Differences in the management of thyroid nodules in children and adolescents as compared to adults

Abstract

Purpose of reviewTo describe recent advances in the diagnosis and management of thyroid nodules in both children and adults, highlighting differences between the two groups. Recent findingsThyroid nodules are less common in children than adults but the risk of malignancy is higher. Screening recommendations for patients with certain genetic syndromes or specific risk factors for thyroid nodules and cancer continue to evolve ultrasound is the most appropriate imaging modality for evaluating thyroid nodules in all patients, but radiographic risk stratification systems validated in adults have not been extensively studied in children. Criteria for proceeding to fine needle aspiration (FNA) biopsy differ some between children and adults, with nodule size being less of a consideration in young patients. Molecular testing continues to improve the diagnostic capabilities of FNA for all age groups, but options for pediatric thyroid nodules are currently limited. In children, only oncogene panels are validated and their exact utility, along with miRNA classifiers, is an evolving area of study. For adults, data support selection of a specific molecular test based on ultrasound characteristics and pretest probability of malignancy. Multiple series have shown that fusion mutations are more common in pediatric thyroid nodules, while point mutations are seen more often in adult thyroid nodules. Molecular data help guide management recommendations regarding the need for surgery when FNA is indeterminate, but clinical use is still being refined. Radiofrequency ablation is a nonoperative approach that has gained significant traction for the treatment of symptomatic benign nodules in adults, but data are currently extremely limited in children. SummaryThere are difference in the diagnosis and treatment of thyroid nodules in adults and children, the nuances of which are important for clinical management.

The Complex Cyto-Molecular Landscape of Thyroid Nodules in Pediatrics

“…To further expand the information to articles published before the censoring period, a secondary search of the literature was manually conducted from the references of our primary search, including papers by the application of the same inclusion and exclusion criteria. Articles satisfying the following inclusion criteria were included in our review (regardless of the study design): [ 1 ] study was written in English; [ 2 ] the full article could be obtained. Articles satisfying the following exclusion criteria were excluded from our review: [ 1 ] study was written in a non-English language; [ 2 ] the full article was not available; [ 3 ] study was not related to thyroid FNA in pediatrics; [ 4 ] study was not published in a peer-reviewed journal.…”

“…Articles satisfying the following inclusion criteria were included in our review (regardless of the study design): [ 1 ] study was written in English; [ 2 ] the full article could be obtained. Articles satisfying the following exclusion criteria were excluded from our review: [ 1 ] study was written in a non-English language; [ 2 ] the full article was not available; [ 3 ] study was not related to thyroid FNA in pediatrics; [ 4 ] study was not published in a peer-reviewed journal. Literature review and data extraction were conducted independently by two reviewers (D.S.…”

“…In recent years, the overall incidence of thyroid malignancy has increased mainly due to significant improvements in high-resolution ultrasonography (US)-guided fine-needle aspiration (FNA), leading to earlier cancer detection [ 1 ]. US is a non-invasive imaging method that is suitable for thyroid evaluation and is well accepted by patients of all ages, whereas FNA is considered the best method for evaluating thyroid nodules to minimize unnecessary surgeries or establish the proper extent of surgery [ 2 , 3 ]. Histological assessment remains the reference standard for thyroid nodule diagnosis [ 4 ].…”

“…Substantial differences in the clinical, pathological and molecular aspects of pediatric thyroid cancers make their preoperative assessment more challenging. From a clinical standpoint, pediatric nodules are relatively less frequent (0.2–5% vs. 20–70%), but they have a greater risk of malignancy (mean ROM, 19–26% vs. 5–15%) and cancer prevalence (estimated from 1.6-fold to 2.5-fold higher), with the peak of incidence being among 15–19 years old [ 2 , 3 , 4 , 6 , 7 , 10 , 11 , 12 , 13 , 14 ]. Moreover, pediatric patients often present with occult diffuse infiltrative lesions and extrathyroidal extension (e.g., metastases in regional lymph nodes or pulmonary metastases), stressing the role of non-invasive methods (US + FNA) for their correct assessment [ 3 , 6 ].…”

“…They are more often associated with female sex (especially in the post-pubertal >14 years age group, probably due to different endocrine, metabolic and immune characteristics), Asian origins, radiation exposure and inherited syndromes (5–15% of cases) [ 7 , 9 , 10 , 15 ]. Correctly recognizing malignant nodules in children is essential because of their greater rate of complications related to surgical treatment, with potential long-term impact on growth and bone health, and for their better response to radioactive iodine therapy (RAI) [ 2 , 10 ]. For preoperative assessment, the commonly used US size cut-offs for risk stratification of thyroid nodules may not be adequate for the age thyroid volume; moreover, the molecular landscape of the most frequent histotype, papillary thyroid carcinoma (PTC), representing approximately 80–90% of cases, is characterized by lower rates of BRAF p.V600E mutation and higher rates of RET/PTC translocations, as compared to what is described in the adult counterpart, and 15–40% of PTC cases are of histological high-risk variants (e.g., tall cell, diffuse sclerosing and solid/trabecular variants) [ 3 , 7 , 9 , 10 , 14 , 15 ].…”