Surgical Management of Thyroid Disease in Children
Purpose of Review
To provide a comprehensive, up-to-date guide for the surgical management of the most common malignant and benign thyroid diseases within the pediatric population.
26.4% of nodules are malignant in the pediatric population. Concerning ultrasound features of hypoechogenicity, irregular margins, increased intranodular blood flow, or microcalcifications should prompt FNA, while size criteria is less important. The Bethesda System is effective in stratifying risk in pediatric nodules. The role of molecular genetic testing to guide patient management is emerging. Total thyroidectomy has become more frequent in the treatment of differentiated thyroid cancer due to its aggressive nature in the pediatric population and concern for recurrence. The role of adjunctive radiofrequency iodine ablation and the impact of extensive resection on survival are controversial.
Management of pediatric thyroid disease can be complex and should be managed by a multidisciplinary team with an experienced, high-volume surgeon.
KeywordsPediatric Thyroid Carcinoma Guidelines Nodule Surgery
Compliance with Ethical Standards
Conflict of Interest
The authors declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 1.•• Francis GL, Waguespack SG, Bauer AJ, Angelos P, Benvenga S, Cerutti JM, et al. Management guidelines for children with thyroid nodules and differentiated thyroid cancer. Thyroid. 2015;25(7):716–59. The first task force created guidelines for management of thyroid disease specifically in children as placed forward by the American Thyroid Association. CrossRefPubMedPubMedCentralGoogle Scholar
- 3.Buryk MA, Simons JP, Picarsic J, Monaco SE, Ozolek JA, Joyce J, et al. Can malignant thyroid nodules be distinguished from benign thyroid nodules in children and adolescents by clinical characteristics? A review of 89 pediatric patients with thyroid nodules. Thyroid. 2015;25(4):392–400. https://doi.org/10.1089/thy.2014.0312.CrossRefPubMedGoogle Scholar
- 4.Ly S, Frates MC, Benson CB, Peters HE, Grant FD, Drubach LA, et al. Features and outcome of autonomous thyroid nodules in children: 31 consecutive patients seen at a single center. J Clin Endocrinol Metab. 2016;101(10):3856–62. https://doi.org/10.1210/jc.2016-1779.CrossRefPubMedPubMedCentralGoogle Scholar
- 5.• Lim-Dunham JE, Erdem Toslak I, Alsabban K, Aziz A, Martin B, Okur G, et al. Ultrasound risk stratification for malignancy using the 2015 American Thyroid Association Management Guidelines for Children with Thyroid Nodules and Differentiated Thyroid Cancer. Pediatr Radiol. 2017;47(4):429–36. Recent review evaluating the reproducibility of the ATA recommendations for fine needle aspiration of thyroid nodules in children based on imaging characteristics, and how it translates to estimating malignancy risk. CrossRefPubMedGoogle Scholar
- 6.Gupta A, Ly S, Castroneves LA, Frates MC, Benson CB, Feldman HA, et al. A standardized assessment of thyroid nodules in children confirms higher cancer prevalence than in adults. J Clin Endocrinol Metab. 2013;98(8):3238–45. https://doi.org/10.1210/jc.2013-1796.CrossRefPubMedPubMedCentralGoogle Scholar
- 8.Rossi ED, Martini M, Cenci T, Capodimonti S, Larocca LM. The role of thyroid FNA cytology in pediatric malignant lesions: an overview of the literature. Cancer 2017.Google Scholar
- 11.Noureldine SI, Najafian A, Aragon Han P, Olson MT, Genther DJ, Schneider EB, et al. Evaluation of the effect of diagnostic molecular testing on the surgical decision-making process for patients with thyroid nodules. JAMA Otolaryngol Head Neck Surg. 2016;142(7):676–82. https://doi.org/10.1001/jamaoto.2016.0850.CrossRefPubMedGoogle Scholar
- 12.Canfarotta M, Moote D, Finck C, Riba-Wolman R, Thaker S, Lerer TJ, et al. McGill thyroid nodule score in differentiating benign and malignant pediatric thyroid nodules: a pilot study. Otolaryngol Head Neck Surg 2017:194599817715629.Google Scholar
- 14.Rivkees SA, Mazzaferri EL, Verburg FA, Reiners C, Luster M, Breuer CK, et al. The treatment of differentiated thyroid cancer in children: emphasis on surgical approach and radioactive iodine therapy. Endocr Rev. 2011;32(6):798–826. https://doi.org/10.1210/er.2011-0011.CrossRefPubMedPubMedCentralGoogle Scholar
- 15.Suh CH, Baek JH, Choi YJ, Lee JH. Performance of CT in the preoperative diagnosis of cervical lymph node metastasis in patients with papillary thyroid cancer: a systematic review and meta-analysis. AJNR Am J Neuroradiol. 2017;38(1):154–61. https://doi.org/10.3174/ajnr.A4967.CrossRefPubMedGoogle Scholar
- 16.Stulak JM, Grant CS, Farley DR, Thompson GB, van Heerden JA, Hay ID, et al. Value of preoperative ultrasonography in the surgical management of initial and reoperative papillary thyroid cancer. Arch Surg. 2006;141(5):489–94; discussion 94-6. https://doi.org/10.1001/archsurg.141.5.489.CrossRefPubMedGoogle Scholar
- 17.Spinelli C, Strambi S, Rossi L, Bakkar S, Massimino M, Ferrari A, et al. Surgical management of papillary thyroid carcinoma in childhood and adolescence: an Italian multicenter study on 250 patients. J Endocrinol Investig. 2016;39(9):1055–9. https://doi.org/10.1007/s40618-016-0474-0.CrossRefGoogle Scholar
- 19.• Nice T, Pasara S, Goldfarb M, Doski J, Goldin A, Gow KW, et al. Pediatric papillary thyroid cancer >1 cm: is total thyroidectomy necessary? J Pediatr Surg. 2015;50(6):1009–13. Recent review of 3861 pediatric papillary thyroid cancer patients with tumor size > 1cm using the national cancer database to determine the overall survival rates for patients undergoing total thyroidectomy versus partial thyroidectomy. CrossRefPubMedGoogle Scholar
- 21.Hay ID, Gonzalez-Losada T, Reinalda MS, Honetschlager JA, Richards ML, Thompson GB. Long-term outcome in 215 children and adolescents with papillary thyroid cancer treated during 1940 through 2008. World J Surg. 2010;34(6):1192–202. https://doi.org/10.1007/s00268-009-0364-0.CrossRefPubMedGoogle Scholar
- 23.Demidchik YE, Demidchik EP, Reiners C, Biko J, Mine M, Saenko VA, et al. Comprehensive clinical assessment of 740 cases of surgically treated thyroid cancer in children of Belarus. Ann Surg. 2006;243(4):525–32. https://doi.org/10.1097/01.sla.0000205977.74806.0b.CrossRefPubMedPubMedCentralGoogle Scholar
- 24.Lazar L, Lebenthal Y, Steinmetz A, Yackobovitch-Gavan M, Phillip M. Differentiated thyroid carcinoma in pediatric patients: comparison of presentation and course between pre-pubertal children and adolescents. J Pediatr. 2009;154(5):708–14. https://doi.org/10.1016/j.jpeds.2008.11.059.CrossRefPubMedGoogle Scholar
- 27.Handkiewicz-Junak D, Wloch J, Roskosz J, Krajewska J, Kropinska A, Pomorski L, et al. Total thyroidectomy and adjuvant radioiodine treatment independently decrease locoregional recurrence risk in childhood and adolescent differentiated thyroid cancer. J Nucl Med. 2007;48(6):879–88. https://doi.org/10.2967/jnumed.106.035535.CrossRefPubMedGoogle Scholar
- 37.Gagel RF, Marx SJ. “Multiple endocrine neoplasia.” Williams Textbook of Endocrinology, Chapter 40, 11th ed., Philadelphia, and Eng C, Clayton D, et al. 2008.Google Scholar
- 40.Elisei R, Romei C, Renzini G, Bottici V, Cosci B, Molinaro E, et al. The timing of total thyroidectomy in RET gene mutation carriers could be personalized and safely planned on the basis of serum calcitonin: 18 years experience at one single center. J Clin Endocrinol Metab. 2012;97(2):426–35. https://doi.org/10.1210/jc.2011-2046.CrossRefPubMedGoogle Scholar
- 43.Minamitani K, Sato H, Ohye H, Harada S, Arisaka O, Committee on Pharmaceutical Affairs JSfPE, and the Pediatric Thyroid Disease Committee, J.pan Thyroid Association (Taskforce for the Revision of the Guidelines for the Treatment of Childhood-Onset Graves’ Disease). Guidelines for the treatment of childhood-onset Graves’ disease in Japan, 2016. Clin Pediatr Endocrinol. 2017;26(2):29–62. https://doi.org/10.1297/cpe.26.29.CrossRefPubMedPubMedCentralGoogle Scholar
- 44.Rivkees SA. 63 years and 715 days to the “boxed warning”: unmasking of the propylthiouracil problem. Int J Pediatr Endocrinol 2010;2010.Google Scholar
- 46.Breuer CK, Solomon D, Donovan P, Rivkees SA, Udelsman R. Effect of patient age on surgical outcomes for Graves’ disease: a case-control study of 100 consecutive patients at a high volume thyroid surgical center. Int J Pediatr Endocrinol. 2013;2013(1):1. https://doi.org/10.1186/1687-9856-2013-1.CrossRefPubMedPubMedCentralGoogle Scholar
- 47.• Kundel A, Thompson GB, Richards ML, Qiu LX, Cai Y, Schwenk FW, et al. Pediatric endocrine surgery: a 20-year experience at the Mayo Clinic. J Clin Endocrinol Metab. 2014;99(2):399–406. Recent review conducted at the Mayo Clinic reporting their operative experience and outcomes of 241 cases of children < 19 years old performed by high-volume endocrine surgeons. CrossRefPubMedGoogle Scholar
- 50.Grant CS, Stulak JM, Thompson GB, Richards ML, Reading CC, Hay ID. Risks and adequacy of an optimized surgical approach to the primary surgical management of papillary thyroid carcinoma treated during 1999-2006. World J Surg. 2010;34(6):1239–46. https://doi.org/10.1007/s00268-009-0307-9.CrossRefPubMedGoogle Scholar
- 51.Kluijfhout WP, van Beek DJ, Verrijn Stuart AA, Lodewijk L, Valk GD, van der Zee DC, et al. Postoperative complications after prophylactic thyroidectomy for very young patients with multiple endocrine neoplasia type 2: retrospective cohort analysis. Medicine (Baltimore). 2015;94(29):e1108. https://doi.org/10.1097/MD.0000000000001108.CrossRefGoogle Scholar
- 52.Schietroma M, Cecilia EM, Carlei F, Sista F, De Santis G, Lancione L, et al. Dexamethasone for the prevention of recurrent laryngeal nerve palsy and other complications after thyroid surgery: a randomized double-blind placebo-controlled trial. JAMA Otolaryngol Head Neck Surg. 2013;139(5):471–8. https://doi.org/10.1001/jamaoto.2013.2821.CrossRefPubMedGoogle Scholar
- 53.Piccirillo JF, Bauchner H. Expression of concern: Schietroma M, Cecilia EM, Carlei F, Sista F, De Santis G, Lancione L, Amicucci G. Dexamethasone for the prevention of recurrent laryngeal nerve palsy and other complications after thyroid surgery: a randomized double-blind placebo-controlled trial. JAMA Otolaryngol Head Neck Surg 2013;139(5):471–478. doi:10.1001/jamaoto.2013.2821. JAMA Otolaryngol Head Neck Surg. 2017; https://doi.org/10.1001/jamaoto.2017.1641.
- 55.Stack BC, Bimston DN, Bodenner DL, Brett EM, Dralle H, Orloff LA, et al. American Association of Clinical Endocrinologists and American College of Endocrinology Disease State clinical review: postoperative hypoparathyroidism—definitions and management. Endocr Pract. 2015;21(6):674–85. https://doi.org/10.4158/EP14462.DSC.CrossRefPubMedGoogle Scholar