Transcription:
Thyroid Nodules and Differentiated Carcinoma (Diagnosis, Treatment and Long-term Management))

Melanie Cole (Host):  The Thyroid Nodule and Carcinoma Clinic at Children's Mercy, Kansas City is the only pediatric clinic of its kind in the region, to provide the comprehensive evaluation, diagnosis, treatment and long-term management of thyroid nodules and differentiated carcinoma. Welcome to Pediatrics in Practice with Children's Mercy, Kansas City.

I'm Melanie Cole and joining me is Dr. Naim Mitre. He's a Pediatric Endocrinologist and the Medical Director of the Thyroid Nodule and Carcinoma Clinic at Children's Mercy, Kansas City. Dr. Mitre, as we get started, tell us a little bit about thyroid nodules and the prevalence of thyroid cancer in children.

Naim Mitre, MD (Guest): Sure, thank you for having me. I always like to start by defining what is the thyroid gland. So, you know, the thyroid gland is like a butterfly shaped gland that is located on the neck, on the anterior lower part of the neck. And it produces thyroid hormone, which is very important for growth and brain development in children. And it regulates the metabolism in older children and adults. So, a thyroid nodule is a solid, or it can be fluid filled lump that develops within the thyroid gland. Thyroid nodules are actually pretty common, in adults are very common and in children, they're less common, but the difference is that thyroid nodules in children can be up to 25% malignant.

So, that's why it's so important to detect them and to follow them. On average, you know, the studies show that incidence of thyroid cancer, it's about five cases per 1 million in the zero to 19 age group. And we think about all the thyroid cancers in children, thyroid malignancy is about 1.5% all of the cancers in children.

Host: Well, thank you for that, Dr. Mitre and previous guidelines for the management of thyroid nodules and cancer were typically geared towards adults. However, in the pediatric population, they do exhibit differences in pathophysiology, clinical presentation and long-term outcomes. Tell us a little bit about how therapy that may be recommended for an adult may not be appropriate for a child. Why do we need specific guidelines for children with thyroid nodules and thyroid cancer?

Dr. Mitre: Yeah, that's a great question. So, actually we currently have some guidelines for and the American Thyroid Association for thyroid nodules and cancer in children, which had a little different from the adults. And the reason why it's important is because usually that presentation is different in children than in adults. Like I was saying previously, children, nodules are less common, but usually when you find a nodule, and if that nodule is cancer, usually that disease is more widespread compared to adults. So, that means that when we diagnose a patient with thyroid cancer, you know, they already have metastasis out of the thyroid gland, which usually is in the neck, around the thyroid gland. And if it's like really extensive disease at presentation, it could be also going to the lungs.

And so it's different to have different guidelines because the presentation is different and the treatment and standards also can differ based on how children present. So, these guidelines that we have right now are really important because they tell us how to approach and how to follow the children in a way that the treatment is successful and they don't have long-term consequences.

Host: Tell us a little bit about diagnosis, Dr. Mitre. What does a comprehensive evaluation entail at the Children's Mercy Thyroid Nodule and Carcinoma Clinic? And are these typically incidental findings? How are they diagnosed?

Dr. Mitre: Sure. Actually thyroid nodules, are almost always, I will say asymptomatic. So, that means, the patient doesn't know they have a nodule. The family doesn't know. The primary doctor doesn't know, but usually when the primary doctors see the children for their well-child checks, and they palpate the neck, that's when they may identify the nodule because these nodules tend to be small.

So, you don't obviously see them and even with palpation. Usually a lot of these nodules are diagnosed and from our different reasons. So, usually patients are having imaging of the neck or the chest for a different reason, and then they can see a thyroid nodule. And then from there they know that they have a thyroid nodule in the neck, of course, sometimes they can be very large and when they are very large, then it's obvious to everyone and then they will notice a nodule.

I always like to tell, especially primary care providers that the best test, the most sensitive test to diagnose a thyroid nodule, or if you suspect a thyroid nodule, is to do a thyroid ultrasound. There's no need to do fancy CT scans or MRIs, not at the initial stage. The thyroid ultrasound is the best test. And the evaluation, you know, in our clinic, which is comprehensive, consists mainly first of seeing a pediatric endocrinologist which is a clinician. So, it's a doctor that specializes in thyroid cancer or nodules, first, and we will see the patient, for an evaluation, for a good exam. And then we also will do that thyroid ultrasound I was referring to, and also usually we do blood work to look at the function of that thyroid gland. And then based on those initial results that we will decide if a fine needle aspiration biopsy or FNA is needed to diagnose the nature of the thyroid nodule. So, that's kind of the first evaluation in the clinic for these patients.

Host: Tell us a little bit about the importance of a multidisciplinary team for these patients. Which specialties collaborate to provide expert care for children with thyroid nodules and differentiated carcinoma? Speak about this multidisciplinary approach and who's in charge of guiding patients care.

Dr. Mitre: Sure. The multidisciplinary clinic at Children's Mercy is mainly a clinic that collaborates with a pediatric endocrinologist, as usually the head of that team. You know, so the pediatric endocrinologist is the doctor that will see the patient first, we'll evaluate, we'll review images and testing and decide next steps.

So, if the patient is needed a biopsy, a fine needle aspiration biopsy, after the initial evaluation, then pediatric radiology or interventional radiology, we will help us get those biopsies for the children. And then if the patient needs surgery, for the treatment, then pediatric surgery, we will helping us with the surgeries. So, basically the clinic, you know, is usually run by the pediatric endocrinologist with the assistance of a specific pediatric surgeon and pediatric radiology.

Host: So I'd like you to talk now a little bit Doctor, about treatment protocols that are available. Any technologies, protocols for treatment that you feel are worth telling other providers about? How have advances in radiologic imaging really augmented your diagnostic and therapeutic capability? Speak about any that have changed the landscape for you, if you would.

Dr. Mitre: Sure. The main thing that I always like to tell primary care providers and family practitioners is that thyroid cancer and thyroid nodules are very treatable. So, we know how to treat them and we can treat them very well. Like I was saying before, we usually follow the American Thyroid Association guidelines for children for treatment.

Now, when it comes to a thyroid nodule, then the treatment could just be follow up, you know, every few months, to see the change in the nodule. Sometimes if the nodule changes, then we do a surgery for that nodule. Now, when it comes to actually thyroid cancer, surgery is always the initial treatment for thyroid cancer. And in some patients, radioactive iodine may will be given. In terms of new diagnosis tools or, you know, treatments, the imaging, like I said, the main imaging is a good thyroid ultrasound. And we have to have good thyroid ultrasound protocols to know how to report these findings.

That's kind of very important. There's now new technology in terms of like newer and more sensitive ultrasound machines that can detect, you know, small lesions with great quality, but more importantly is not only the technology, but knowing how to look at the images, how to collect them and then how to report the images. So, when we look at the thyroid nodules thinking about thyroid cancer, maybe for patients, we need to know certain characteristics of these nodules, that should be described in good detail, with a certain protocol that we have, so we can decide if this patient needs more workup or a biopsy, et cetera.

Now other testing, I like imaging like fancy modern imaging really for this type of cancer is not really that needed because that ultrasound usually is good enough. In extensive disease, in some patients who have a lot of disease out of the neck with metastases, then sometimes CT scans of the neck and chest are done and to get more fine information about the location of the disease and the lymph nodes, so that this can help the surgeon do a good surgery.

Host: Why is treatment and long-term management so important? What are some of the challenges in this population? What's important to note for the pediatrician in the medical home about watching these children as the years go by and they grow.

Dr. Mitre: So, the most important thing about the treatment for these children is that the patient is sent first to a clinician. So, to a pediatric endocrinologist so that then that clinician can decide if surgery is needed. I mean, very, very important. I always like to emphasize these surgeries for thyroid nodules and especially for thyroid cancer, need to be done by a surgeon that not only has expertise in operating in thyroid cancer, but also is what we call a high volume surgeon. So, a high volume surgeon is a surgeon that operates very frequently on thyroid cancer. And the importance of the treatment is that if you do an initial good surgery and with a good surgeon that has experience and you choose your surgeon well, then it will avoid complication from surgery.

And also it will avoid further need for subsequent surgeries or treatment. So, it is important that primary care providers out there know that when they suspect a thyroid nodule or thyroid cancer in a patient and don't refer them first to the surgeon, because a lot of surgeons, out in the community may not have the expertise to operate on these patients. And then they will just do a basic surgery. And what happens with these kids is that long-term followup is affected and as they grow after the surgery, they continue to have disease or they have metastatic disease or recurrence. Even though these children actually end up doing very well, long-term still, they will continue to have need for surgeries or treatments. So, it's very important that these surgeries are performed by a good, well, a high volume surgeon.

Host: What a great point. Thank you for making that. As we wrap up, Dr. Mitre, tell us about any research you'd like to mention that's taking place to improve clinical outcomes and really what you'd like pediatricians to know about diagnosis and treatment of thyroid nodules and thyroid cancer.

Dr. Mitre: Yes. In terms of research, there's research for adults and children is very similar. One thing that I always like to say in terms of research, because research, usually we think about good outcomes, is that even though children disease can present more extensively the long-term survivals are excellent, like 98 or more percent.

So, that's very important to know. Research nowadays, is focused more on trying to find ways of understanding why children have thyroid nodules and present with more extensive disease. Most recently, the research has focused on molecular testing, which is widely used in adults, to try to identify which thyroid nodules are malignant or need to have surgery.

And this is especially true in patients that we see where biopsies do not tell us it's completely benign or malignant, but tell us it's indeterminate. So, when it's indeterminant and we don't really know exactly what to do with this patient and these molecular testing and research is now going to help us to identify which patients actually need surgery for the treatment.

And finally for the pediatricians out there and advise, and I want them to remember that number one, you know, always when you suspect a thyroid nodule or thyroid cancer, if you want to do a test, you can do a thyroid ultrasound, that's the best tool to do. And please refer these patients to the pediatric endocrinologist first to determine what will be the next course of action.

And finally, always remember, and also for families, pediatricians who tell their families that thyroid nodules and thyroid cancer can be common, but are very treatable and they have excellent prognosis, even if they present with extensive disease.

Host: Thank you so much, Doctor. What an informative episode. Thank you so much for joining us and to refer your patient to the Thyroid Nodule and Carcinoma Clinic at Children's Mercy, Kansas City, please visit children'smercy.org to get connected with one of our providers. This has been Pediatrics in Practice with Children's Mercy, Kansas City. Please remember to subscribe, rate and review this podcast and all the other Children's Mercy podcasts. I'm Melanie Cole.