Don't Miss Thyroid Disease in Kids

Laurie Scudder, DNP, NP; Andrew Bauer, MD

Disclosures

December 05, 2016

Editorial Collaboration

Medscape &

In This Article

Finding the Needle in the Haystack

Medscape: Your review notes that the incidence of thyroid nodules is on the rise. The percentage of these nodules that are malignant is higher in children than adults: 20%-25% vs 10%-15%. These children, too, are likely to be asymptomatic, and the finding of a nodule is likely to be incidental, often discovered as a result of imaging obtained because of persistent cervical lymphadenopathy—a pretty common thing in general pediatrics. The review notes that ultrasound of the thyroid should be obtained in kids with cervical lymphadenopathy. But which kids? What are some findings that should trigger a diagnostic evaluation?

Dr Bauer: As you suggest, cervical lymphadenopathy is a very common finding in children, but the two features that trigger concern are duration and location. Lymph nodes associated with an infection are most commonly located under the jaw and, less commonly, in the mid-portion of the lateral neck or the posterior neck, and they typically decrease in size a couple of weeks after the upper respiratory infection has resolved. So, if the lymph nodes are in the mid-lateral portion of the neck, are not associated with a cold, and are not going away within 4 weeks, then further evaluation is often pursued.

One of the most common approaches is to try a course of antibiotics and then, if they still persist, then refer the patient for surgical removal of the lymph node to assess whether there is evidence of a chronic infection or to evaluate for cancer. The most common type of cancer is lymphoma, especially in an adolescent; however, with the increased incidence of thyroid cancer, it is prudent to perform ultrasound of the thyroid to evaluate for the possibility of thyroid cancer with metastasis to the lymph nodes.

If there are ultrasound suggestions of thyroid cancer, then fine-needle aspiration should be performed to confirm the diagnosis rather than isolated surgical excision of the lymph node. Thyroid ultrasound is relatively inexpensive and easy to perform, and there is no use of radiation to obtain the images.

Figure 1. Illustration of neck anatomy. Image courtesy of The Children's Hospital of Philadelphia

So, before you send the person to a surgeon who is going to remove that lymph node, think about thyroid disease. Make sure you do a thorough exam. You might be lucky and pick up a nodule if it's in the front part of the thyroid gland. Even if you don't, getting a thyroid ultrasound is a worthwhile next step—particularly in adolescent females, because that is the group with the highest incidence of thyroid cancer,[4] although it can occur in any age. Ultrasound provides a lot of information, and if you do find a nodule or thyroid cancer, you probably averted the need for two surgeries.

Medscape: Recently, an international panel reclassified a type of thyroid cancer to reflect that it is noninvasive and has a low risk for recurrence.[5] Encapsulated follicular variant of papillary thyroid carcinoma (EFVPTC) has been renamed as "noninvasive follicular thyroid neoplasm with papillary-like nuclear features" (NIFTP). This decision came in the wake of recognition that the incidence of these types of nodules has risen two- to threefold during the past 20-30 years and now account for 10%-20% of all thyroid tumors. Is that clinical picture also seen in kids?

Dr Bauer: Yes, but there are several different situations to mention about the increased incidence of thyroid nodules and thyroid cancer.

The first issue is that we use more and more diagnostic imaging, and at times, there is an incidental finding of a small thyroid cancer confined to the thyroid gland. These cancers are often smaller than 1 cm (less than 0.5 inch in size), and these patients have no evidence of thyroid cancer anywhere else in the thyroid and no abnormal lymph nodes. These are considered "subclinical" lesions—a cancer that is most likely never going to cause any medical problems, and that you could live with and die of old age before it caused any health issues. These cancers probably exist in pediatrics as well, because they have to develop at some point of our lives.

Some adult patients decide to not have these lesions removed. However, this decision is much more difficult in children, because they have many more years of required surveillance and it may be difficult to convince the family, let alone the provider, that you are going to leave a "small" cancer in place because you believe it is "too small" to cause any issues. It's the lose-sleep factor. If have to keep thinking about it and keep surveilling it, it may start to drive you crazy. Most of us would just get rid of it.

The other situation is a new designation in a specific type of thyroid lesion. These lesions were previously designated as cancers, but there was no evidence that the cells were trying to metastasize into other areas of the thyroid or body. The nodules still need to undergo fine-needle aspiration and still need to be surgically removed to make the diagnosis, but if the lesion meets the six criteria of the new classification, rather than being called a cancer, it is now being referred to as a benign lesion that, unfortunately, has a very long-descriptive name—an NIFTP, or "noninvasive follicular thyroid neoplasm with papillary-like nuclear features."

The advantage of using this diagnosis is that it more accurately describes the lesion as a benign, noncancerous lesion, and no further treatment (surgical or medical) is required. It takes away the inaccurate designation of having had a cancer when the patient had a lesion that had no evidence of ever spreading or continuing to grow. These lesions probably exist in pediatrics, and we will have to see how common they are and whether we can use the same approach to care with our patients.

Medscape: Your recent review emphasizes the role of primary care clinicians in recognizing and appropriately evaluating kids with possible thyroid disease.

Dr Bauer: Yes; the primary care doctor has such a huge and important role to help us screen for patients with thyroid disease. However, the intention of the article was not to put the burden of evaluation and management on primary care doctors. The intention of the review article was to provide a comprehensive review of thyroid disease in children and adolescents, so that our primary care physicians understood our approach to the evaluation and management of common thyroid disorders. Our primary care colleagues are important members of our team, and if all of us understand the diseases, then we can ensure timely and appropriate referrals as well as ensure that patients and parents are compliant with our treatment plans, in an effort to optimize outcomes for our patients.

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