Clinical Presentation

The clinical presentation of childhood thyroid carcinoma has changed in several ways over the past several decades. The 1992 report on the University of Michigan experience demonstrated important changes in history and clinical presentation.4 The study compared patients treated from 1936 to 1970 with those treated from 1971 to 1990. The Michigan surgeons found that 50% of the former group reported a history of head and neck irradiation compared with only 3% in the latter group. Similarly, the incidence of palpable cervical adenopathy at initial presentation decreased from 63% to 36%; the rate of local infiltration of the primary cancer fell from 31% to 6%; and the rate of initial pulmonary metastases decreased from 19% to 6%. Alternatively, the incidence of finding a palpable mass or thyroid nodule on presentation increased from 37% to 73%.4 This meaningful change in presentation may reflect an increased awareness by pediatricians of the importance of routine examination of the thyroid. It appears that, at least in the Michigan experience, patients were being diagnosed at an earlier stage of their disease.

A palpable thyroid nodule in a child or adolescent, especially a male, is thyroid cancer until proved otherwise. Thyroid carcinoma has been found in 22% to 50% of childhood thyroid nodules brought to surgical exploration.54"56 All reports suggest that carcinoma is roughly twice as likely to be found in children with thyroid nodules as in adults.

Persistent lymphadenopathy must be of concern because it is a common presenting finding in childhood thyroid carcinoma.4 Most thyroid cancers in children are asymptomatic. A careful history should be taken to determine whether dysphasia, hoarseness, or a change in the voice is present. These are often findings suggestive of a more locally advanced stage. Pulmonary metastases are usually asymptomatic. Initial pulmonary metastases are not uncommon in childhood thyroid carcinoma and should be screened for by initial chest radiograph, computed tomography (CT) scan of the chest, serum thyroglobulin determination, and postoperative 131I whole-body scanning. Table 10-1 summarizes the initial extent of disease reported in several large series. Cervical lymph node metastases in these reports were confirmed by pathologic examination. Pulmonary and distant metastases were diagnosed by radiograph or 131I scanning or both.

Diagnostic fine-needle aspiration (FNA) biopsy is a useful procedure, especially when it is positive for carcinoma. FNA can be performed on either the primary thyroid nodule and/or a palpable enlarged cervical lymph node. Ultrasound guidance of diagnostic FNA biopsies provides increased assurance of the proper location of the needle tip in a target lesion. When adequate samples are taken, ultrasound-guided FNAs have fewer false-negative results.60 Diagnostic excision lymph node biopsy is occasionally useful if there is no palpable thyroid nodule or if an FNA of the node is negative. If all diagnostic efforts fail, then a child with a palpable thyroid nodule should undergo total lobectomy of the involved side. Nucleation of a nodule is unacceptable, and the diagnostic resection should be nothing less than a total thyroid lobectomy.

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