Medical Care
After initial diagnosis and investigation of the thyroid nodule, medical and/or surgical therapy is decided.
A presumed benign nodule, especially in an adolescent, may simply be observed. Close observation and follow-up care is essential. The patient should be closely monitored for change of size and the development of symptoms.
Treatment of autoimmune thyroiditis involves hormone replacement to maintain a euthyroid state.
Treat infection appropriately. Abscesses should be drained and antibiotics should be administered. In patients with immunocompromise, be aware of the remote possibility of local spread to mediastinal structures.
A warm nodule without physical signs of malignancy is usually benign and may be observed with close follow-up for growth or change in the nodule.
A hot toxic nodule may require medical therapy before surgical removal to allow for operative stability. The patient should receive suppressive doses of antithyroid medications. Once physiologic stability is obtained, the surgeon can proceed with removal of the gland or lobe.
In the past, preoperative thyroid suppression was used to exclude benign disease. This no longer is recommended for several reasons (eg, the incidence of cancer in childhood thyroid nodules is high, and well-differentiated cancers may respond, delaying definitive diagnosis and treatment).
Routine preoperative and postoperative care includes the maintenance of nutrition and hydration as well as the observation for signs of complications.
The pediatrician or other primary care provider should closely cooperate with the surgeon to monitor for nerve injury or hypocalcemia. Calcium supplementation may be necessary in the individual with parathyroid compromise, whether temporarily or permanently. Closely monitor laboratory findings to determine the initial and ongoing requirements.
Recurrent laryngeal nerve injuries may cause dysphagia, which can endanger nutrition. In such an individual, involve speech pathology early to optimize recovery.
After thyroidectomy, thyroid hormone replacement is necessary. This therapy is continued for the child's lifetime. Thyroid hormone levels should be monitored periodically so that adequate therapy is maintained during growth and changing needs. If malignancy is diagnosed, radioablation therapy may be used for any residual disease.
Long-term follow-up care remains vital in such individuals to screen for disease progression or late recurrence.
Surgical Care
The presence of a thyroid nodule in children presents somewhat of a dilemma, given the less-than-ideal reliability of diagnostic tests. However, the increased incidence of malignancy in pediatric nodules has led to a somewhat more aggressive approach than that used in adults.
Indications for surgical excision
Indications for surgery include physical examination findings consistent with malignancy, persistence of a nodule, progressive increase in size, or the presence of significant risk factors, including family history or history of irradiation exposure. All toxic nodules in children should be removed. If the presence of malignancy is still in question after diagnostic tests and procedures have been completed, perform surgical excision. Some authorities recommend the removal of all nonsuppressible thyroid nodules found in children younger than 13 years.
In the presence of a small asymptomatic nodule, the surgeon may elect to perform a simple lobectomy with close follow-up observation. Complications with this surgery are generally low. In such an individual, full thyroid suppression also is recommended as lifetime postoperative therapy. Many adenomas contain mutations, causing them to be hyperresponsive to thyroid-stimulating hormone (TSH). The presence of such an adenoma may signify the presence of other cells bearing the same mutations.
Total thyroidectomy
With the presence of any metastases on diagnosis, including lymph node involvement, total thyroidectomy is the recommended treatment. [3] This procedure has decreased the rates of local and metastatic recurrence.
Postoperative radioablation is also more effective in this case because tissue to absorb the radioiodine is reduced.
Because the rate of pulmonary metastasis is high, postoperative radioiodine scintigraphy is performed 6 weeks after surgery to exclude the presence of pulmonary tumors. Scintigraphy is only reliable after total or subtotal thyroidectomy because any remaining tissue may hide the presence of metastases.
Total thyroidectomy should be performed in individuals with medullary thyroid cancer, preferably before evidence of disease is obvious. This malignancy is aggressive and metastasizes early.
Prophylactic therapy, with removal of the gland in children with a family history and genetic markers, provides the best outcomes with this malignancy.
If Graves disease is diagnosed, thyroidectomy (near-total to total) may be performed. Thyroid hormone replacement therapy may not be needed in this case if some tissue remains.
Surgical technique
During the procedure, both lobes of the thyroid should be closely examined, because contralateral tumor involvement is common.
Lymph node exploration should include nodes in the jugulodigastric chain and along the recurrent laryngeal nerve in the tracheoesophageal groove. Dissection may also be needed in the superior mediastinum. Care should be taken to avoid injury to the recurrent laryngeal nerve or to the parathyroids. Of the parathyroid glands, 1-2 may be preserved and transplanted into the sternocleidomastoid muscle or nondominant forearm if needed.
Thyroidectomy for familial medullary thyroid carcinoma demands a total thyroidectomy with complete lymph node dissection of the entire central compartment, including the paratracheal nodes, delphian nodes, and superior mediastinal nodes.
Adequate dissection should extend to both carotid sheaths and to the innominate artery. A surgical cure is possible for this disease if the tumor has not spread to jugular or lateral cervical nodes or to distant organs.
Consultations
If a thyroid nodule is discovered, several consultations are useful. The team approach involves the pediatrician, pediatric endocrinologist, and pediatric surgeon. A hematologist-oncologist should be involved in caring for the patient with diagnosed malignancy. In addition, the treatment facility should have available experienced radiologists and cytopathologists who are comfortable with thyroid disease and its diagnosis in children.
Diet and Activity
Diet
No specific dietary recommendations for individuals with thyroid nodules are indicated. Supplementary dietary iodine may be useful, especially in persons with iodine deficiency or iodine 131 (131 I) exposure.
Activity
Once an individual has recovered from surgery, no specific activity restrictions are necessary.
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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.
