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.
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.
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.
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A 12-year-old patient with an asymptomatic palpable thyroid nodule noticed upon routine physical examination.
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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.
