ATA Issues First Advice for Thyroid Nodules, Cancer in Children

Marlene Busko

April 27, 2015

The American Thyroid Association (ATA) has issued the first guidelines for managing thyroid nodules and differentiated thyroid cancer in children and adolescents up to age 18.

"Thyroid nodules in children are more likely to be malignant, and the histopathology, molecular profile, and clinical behavior of differentiated thyroid cancer differs substantially [from that in adults]," ATA president Dr Robert C Smallridge (Mayo Clinic, Jacksonville, Florida) said in a statement issued by the ATA.

"These first ATA guidelines highlight these distinguishing features for the clinician faced with caring for a patient with this uncommon thyroid tumor."

Importantly, this document, which is published online April 21 in Thyroid, will help clinicians "to try to identify [pediatric] patients who can get by with less intensive therapy and still do just as well, but with a reduced risk of complications and problems from their treatment," chair of the guidelines task force, Dr Gary L Francis (Virginia Commonwealth University, Richmond), told Medscape Medical News.

"These ATA guidelines fill an important gap and, for the first time, provide structured recommendations for the management of thyroid nodules and thyroid cancer in children [and give] a much-needed overview of the currently existing evidence," added Dr Peter A Kopp (Northwestern University Feinberg School of Medicine, Chicago, Illinois), editor in chief of Thyroid.

New Recommendations for Staging, Use of Radioactive Iodine

The task force reviewed the available evidence for the evaluation, treatment, and follow-up of children and adolescents with thyroid nodules or thyroid cancer.

The guidelines cover topics ranging from the use of ultrasound-guided fine-needle aspiration biopsy of thyroid nodules to preoperative staging of thyroid cancer to the role of radioactive iodine therapy and thyrotropin suppression. They focus on papillary thyroid cancer but include a small section on the rarer follicular thyroid cancer.

The guidance includes a treatment algorithm for evaluating and managing pediatric patients with thyroid nodules.

Thyroid cancer is 10 times more likely to be diagnosed in adolescents than in younger children — an estimated 1% to 1.5% of children and up to 13% of older adolescents have thyroid nodules, and these are more likely to be malignant in children than in adults (22% to 26% vs approximately 5%). Thyroid cancer is also five times more likely to occur in adolescent girls than boys, according to background information in the guidelines.

Whereas "adults would typically present with a nodule or lump in their thyroid, children may have that, but at the same time they would have multiple lymph nodes in the neck involved and often metastases to the lungs," Dr Francis explained.

In the past, most children received the same aggressive therapy that was effective in adults—total thyroidectomy, dissection of neck lymph nodes, and therapy with radioactive iodine, he explained.

However, disease-specific mortality for children with differentiated thyroid cancer is low, compared with adults.

On the other hand, there is an "apparent increased risk of second malignancies and overall mortality among childhood differentiated thyroid cancer survivors who were treated with radiation, [which] underscores the need to better risk-stratify children, so that more aggressive therapy is reserved for those at highest risk," according to the guideline authors.

Thus, they continue, this guideline presents two major differences from adult guidelines. It provides recommendations about pre- and postoperative cancer staging, and it describes the selective use of radioactive iodine in differentiated thyroid cancer in children.

It is imperative to stage the thyroid cancer "as much as you can preoperatively and again postoperatively to try to help categorize their risk of recurrence so you can tailor-make an approach for the individual patient," Dr Francis explained.

"The guidelines suggest that patients who need radioactive iodine should certainly get it…but we can follow [patients'] response to treatment" to see whether thyroglobulin levels drop and they no longer need the radioactive iodine, he added.

Three further algorithms focus on initial postoperative staging of intermediate- and high-risk patients with thyroid cancer, managing patients with known or suspected residual or recurrent disease but no known distant metastases, and managing patients with distant metastases.

Practical Implications

Dr Scott Rivkees (University of Florida, Gainesville), who was not involved with these guidelines, told Medscape Medical News that they provide three practical take-away messages.

First, they describe when the appearance of a thyroid nodule (as opposed to just its size) indicates that the child should have a biopsy, and they recommend that biopsies should be done using ultrasound guidance.

Second, they recommend that children with thyroid cancer should be evaluated by pediatric endocrinologists who specialize in thyroid cancer, and they point out that the best outcomes are obtained by surgeons who have a lot of experience in operating on children and adolescents with this type of cancer.

Third, the guidelines provide useful ways to help clinicians tailor treatment to individual patients, by grouping children into low-, medium-, and high-risk categories.

Dr Francis said the new recommendations will be helpful not only for specialists in pediatric thyroid cancer, but also ear, nose, and throat surgeons, oncology surgeons, pediatric surgeons, nuclear medicine physicians, and endocrinologists, including adult endocrinologists who may see adolescents transitioning to their care or adults who were treated for thyroid cancer as children.

The guidelines were funded by the American Thyroid Association and by an unrestricted educational grant from the patient organization, ThyCa: Thyroid Cancer Survivors' Association. Dr Francis receives research support from Grifols, Novo Nordisk, and the Juvenile Diabetes Research Foundation and is an advisor to ThyCa. Disclosures for the coauthors are listed in the article. Drs Rivkees and Francis have reported no relevant financial relationships.

Thyroid 2015. Published online April 21, 2015. Article

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