eMedicine Specialties > Pediatrics: General Medicine > Endocrinology

Solitary Thyroid Nodule: Follow-up

Author: Andre Hebra, MD, Chief, Division of Pediatric Surgery, Medical University of South Carolina; Professor of Surgery and Pediatrics, Medical University of South Carolina
Coauthor(s): Melissa Miller, MD, Department of Surgery, Medical University of South Carolina; Patrick B Thomas, MD, Fellow, Department of Pediatric Surgery, Texas Children's Hospital
Contributor Information and Disclosures

Updated: Nov 26, 2008

Follow-up

Further Inpatient Care

• Postoperative inpatient care should be routine.
• Monitor calcium levels to identify individuals with parathyroid complications who may need supplementation.
• A pediatric endocrinologist should remain involved in the patient's long-term care to help determine timing and dosing of thyroid hormone supplementation if needed.
• Antithyroid radiotherapy may also be necessary, requiring the participation of a thyroidologist or hematologist-oncologist.
• Postoperative complications such as wound infections or nerve injury require monitoring and appropriate support.

Further Outpatient Care

• After surgery for a diagnosed thyroid malignancy, outpatient follow-up care is vital to optimize patient survival.
• Radioiodine scintiscan may be used 6 weeks postsurgery to monitor for metastases. Uptake in the lungs, lateral neck, or around the recurrent laryngeal nerve indicates metastasis or residual disease. If these are discovered, therapeutic dosing of¹³¹ I is indicated to ablate remaining tumor cells.
• Thyroxine in full replacement doses to suppress thyroid-stimulating hormone (TSH) stimulation of malignant cells is necessary, even if some thyroid tissue remains.
• Pediatric patients require periodic monitoring of thyroid hormone levels as the child grows to ensure adequate dosing.
• Annual radioiodine scan is recommended to monitor for long-term recurrence of disease.
• Thyroglobulin levels may also be used to monitor for recurrence of disease, but only if a total thyroidectomy has been performed.
  • Levels vary based on replacement therapy.
  • Levels more than 1 ng/mL in patients on replacement therapy and 10 ng/mL in patients off thyroxine indicate recurrence of disease.
• In patients with medullary thyroid cancer, calcitonin levels may be used to monitor for recurrence.
• Late mortality caused by unmonitored recurrence of disease is tragic. Therefore, primary care physicians should be diligent in maintaining long-term follow-up care.

Inpatient & Outpatient Medications

• Antithyroid medications are given preoperatively to stabilize a toxic thyroid nodule.
• Beta-blockers may be used for cardiac arrhythmias.
• Thyroid replacement is necessary after thyroidectomy. This therapy must be continued for life. Prescribe full replacement doses to minimize TSH stimulation of residual tumor cells.

Transfer

• In treating a patient with a solitary thyroid nodule, optimal care involves a team approach that includes the primary care provider, an experienced radiologist and cytopathologist, and a surgeon comfortable with thyroid surgery in children (whether an otolaryngologist, pediatric surgeon, or endocrine surgeon). In addition, the cooperation of a pediatric endocrinologist and hematologist-oncologist is preferred. If any of these professional resources are not available, consider transferring the child to an appropriate referral center.

Deterrence/Prevention

• No specific measures to prevent thyroid nodules have been determined other than minimizing exposure to risk factors as much as possible.
• Sufficient dietary iodine helps prevent the formation of goiters and may offer some protection against malignancy, especially follicular and anaplastic types. However, iodine sufficiency may increase risk of papillary cancer. The nuclear fallout at Chernobyl included large amounts of¹³¹ I. The extremely high rates of thyroid cancer in the surrounding areas over the next decade could have been decreased greatly by sufficient intake of dietary iodine to block the uptake of¹³¹ I. Early detection also aids in improving outcomes. Children with a family history of thyroid disease or a medical history of malignancy, especially Hodgkin lymphoma or head and neck irradiation, have a higher risk of disease. The development of thyroid masses in these children raises the index of suspicion for malignancy.
• Patients with a family history of multiple endocrine neoplasia (MEN) 2A or MEN 2B warrant close monitoring for the development of symptoms. Genetic testing for ret mutations is now available and can substantially improve outcomes by identifying children with the mutation before the onset of symptoms, allowing treatment before metastasis.
  • Children with mucosal neuromas and a family history of MEN 2B show evidence of the mutation. Medullary thyroid carcinoma should be assumed.
  • Patients with confirmed MEN should receive total thyroidectomy at an early age to prevent metastases. The author recommends this surgery by the time patients with MEN 2A are aged 5-10 years and by the time patients with MEN 2B are aged 3 years.

Complications

• The most common complications of thyroidectomy are injuries to the recurrent laryngeal nerve and parathyroid compromise, causing hypocalcemia.
  • Both of these complications have been divided into temporary (<6 mo) and permanent categories.
  • Permanent hypocalcemia has occurred in 6-27% of operative cases, whereas, in some studies, temporary hypocalcemia has affected an additional 29%.
  • In one study, recurrent laryngeal nerve damage temporarily caused difficulties in 12% of cases and permanently caused difficulties in 2%.
  • Overall, permanent damage rates have been estimated at 0-24%. This wide range is most likely the result of differing treatment and surgical techniques.
  • Some centers remove tumor-invaded recurrent laryngeal nerves, whereas others have achieved good results with careful dissection and subsequent treatment with¹³¹ I.
  • Millman et al assert that, with experience and proper technique, the rates of both these complications should approach 1%.⁹
• Much more rarely, other major complications can affect recovery.
• Damage can occur in cranial nerves VII, X, and XI and the superior laryngeal nerve. An occasional postoperative pneumothorax has been noted.
• Postoperative hemorrhage can be devastating because of possible airway compromise and may cause emergent reoperation.
• In addition, required tracheostomy and extensive wound necrosis or infection can occur, severely delaying recovery.
• Minor complications include hypertrophic scarring, delayed healing, seromas, temporary dysphagia, facial edema, and serous otitis media.
• In general, complications are proportional to the amount of gland removed.
  • Simple lobectomy is associated with a low risk of complication, whereas total thyroidectomy may cause more problems.
  • In addition, children with malignant nodules tend to sustain more complications than children with benign disease.

Prognosis

• Because mortality rates for thyroid cancer approach zero, prognosis is based on diagnosis of malignancy and progression-free survival rates.
• Most pediatric patients with a solitary thyroid nodule can expect a normal life span.
• Even in patients with malignancy, the progression-free survival rate is 60-70% at 10-20 years.
• Determinants of poor prognosis include younger age (<10 y), extensive pulmonary metastases, and tracheal and laryngeal invasion.
• Medullary thyroid cancer and anaplastic cancer also result in poor outcomes.
• Nondiploid DNA in tumor cells, overexpression of p21 ras, or mutations of the n-ras gene indicate poor prognosis.
• Close follow-up care after treatment is essential because late deaths from extension of residual disease can occur.

Patient Education

• Patient and family education should focus on the monitoring of symptoms. Parents of children with a strong family history, past exposure to head and neck irradiation, or a prior malignancy should be informed of the risk of thyroid cancer and the importance of a neck mass.
  • Postoperatively, parents and patients should monitor for recurrence of disease.
  • If thyroid replacement is used, families should understand symptoms of insufficient or excessive dosing.
• In the catastrophic event of nuclear fallout, all families within the vicinity should be educated about the possibility of thyroid cancer and take preventative measures if possible.
• For excellent patient education resources, visit eMedicine's Cancer and Tumors Center and Endocrine System Center. Also, see eMedicine's patient education articles Cancer of the Mouth and Throat and Thyroid Problems.

Miscellaneous

Medicolegal Pitfalls

• When evaluating a child with an anterior neck mass, consider the possibility of a thyroid nodule in the differential diagnosis. This is particularly important because a thyroid nodule in a child is more likely to be malignant than thyroid nodules in adult patients.
• If a thyroglossal duct cyst is suspected and problematic to the child, full investigation should be made into the presence and location of thyroid tissue before considering surgery. Some thyroglossal duct cysts may contain the only thyroid tissue the child has; thus, removal in this case necessitates lifelong replacement for a condition that is not life-threatening.
• Thorough and conscientious investigation and follow-up is required when thyroidectomy is considered. Mistaking a unilateral thyroid for a nodule could result in unnecessary surgery and possible litigation. In addition, the physician should closely monitor children on thyroid hormone replacement therapy, given the necessity of appropriate hormones for growth, development, and the growing child's changing needs. Failure to do so may be perceived as neglect.

Special Concerns

• Use extra care with pregnant patients who have thyroid nodules. Exposure to radioiodine may harm the fetal thyroid and should be avoided. If antithyroid medications are needed, propylthiouracil is preferable to methimazole.

• Search for CME/CE on This Topic »

• Thyroid, Evaluation of Solitary Thyroid Nodule (Otolaryngology and Facial Plastic Surgery)

• Cancer of the Mouth and Throat Overview
• Mouth and Throat Cancer Treatment
• Mouth and Throat Cancer Causes
• Cancer and Tumors Center
• Mouth and Throat Cancer Symptoms
• Endocrine System Center
• Thyroid Problems Overview

• A Germline Mutation (A339V) in Thyroid Transcription Factor-1 (TITF-1/NKX2.1) in Patients With Multinodular Goiter and Papillary Thyroid Carcinoma