified according to the new classification (2002/2003) and vice versa by cross checking with original pathologist's reports.

RESULTS

Twenty males and 62 females at a mean age of 12.5 years were evaluated. We observed a definite shift from patients formerly classified as T2 (1-4 cm) to category T1 (</=2 cm) according to the 2002 TNM classification. Among these patients a threefold increase of lymph node involvement and/or distant metastases could be demonstrated.

CONCLUSIONS

The 2002 UICC-classification may have a disadvantage for children with tumours measuring between 1 and 2 cm, as those are now classified as T1. A high rate of lymph node involvement in this group reflects the risk of under-diagnosis and -treatment of this group. The current TNM classification for DTC in children should be changed taking the physiological and anatomical differences between children and adults into consideration.

Differentiated thyroid cancer in children: diagnosis and management

PURPOSE OF REVIEW

Differentiated thyroid cancer is the most common endocrine malignancy in children. In 2006, the American Thyroid Association Guidelines Taskforce released detailed management recommendations for differentiated thyroid cancer, which primarily addressed the approach for treating adult patients. Children with differentiated thyroid cancer present with more advanced disease and yet have a more favorable outcome than adults. Thus optimal treatment for younger patients with differentiated thyroid cancer may differ from that for adults.

RECENT FINDINGS

All available data regarding differentiated thyroid cancer treatment in children are retrospective. In the past year, several large case series have been published that strengthen the argument for total thyroidectomy at the time of diagnosis, followed by administration of radioactive iodine for remnant ablation. There have also been recent advances in understanding the genetic abnormalities associated with pediatric thyroid cancer.

SUMMARY

The optimal treatment of differentiated thyroid cancer in pediatric patients continues to be debated. Recent publications from institutions around the world provide useful data regarding current approaches to this unusual disease. Further collaborative studies are needed to further refine the surgical approach, particularly the extent of lymph-node dissection, radioactive iodine dosing, and the role of genetic analysis in diagnosis and clinical approach.

Papillary thyroid carcinoma with lymph node metastases

Papillary thyroid cancer (PTC) is the most frequently occurring human thyroid cancer with good prognosis following appropriate treatment. Lymph node (LN) metastases are the main way through which PTC spread cancer cells. The mechanisms underlying PTC with local invasion, LN metastases and distant metastases are not well investigated. Tumor secrete cytokines, such as vascular endothelial growth factor (VEGF)-C and -D bind to VEGF receptors on lymphatic endothelial cells and induce proliferation (budding) from nearby lymphatic capillaries and growth of new lymphatic capillaries. About one-third of patients can be diagnosed at the time of surgical findings. Different image studies, such as ultrasonography with fine needle aspiration cytology, scintigraphic localization and positron emission tomography were reported to detect LN metastases. Important factors in predicting LN metastases are vascular invasion, male gender, absence of tumor capsule, and perithyroid involvement. Tumor recurrence in LN after primary treatment of PTC had an independent and highly significant negative effect on survival in patients over 45 year-old. Recombinant adeno-associated virus-mediated gene transfer of sVEGFR3-Fc is a feasible therapeutic scheme for blocking lymphogenous metastasis. In conclusion, aggressive surgical procedures performed by experienced surgeons or postoperative radioactive iodine therapy to minimize local recurrence of LN for PTC patients with high risk.