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Solitary Thyroid Nodule Follow-up

  • Author: Andre Hebra, MD; Chief Editor: Stephen Kemp, MD, PhD  more...
 
Updated: Apr 28, 2014
 

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.

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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.

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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.

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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.

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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.

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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%.[12]

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.

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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.

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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 eMedicineHealth's Cancer Center and Thyroid and Metabolism Center. Also, see eMedicineHealth's patient education articles Cancer of the Mouth and Throat and Thyroid Problems.

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Contributor Information and Disclosures
Author

Andre Hebra, MD Chief, Division of Pediatric Surgery, Professor of Surgery and Pediatrics, Medical University of South Carolina College of Medicine; Surgeon-in-Chief, Medical University of South Carolina Children's Hospital

Andre Hebra, MD is a member of the following medical societies: Alpha Omega Alpha, Florida Medical Association, Society of American Gastrointestinal and Endoscopic Surgeons, Children's Oncology Group, International Pediatric Endosurgery Group, American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Society of Laparoendoscopic Surgeons, South Carolina Medical Association, Southeastern Surgical Congress, Southern Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Lynne Lipton Levitsky, MD Chief, Pediatric Endocrine Unit, Massachusetts General Hospital; Associate Professor of Pediatrics, Harvard Medical School

Lynne Lipton Levitsky, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Diabetes Association, American Pediatric Society, Endocrine Society, Pediatric Endocrine Society, Society for Pediatric Research

Disclosure: Received grant/research funds from Eli Lilly for pi; Received grant/research funds from NovoNordisk for pi; Received consulting fee from NovoNordisk for consulting; Partner received consulting fee from Onyx Heart Valve for consulting.

Chief Editor

Stephen Kemp, MD, PhD Former Professor, Department of Pediatrics, Section of Pediatric Endocrinology, University of Arkansas for Medical Sciences College of Medicine, Arkansas Children's Hospital

Stephen Kemp, MD, PhD is a member of the following medical societies: American Academy of Pediatrics, American Association of Clinical Endocrinologists, American Pediatric Society, Endocrine Society, Phi Beta Kappa, Southern Medical Association, Southern Society for Pediatric Research

Disclosure: Nothing to disclose.

Additional Contributors

Arlan L Rosenbloom, MD Adjunct Distinguished Service Professor Emeritus of Pediatrics, University of Florida College of Medicine; Fellow of the American Academy of Pediatrics; Fellow of the American College of Epidemiology

Arlan L Rosenbloom, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Epidemiology, American Pediatric Society, Endocrine Society, Pediatric Endocrine Society, Society for Pediatric Research, Florida Chapter of The American Academy of Pediatrics, Florida Pediatric Society, International Society for Pediatric and Adolescent Diabetes

Disclosure: Nothing to disclose.

Acknowledgements

Melissa Miller, MD Department of Surgery, Medical University of South Carolina College of Medicine

Melissa Miller, MD is a member of the following medical societies: American Medical Association and American Medical Student Association/Foundation

Disclosure: Nothing to disclose.

Patrick B Thomas, MD Fellow, Department of Pediatric Surgery, Texas Children's Hospital

Patrick B Thomas, MD is a member of the following medical societies: American Medical Association and South Carolina Medical Association

Disclosure: Nothing to disclose.

References
  1. Kihara M, Hirokawa M, Masuoka H, Yabuta T, Shindo H, Higashiyama T, et al. Evaluation of cytologically benign solitary thyroid nodules by ultrasonography: A retrospective analysis of 1877 cases. Auris Nasus Larynx. 2012 Oct 23. [Medline].

  2. Raval MV, Browne M, Chin AC, et al. Total thyroidectomy for benign disease in the pediatric patient--feasible and safe. J Pediatr Surg. 2009 Aug. 44(8):1529-33. [Medline].

  3. Desjardins JG, Khan AH, Montupet P, et al. Management of thyroid nodules in children: a 20-year experience. J Pediatr Surg. 1987 Aug. 22(8):736-9. [Medline].

  4. Hung W, Anderson KD, Chandra RS, et al. Solitary thyroid nodules in 71 children and adolescents. J Pediatr Surg. 1992 Nov. 27(11):1407-9. [Medline].

  5. Hung W. Solitary thyroid nodules in 93 children and adolescents. a 35-years experience. Horm Res. 1999. 52(1):15-8. [Medline].

  6. Chiesa F. Thyroid disease in northern Italian children born around the time of the Chernobyl nuclear accident. Annals of Oncology. 2004. 15:1842-6. [Medline].

  7. Newman KD, Black T, Heller G, Azizkhan RG, Holcomb GW 3rd, Sklar C, et al. Differentiated thyroid cancer: determinants of disease progression in patients 1111111111111111Ann Surg</i>. 1998 Apr. 227(4):533-41. [Medline].

  8. Bouhabel S, Payne RJ, Mlynarek A, Hier M, Caglar D, Tamilia M. Are solitary thyroid nodules more likely to be malignant?. J Otolaryngol Head Neck Surg. 2012 Apr. 41(2):119-23. [Medline].

  9. Fowler CL, Pokorny WJ, Harberg FJ. Thyroid nodules in children: current profile of a changing disease. South Med J. 1989 Dec. 82(12):1472-8. [Medline].

  10. Al-Shaikh A, Ngan B, Daneman A, Daneman D. Fine-needle aspiration biopsy in the management of thyroid nodules in children and adolescents. J Pediatr. 2001 Jan. 138(1):140-2. [Medline].

  11. Lugo-Vicente H, Ortiz VN, Irizarry H, et al. Pediatric thyroid nodules: management in the era of fine needle aspiration. J Pediatr Surg. 1998 Aug. 33(8):1302-5. [Medline].

  12. Millman B, Pellitteri PK. Nodular thyroid disease in children and adolescents. Otolaryngol Head Neck Surg. 1997 Jun. 116(6 Pt 1):604-9. [Medline].

  13. Bentley AA, Gillespie C, Malis D. Evaluation and management of a solitary thyroid nodule in a child. Otolaryngol Clin North Am. 2003 Feb. 36(1):117-28. [Medline].

  14. Bukhari MH. An updated audit of fine needle aspiration cytology procedure of solitary thyroid nodule. Diagn Cytopathol. 2008. 36:104-12. [Medline].

  15. Canadian Pediatric Thyroid Nodule (CaPTN) Study Group. The Canadian Pediatric Thyroid Nodule Study: an evaluation of current management practices. J Pediatr Surg. 2008. 43:826-30. [Medline].

  16. Cotran RS, Kumar V, Robbins SL. The thyroid. Robbins Pathologic Basis of Disease. 5th ed. 1994. 1121-42.

  17. Dreimane D, Varma SK. Common childhood thyroid disorders. Indian J Pediatr. 1997 Jan-Feb. 64(1):3-10. [Medline].

  18. Fisher DA. The thyroid gland. Clinical Paediatric Endocrinology. 1989. 309-37.

  19. Flannery TK, Kirkland JL, Copeland KC, et al. Papillary thyroid cancer: a pediatric perspective. Pediatrics. 1996 Sep. 98(3 Pt 1):464-6. [Medline].

  20. Herrmann MA, Hay ID, Bartelt DH Jr, et al. Cytogenetic and molecular genetic studies of follicular and papillary thyroid cancers. J Clin Invest. 1991 Nov. 88(5):1596-604. [Medline].

  21. [Guideline] Iqbal CW, Wahoff DC. Diagnosis and management of pediatric endocrine neoplasms. Curr Opin Pediatr. 2009 Jun. 21(3):379-85. [Medline].

  22. Loh KC, Greenspan FS, Gee L, et al. Pathological tumor-node-metastasis (pTNM) staging for papillary and follicular thyroid carcinomas: a retrospective analysis of 700 patients. J Clin Endocrinol Metab. 1997 Nov. 82(11):3553-62. [Medline].

  23. Lugo-Vicente H, Ortiz VN. Pediatric thyroid nodules: insights in management. Bol Asoc Med P R. 1998 Apr-Jun. 90(4-6):74-8. [Medline].

  24. Niedziela M. Pathogenesis, diagnosis and management of thyroid nodules in children. Endocr Relat Cancer. 2006. 13:427-53. [Medline].

  25. Sclafani AP, Valdes M, Cho H. Hashimoto's thyroiditis and carcinoma of the thyroid: optimal management. Laryngoscope. 1993 Aug. 103(8):845-9. [Medline].

  26. Stevens C, Lee JK, Sadatsafavi M, Blair GK. Pediatric thyroid fine-needle aspiration cytology: a meta-analysis. J Pediatr Surg. 2009. 44:2184-91.

  27. Stezhko VA, Buglova EE, Danilova LI. A cohort study of thyroid cancer and other thyroid diseases after the Chornobyl accident: objectives, design and methods. Radiat Res. 2004 Apr. 161(4):481-92. [Medline].

  28. Takahashi T, Fujimori K, Simon SL. Thyroid nodules, thyroid function and dietary iodine in the Marshall islands. Int J Epidemiol. 1999 Aug. 28(4):742-9. [Medline].

  29. Tucker ME. Radiofrequency Bests Laser for Ablation of Thyroid Nodules. Medscape Medical News. May 8, 2013. Available at http://www.medscape.com/viewarticle/803790. Accessed: May 15, 2013.

  30. Walfish PG, Tseng KH. Thyroid physiology and pathology. Pediatric Endocrinology. 1989. 367-448.

  31. Yip FW, Reeve TS, Poole AG. Thyroid nodules in childhood and adolescence. Aust N Z J Surg. 1994 Oct. 64(10):676-8. [Medline].

 
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A 12-year-old patient with an asymptomatic palpable thyroid nodule noticed upon routine physical examination.
Surgical specimen of a thyroid lobe with papillary carcinoma taken from a 12-year-old patient with an asymptomatic palpable thyroid nodule noticed upon routine physical examination.
 
 
 
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