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Hindawi Publishing Corporation Journal of Oncology Volume 2011, Article ID 974125, 4 pages doi:10.1155/2011/974125 Clinical Study Nini Khozeimeh and Cynthia Gingalewski Department of Pediatric Surgery, Children’s National Medical Center, 111 Michigan Avenue NW, Washington, DC 20010, USA Correspondence should be addressed to Cynthia Gingalewski, firstname.lastname@example.org Received 1 June 2011; Revised 11 August 2011; Accepted 13 August 2011 Academic Editor: David Ball Copyright © 2011 N. Khozeimeh and C. Gingalewski. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Thyroid nodules in children are uncommon but often present an increased risk of malignancy in comparison to their adult counterpart. Multiple diagnostic modalities are frequently employed to characterize these nodules including ultrasound, radionuclide scans, ﬁne needle aspiration (FNA), thyroid function tests, and evaluation of patient demographics. We chose to evaluate if any of these modalities inﬂuence treatment or signify a tendency for a nodule to represent a malignant lesion. A retrospective review of patients <21 years of age who underwent partial or total thyroidectomy from 2004 to 2009 was performed (IRB no. 4695). Other than an FNA indicating a malignancy, there does not appear to be any value to extensive preoperative imaging, nor can patient risk be stratiﬁed based upon age. We conclude that there is minimal utility in an extensive preoperative workup in a child with a thyroid nodule. 1. Introduction 2. Methods A retrospective chart review was performed (2004–2009) Thyroid cancer is the most common endocrine malignancy at a tertiary medical center with a 100% pediatric patient in pediatric patients [1–3]. However, thyroid nodules in population (IRB approval no. 4695). Fifty patients <21 children are only found in 3.7% of healthy children aged 11– years of age were identiﬁed who underwent partial or 18 years old . Compared to adults, these nodules have an total thyroidectomy. Five patients with a family history of increased risk of being malignant (16% in children versus 5% multiple endocrine neoplasia (MEN) were excluded, giving in adults) [4–6]. Thyroid cancer in children is also unusual in a total of 45 patients evaluated in the present study. Patient that it often presents with advanced disease including lymph demographics, preoperative workup, type of procedure per- node involvement and lung metastasis as compared to their formed, and pathology results were reviewed. Calculations adult counterpart [5, 7–9]. were performed using a 2-tailed Student’s t-test. Multiple modalities are frequently employed in an attempt to characterize thyroid nodules including ultra- 3. Results sound, radionuclide scans, ﬁne needle aspiration (FNA), thyroid function tests, and evaluating patient demographics. 3.1. Demographics. Forty-ﬁve patients underwent either par- In the adult population these results are frequently used to tial or total thyroidectomy; the majority of patients were determine those patients who do not require thyroidectomy. female (n = 41). There was no diﬀerence in the median Although these tests are also performed in the pediatric age at presentation for malignant and benign lesions 15 years population, these patients frequently undergo partial or total (range of 7–19 years) versus 14 years (range of 8–21 years) thyroidectomy for diagnosis (P = .88), respectively. None of the patients identiﬁed had The aim of this paper is to explore the utility of radio- a history of previous neck irradiation. Patient demographics graphic imaging and preoperative ﬁne needle aspiration and tumor characteristics are summarized in Table 1. (FNA) in the evaluation of pediatric thyroid nodules, more speciﬁcally, to determine if any of these modalities identiﬁes 3.2. Preoperative Workup. Ninety-one percent of patients those thyroid nodules that are at high risk of harboring a underwent preoperative imaging with ultrasound (n = 31), malignancy. CT scan (n = 4), I scan (n = 2), or ultrasound 2 Journal of Oncology Table 1: Demographic, tumor, and clinical characteristics. Thyroid second patient had a CT scan that showed a small nodule. nodules were identiﬁed as malignant or benign based on pathologic In addition, one patient was diagnosed with papillary characteristics. These nodules were then characterized based on carcinoma on an intraoperative frozen section and had a patient age, gender, and preoperative workup including imaging or completion thyroidectomy at that time. One patient had an FNA. incidentally found micropapillary carcinoma in the setting of Grave’s disease, and one patient with a multinodular goiter Entire cohort n = 45 had a preoperative FNA showing follicular cells, and the ﬁnal Malignant Benign pathologic diagnosis was papillary carcinoma. These patients Total patients 9 36 did have preoperative imaging that showed nodules. Gender Of those patients with benign disease (n = 36), 12 (33%) Female 8 33 underwent a total thyroidectomy for either an enlarging Male 1 3 multinodular goiter or Grave’s disease refractory to medical Average age at diagnosis (years) 14.1 14.2 treatment. Twenty-four patients underwent lobectomy. Six- Average size of nodule (cm) 2.7 2.9 teen underwent a right lobectomy (45%), and 8 had a left FNA lobectomy (22%). Yes 5 17 Hypocalcemia was the most common postoperative complication, occurring in 8 patients (38%). Half of these No 4 19 patients (n = 4) experienced symptoms with tingling or Radiologic imaging paresthesias, whereas the other half (n = 4) were identiﬁed Ultrasound 5 26 with hypocalcemia on routine postoperative labs mea- CT scan 3 1 surements. All patients were managed with supplemental Nuclear medicine 0 2 oral calcium, and none experienced permanent hypocal- Ultrasound and 2nd modality 1 3 cemia/hypoparathyroidism. All patients had normalization of their calcium levels within 3 months postoperatively. There were no injuries to the recurrent laryngeal nerve. and a second modality (n = 4). Of the 4 patients who The average length of stay was similar for all patients after had no preoperative imaging, three patients underwent total thyroidectomy: 1.46 days for those with malignancy thyroidectomy for a symptomatic, enlarging multinodular (range 1–5 days) and 1.53 days for benign pathology (range goiter. None of these patients were found to have malignancy. 1–8 days). All patients undergoing a thyroid lobectomy were There were no herald radiologic ﬁndings to distinguish a discharged after a 23-hour observation period. lesion as malignant. Several nodules (n = 12) were found to have increased vascularity concerning malignancy; however, 4. Discussion these nodules were found to be both malignant (n = 3) and benign (n = 9). FNA was performed in forty-nine Thyroid nodules in children represent an uncommon entity percent of patients (n = 22). Of the nine patients found but carry a greater risk for malignancy than in their to have malignancy, ﬁve underwent preoperative FNA. Four adult counterpart. In the pediatric population, an extensive FNAs were interpreted as malignant returning as papillary preoperative workup of a thyroid nodule is not necessary. carcinoma. One FNA was interpreted as a follicular lesion but This should be limited to an ultrasound examination to returned multifocal papillary carcinoma on ﬁnal pathologic determine that if indeed the nodule is within the thyroid evaluation. This yields a sensitivity of 80% and speciﬁcity of gland. If feasible, given the patients age and anxiety level, 100%. a FNA should be performed. In those patients who have an inadequate FNA, or FNA is not performed, surgical 3.3. Disease Characteristics. Nine out of forty-ﬁve patients excision should be performed for diagnosis. Total thyroidec- were identiﬁed with papillary carcinoma on pathologic tomy remains the procedure of choice for those lesions examination (20%). Cervical lymph node involvement was identiﬁed preoperatively as cancer, while lobectomy should identiﬁed in 56% percent of patients (n = 5) at the time be employed for those lesions in which the diagnosis is of thyroidectomy. No patient had evidence of pulmonary 131 uncertain [10–14]. This facilitates the use of I therapy metastases. There was no signiﬁcant diﬀerence in the average postoperatively as well as the ability to monitor thyroglobulin size of the nodules in patients with malignant or benign levels after treatment for recurrent disease. Overall, thyroid disease (2.7 cm and 2.9 cm, resp., P = .63). cancer has a very good prognosis with a 98.8% survival at 10 years in children [2, 7]. 3.4. Surgical Procedure. Total thyroidectomy was performed The female predominance of thyroid nodules noted in as the initial procedure in those patients identiﬁed with our cohort has been previously reported in the literature and malignancy by FNA (n = 4). Two patients underwent is likely secondary to the estrogen sensitivity of the thyroid completion thyroidectomy after pathologic examination of gland [15–18]. their thyroid lobe revealed papillary carcinoma. Both of In our cohort, patient age and radiologic imaging bears these patients did not undergo preoperative FNA. Both no impact in determining whether a nodule was malignant patients underwent preoperative imaging; the ﬁrst patient or benign. Increased intranodular vascularity is an ultra- with an ultrasound that showed a vascular nodule, while the sound characteristic that has been suggested as an indicator Journal of Oncology 3 of malignancy [19, 20]. In our group, patients were found intrathyroidal location, an FNA if feasible, and then either to have intranodular vascularity suggestive of malignancy total thyroidectomy for those with malignancy identiﬁed (n = 12) however, the lesions returned both benign (n = 9) on cytology or lobectomy for those whose diagnosis is and malignant (n = 3). Average nodule size also did not uncertain. signify a predisposition for malignancy. Fine needle aspiration and cytology evaluation in the References pediatric patient is controversial [5, 21–25]. FNA is useful for preoperative planning if the lesion is identiﬁed as malignant.  C. A. Dinauer, C. Breuer, and S. A. Rivkees, “Diﬀerentiated But the lesion may be identiﬁed as benign, indeterminate, thyroid cancer in children: diagnosis and management,” or follicular. Follicular lesions cannot be diﬀerentiated as Current Opinion in Oncology, vol. 20, no. 1, pp. 59–65, 2008. malignant or benign because of the inability of FNA to assess  M. T. 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Published: Oct 6, 2011
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