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Thyroid Nodules in Children: A Single Institution's Experience

Thyroid Nodules in Children: A Single Institution's Experience 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, cgingale@cnmc.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 [4]. 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. [1] 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 [2] M. T. Parisi and D. Mankoff,“Differentiated pediatric thyroid capsular invasion. If the lesion is identified as malignant, cancer: correlates with adult disease, controversies in treat- the patient should undergo a total thyroidectomy at initial ment,” Seminars in Nuclear Medicine, vol. 37, no. 5, pp. 340– 356, 2007. operation versus an initial lobectomy when indeterminate [3] L. Ries, D. Melbert, M. Krapcho et al., “SEER Cancer Statistics or benign. If FNA identifies the nodule as benign or a cyst, Review,” 2008. a patient can be followed if the lesion is small and avoid [4] M. L. Rallison, B. M. Dobyns, A. W. Meikle, M. Bishop, J. operative intervention. In adults, the accuracy of FNA can L. Lyon, and W. Stevens, “Natural history of thyroid abnor- reach 97%, while the pediatric population accuracy only malities: prevalence, incidence, and regression of thyroid reaches 90% [5, 8, 21, 23, 26]. Other limitations of FNA diseases in adolescents and young adults,” American Journal include sampling error, experience of the cytopathologist, or of Medicine, vol. 91, no. 4, pp. 363–370, 1991. need for sedation in younger children. [5] S.S.Raab,J.F.Silverman,T.M.Elsheikh, P. A. Thomas,and P. Postoperative complications of hypocalcemia and recur- E. Wakely, “Pediatric thyroid nodules: disease demographics rent laryngeal nerve injury are a great cause of concern in and clinical management as determined by fine needle patients undergoing total thyroidectomy. The most common aspiration biopsy,” Pediatrics, vol. 95, no. 1, pp. 46–49, 1995. complication following total thyroidectomy is hypocalcemia. [6] J. I. Cohen and K. D. Salter, “Thyroid disorders: evaluation and management of thyroid nodules,” Oral and Maxillofacial Hypocalcemia is largely due to incidental stunning or Surgery Clinics of North America, vol. 20, no. 3, pp. 431–443, removal of the parathyroid glands, which may be embedded in the thyroid gland [7, 27]. The parathyroid glands may [7] Y. E. Demidchik, E. P. Demidchik, C. Reiners et al., “Compre- also be devascularized during thyroid gland dissection. The hensive clinical assessment of 740 cases of surgically treated resultant hypocalcemia can be either transient or permanent. thyroid cancer in children of Belarus,” Annals of Surgery, vol. Permanent hypocalcemia was not encountered in our 243, no. 4, pp. 525–532, 2006. patient population. Another risk of total thyroidectomy [8] A. Al-Shaikh, B. Ngan, A. Daneman, and D. Daneman, is recurrent laryngeal nerve injury (RLN), resulting in “Fine-needle aspiration biopsy in the management of thyroid hoarseness, dysphagia, and respiratory failure if a bilateral nodules in children and adolescents,” Journal of Pediatrics, vol. injury occurs. Permanent RLN after total thyroidectomy has 138, no. 1, pp. 140–142, 2001. been reported as 1% in the literature [28, 29]. We report no [9] C. A. Gingalewski and K. D. Newman, “Seminars: contro- versies in the management of pediatric thyroid malignancy,” instances of RLN injury in our group. Journal of Surgical Oncology, vol. 94, no. 8, pp. 748–752, 2006. In our retrospective review, we report no instances of [10] P. W. Grigsby, A. Gal-or, J. M. Michalski, and G. M. Doherty, major complications, such as RLN injury or permanent “Childhood and adolescent thyroid carcinoma,” Cancer, vol. hypocalcemia, following total thyroidectomy. Transient 95, no. 4, pp. 724–729, 2002. hypocalcemia is considered to be of moderate risk and is [11] I. Demidchik and V. A. Kontratovich, “Repeat surgery for readily managed with oral calcium supplementation. recurrent thyroid carcinoma in children,” Voprosy Onkologii, In conclusion, there does not seem to be any component vol. 49, no. 3, pp. 366–369, 2003. found in the preoperative evaluation of a pediatric thyroid [12] D. Handkiewicz-Junak, J. Wloch, J. Roskosz et al., “Total nodule, with the exception of a positive FNA to indicate thyroidectomy and adjuvant radioiodine treatment indepen- that a lesion is malignant or benign. Our experience suggests dently decrease locoregional recurrence risk in childhood and that patients cannot be risk stratified based on age, size adolescent differentiated thyroid cancer,” Journal of Nuclear Medicine, vol. 48, no. 6, pp. 879–888, 2007. of the thyroid lesion, or characteristics of the lesion by all [13] H. Gharib and E. Papini, “Thyroid nodules: clinical radiographic imaging techniques. In addition, postoperative importance, assessment, and treatment,” Endocrinology and risk to patients undergoing lobectomy or total thyroidec- Metabolism Clinics of North America, vol. 36, no. 3, pp. 707– tomy remains low and predominantly consists of transient 735, 2007. hypocalcemia. At our institution we have found minimal [14] C. Spinelli, A. Bertocchini, A. Antonelli, and P. Miccoli, utility of an extensive preoperative workup in a child with a “Surgical therapy of the thyroid papillary carcinoma in thyroid nodule. CT scans have not been shown to be sensitive children: experience with 56 patients < or = 16 years old,” or specific for determining whether a lesion is cancerous Journal of Pediatric Surgery, vol. 39, no. 10, pp. 1500–1505, or benign. Therefore, the lifelong risk of cancer associated with CT is not justified (lifetime cancer risk associated with [15] K. D. Newman, T. Black, G. Heller et al., “Differentiated CT is estimated to be 2/1000 to 3/1000 in children under thyroid cancer: determinants of disease progression in patients age 15). We advocate ultrasound evaluation to determine an <21 years of age at diagnosis: a report from the surgical 4 Journal of Oncology discipline committee of the children’s cancer group,” Annals of Surgery, vol. 227, no. 4, pp. 533–541, 1998. [16] N. L. Shapiro and N. Bhattacharyya, “Population-based out- comes for pediatric thyroid carcinoma,” Laryngoscope, vol. 115, no. 2, pp. 337–340, 2005. [17] K. W. Gow, S. Lensing, D. A. Hill et al., “Thyroid carcinoma presenting in childhood or after treatment of childhood malignancies: an institutional experience and review of the literature,” Journal of Pediatric Surgery, vol. 38, no. 11, pp. 1574–1580, 2003. [18] Y. Imai, M. Yamakawa, M. Matsuda, and T. Kasajima, “Endogenous sex hormone and estrogen binding activity in thyroid cancer,” Histology and Histopathology,vol. 4, no.1,pp. 39–45, 1989. [19] T. Rago and P. Vitti, “Role of thyroid ultrasound in the diagnostic evaluation of thyroid nodules,” Best Practice & Research Clinical Endocrinology & Metabolism,vol. 22, no.6, pp. 913–928, 2008. [20] S. Bastin, M. J. Bolland, and M. S. Croxson, “Role of ultrasound in the assessment of nodular thyroid disease,” Journal of Medical Imaging and Radiation Oncology, vol. 53, no. 2, pp. 177–187, 2009. [21] H. Gharib, “Fine-needle aspiration biopsy of thyroid nodules: advantages, limitations, and effect,” Mayo Clinic Proceedings, vol. 69, no. 1, pp. 44–49, 1994. [22] F. W. Yip, T. S. Reeve, A. G. Poole, and L. Delbridge, “Thyroid nodules in childhood and adolescence,” Australian and New Zealand Journal of Surgery, vol. 64, no. 10, pp. 676–678, 1994. [23] E. L. Mazzaferri, “Management of a solitary thyroid nodule,” The New England Journal of Medicine, vol. 328, no. 8, pp. 553– 559, 1993. [24] H. Lugo-Vicente,V.N.Ort´ız, H. Irizarry, J. I. Camps, and V. Pagan, ´ “Pediatric thyroid nodules: management in the era of fine needle aspiration,” Journal of Pediatric Surgery, vol. 33, no. 8, pp. 1302–1305, 1998. [25] M. Amrikachi, T. B. Ponder, T. M. Wheeler, D. Smith, and I. Ramzy, “Thyroid fine-needle aspiration biopsy in children and adolescents: experience with 218 aspirates,” Diagnostic Cytopathology, vol. 32, no. 4, pp. 189–192, 2005. [26] S. Corrias, E. Einaudi, G. Chiorboli et al., “Accuracy of fine needle aspiration biopsy of thyroid nodules in detecting malig- nancy in children: comparison with conventional clinical, laboratory, and imaging approaches,” The Journal of Clinical Endocrinology & Metabolism, vol. 8, pp. 4644–4648, 2001. [27] L. Rosato, N. Avenia, P. Bernante et al., “Complications of thyroid surgery: analysis of a multicentric study on 14,934 patients operated on in Italy over 5 Years,” World Journal of Surgery, vol. 28, no. 3, pp. 271–276, 2004. [28] M. P. La Quaglia, T. Black, G. W. Holcomb III et al., “Dif- ferentiated thyroid cancer: clinical characteristics, treatment, and outcome in patients under 21 years of age who present with distant metastases. A report from the surgical discipline committee of the children’s cancer group,” Journal of Pediatric Surgery, vol. 35, no. 6, pp. 955–960, 2000. [29] T. Reeve and N. W. Thompson, “Complications of thyroid surgery: how to avoid them, how to manage them, and observations on their possible effect on the whole patient,” World Journal of Surgery, vol. 24, no. 8, pp. 971–975, 2000. 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Thyroid Nodules in Children: A Single Institution's Experience

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Copyright © 2011 Nini Khozeimeh and Cynthia 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.
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Abstract

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, cgingale@cnmc.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 [4]. 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. [1] 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 [2] M. T. Parisi and D. Mankoff,“Differentiated pediatric thyroid capsular invasion. If the lesion is identified as malignant, cancer: correlates with adult disease, controversies in treat- the patient should undergo a total thyroidectomy at initial ment,” Seminars in Nuclear Medicine, vol. 37, no. 5, pp. 340– 356, 2007. operation versus an initial lobectomy when indeterminate [3] L. Ries, D. Melbert, M. Krapcho et al., “SEER Cancer Statistics or benign. If FNA identifies the nodule as benign or a cyst, Review,” 2008. a patient can be followed if the lesion is small and avoid [4] M. L. Rallison, B. M. Dobyns, A. W. Meikle, M. Bishop, J. operative intervention. In adults, the accuracy of FNA can L. Lyon, and W. Stevens, “Natural history of thyroid abnor- reach 97%, while the pediatric population accuracy only malities: prevalence, incidence, and regression of thyroid reaches 90% [5, 8, 21, 23, 26]. Other limitations of FNA diseases in adolescents and young adults,” American Journal include sampling error, experience of the cytopathologist, or of Medicine, vol. 91, no. 4, pp. 363–370, 1991. need for sedation in younger children. [5] S.S.Raab,J.F.Silverman,T.M.Elsheikh, P. A. Thomas,and P. Postoperative complications of hypocalcemia and recur- E. Wakely, “Pediatric thyroid nodules: disease demographics rent laryngeal nerve injury are a great cause of concern in and clinical management as determined by fine needle patients undergoing total thyroidectomy. The most common aspiration biopsy,” Pediatrics, vol. 95, no. 1, pp. 46–49, 1995. complication following total thyroidectomy is hypocalcemia. [6] J. I. Cohen and K. D. 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