Pediatric Thyroid Nodules and Pediatric Thyroid Cancer

While it's scary for any family member to learn that they might have cancer, that is especially true when it comes to children. Pediatric thyroid nodules are rare, and pediatric thyroid cancer is even more rare. When a pediatric thyroid problem happens, having the right team is what matters the most in reaching the best outcome. And there are some things that you should know if you are worried about your child and their thyroid nodule.

First, why are pediatric thyroid nodules or pediatric thyroid cancers different? Because they are caused by different sources than adult nodules. Adults commonly develop conditions such as Graves' Disease or Hashimoto's Thyroiditis. Both of these conditions can cause inflammation that ultimately leads to thyroid nodules or thyroid cancer independent of any specific mutation. With young people, on the other hand, thyroid nodules are much less common and are more likely to be caused by mutations that are also associated with thyroid cancer. One example illustrates the difference in the causes of nodules: in adults, about 10% of thyroid nodules have thyroid cancer. In children or pediatric patients, the rate of thyroid cancer is more than twice as high.

Second, why would we manage these pediatric thyroid nodules differently? Because of the timeline that children have. In general, thyroid cancer grows and spreads slowly. For adults, that means that we can be patient and not rush to surgery. With children, however, we tend to recommend surgery for nodules in most cases because we understand that problems are more likely to become worse with time. And children have much longer to watch their thyroid nodules, so we tend to believe that we should treat the problems before they become worse.

So what is the recommendation for a child with a thyroid nodule? Usually, the first step is a fine needle aspiration (FNA) biopsy. These almost never require anesthesia, and often can be done by the same surgeon who will do the surgery. This allows the patient and the family to begin forming a bond with the team and to observe the surgeon in action. It also allows the surgeon the opportunity to examine the nodule very closely and begin to anticipate any potential nuances during surgery. The results of the biopsy will either confirm a diagnosis of cancer, suggest that the nodule is benign, or be indeterminate. Usually, the first and the last of those are treated with surgery. Often, even benign pediatric thyroid nodules are recommended for surgery, especially if the nodule is large (more than 2cm), growing, or causing symptoms. Molecular markers can be used to determine if a nodule has any mutations that would necessitate surgery, but the absolute value that they add in pediatric thyroid nodules is somewhat debatable.

At this point, we should note that some pediatric cancers, such as medullary thyroid cancer, can be predicted based on mutations. In these cases, there is a small group of children for whom a prophylactic thyroidectomy may be recommended. In these situations, a patient has their thyroid removed before the cancer has a chance to develop. This decision is made in close consultation with genetics and oncology as well as the family pediatrician.

Once you have decided that surgery is required, the next step is to find a surgeon. This can become quite challenging! Most parents will intuitively believe that a pediatric surgeon is the best choice for pediatric surgery. This is not necessarily true. The reason for this is that pediatric thyroid surgery is so rare that even the most experienced pediatric thyroid centers in the world do not do 100 thyroid surgeries in a year (100 cases annually is the minimum for being a "high volume thyroid center" according to published research). That's why adult surgeons generally are believed to have better outcomes. For this reason, high volume adult surgeons such as Dr Russell who do more than 500 thyroid and parathyroid surgeries each year are often chosen to lead pediatric thyroid surgery cases. During his time at Johns Hopkins, Dr Russell was the the highest volume pediatric thyroid and parathyroid surgeon and also the highest volume adult thyroid and parathyroid surgeon. The more you do, the better your outcomes!

It is critical here to note that you should ALWAYS feel comfortable getting a second opinion. Or a 3rd. Or a 4th. (but eventually you just need to move forward with treatment!)

Once you have found your surgeon, the next step is to decide how much surgery should be completed. It is common to consider a total thyroidectomy for any pediatric patient with thyroid cancer for the reasons stated above. Those guidelines are somewhat variable based on family desires, the risks and size of the cancer, and the presence of lymph nodes. In most cases, radioactive iodine is not needed, and so a thyroid lobectomy (hemithyroidectomy) can be considered. There are pros and cons to this approach that should be discussed with your surgeon and endocrinologist. A big risk is hypocalcemia after pediatric thyroid surgery- so find an experienced surgeon!

At the Russell Center, we also offer radiofrequency ablation and other innovative options such as scarless thyroid surgery. In fact, Dr Russell was a lead surgeon on the largest review of scarless thyroid surgeries for pediatric patients. We recognize that these options can be very valuable to pediatric patients who would like to preserve their thyroid function or minimize any problems that a scar could cause. We do offer these options to pediatric patients, but only when we are confident that it is an acceptable option. Health is always our first priority, and we do not compromise. What we also offer is the ability to provide a very personalized care plan in a setting that is much more relaxed than many busy hospital settings. We find that this makes the experience much better - not just better outcomes, but more relaxed and pleasant.

As you can see, pediatric thyroid nodules and pediatric thyroid cancer are very complicated and require experience. There are many choices to make, but the most important choice is to find the right surgeon. With focus and hard work, pediatric thyroid cancer or pediatric thyroid nodules can do extremely well. A final positive note to finish on: the prognosis in pediatric thyroid cancer is extremely excellent, even in the most advanced cases! Be Well!