[size=6]A 15-year old girl comes to clinic with a new neck mass. On palpation, there is a nodule in the left lobe of the thyroid gland. Thyroid stiluating hormone and T4 are normal. An ultrasound shows a 3.5 cm mass in the left lobe of the thyroid. There are no palpable nodes on physical exam. The fine needle aspiration cytology returns papillary carcinoma. The next step in management of this patient with a thyroid mass should be

 

a left hemithyroidectomy.

 

b total thyroidectomy.

 

c thyroid scan.

 

d radioactive iodine.

 

e computerized tomography with contrast.[/size]

B

B

[size=6]A 15-year old girl comes to clinic with a new neck mass. On palpation, there is a nodule in the left lobe of the thyroid gland. Thyroid stiluating hormone and T4 are normal. An ultrasound shows a 3.5 cm mass in the left lobe of the thyroid. There are no palpable nodes on physical exam. The fine needle aspiration cytology returns papillary carcinoma. The next step in management of this patient with a thyroid mass should be

 

a left hemithyroidectomy.

 

b total thyroidectomy.

 

c thyroid scan.

 

d radioactive iodine.

 

e computerized tomography with contrast.[/size]

B

correct answer

b total thyroidectomy.

 

In 2015 the American Thyroid Association published management guidelines for children with thyroid cancer. Thyroid malignancies are more common in adolescents compared to younger children and there is a 5:1 female predominance in this age group. Ninety percent of all pediatric thyroid cancers are papillary. Follicular, anaplastic and medullary carcinomas are much less common with follicular carcinomas being the second most common.

 

The primary risk factor for papillary carcinoma is radiation exposure. In children at risk due to radiation exposure an annual physical exam is recommended with an ultrasound if new nodules are identified. Papillary carcinomas are commonly multifocal, bilateral and often have nodal disease at the time of diagnosis. Hematogenous spread of papillary carcinoma is generally seen only with extensive nodal disease and can be seen in up to 25% of patients. Preoperative evaluation should include an ultrasound, thyroid stimulating hormone (TSH) and T4. If nodal disease is suspected preoperatively by ultrasound, fine needle aspiration of the node is indicated to plan a central or lateral lymph node dissection. If there is obvious nodal involvement, alternatively, a node dissection can be planned. If there is bulky thyroid disease or concern for vocal cord involvement computerized tomography or magnetic resonance imaging is indicated.

 

For most children with papillary thyroid carcinoma, a total thyroidectomy is indicated given the high risk of multicentric or bilateral disease. The performance of a central node dissection is controversial with some evidence suggesting decreased local recurrence. In general, berry picking is discouraged. If there is documented involvement of the central or lateral neck, a complete node dissection is indicated. Without clinical evidence of disease central node dissection can still be selectively considered. The American Joint Committee on Cancer TNM system should be used in describing pediatric thyroid cancers. Thyroglobulin and neck ultrasound should be followed yearly for patients with papillary thyroid carcinomas.

 

In the setting of a suppressed TSH and a nodule, an autonomous nodule should be treated with thyroid lobectomy. Up to one-third of these patients will have a thyroid malignancy associated with the nodule.

 

Follicular neoplasms act distinctly different from papillary carcinomas. Follicular carcinomas tend to be unifocal, tend to spread hematogenously and the primary risk factor worldwide is iodine deficiency.