Low Sex Drive and Thyroid Disease:

According to a Journal of the American Medical Association (JAMA) study reported on in February 1999, about 43 percent of women and 31 percent of men suffer sexual inadequacy for one reason or another. The reasons cited included low desire, performance anxiety, premature ejaculation and/or pain during intercourse. Interestingly, this is thought to actually underestimate the real level of sexual dysfunction in the U.S. Research indicated that many of the sexual concerns were likely treatable, as they are due to physical and health issues. These health concerns can include common hormonal imbalances such as hypothyroidism.

Many people -- women in particular -- still complain of a lack of sexual desire even after their doctors consider the thyroid problem sufficiently treated. Low libido is just one of many symptoms that are not resolved for many people, despite treatment. Here are ten ways to revive your sex drive.

1. Make sure your thyroid drug treatment is optimal.

2. Make sure your TSH level is the best for your health

3. Check your hormones - get a full profile

4. Have a thorough physical to rule out other non-thyroid health conditions

5. Get testosterone supplementation, if necessary

6. For women, supplement estrogen/progesterone if needed

7. With your doctor's approval, consider supplements

8. Lose weight if you can. Some people have metabolic disorders that make difficult, sometimes, impossible to lose weight so have a full medical evaluation and be realistic.

9. Exercise, even moderate excersice can help you feel better overall. Start slow and build up duration and frequency. You can start by walking 20 minutes a day every other day.

10. Consider counseling or psychotherapy, either alone or with your partner.

VIDEO: Protecting yourself from Thyroid Cancer

Ashley Glass from ABC Action News 

talks to doctors about how to detect and protect yourself from Thyroid Cancer. 

Pediatric Thyroid Cancer Post Operative Care

After thyroidectomy and/or neck resection to remove malignant thyroid tumors thyroid hormone replacement with levothyroxine is started in the first few days after total thyroidectomy. This replacement is withheld in patients who will receive radioactive iodine which is administered only to patients with extensive neck disease or distant metastases.

• Cytomel or synthetic T3 is often used in place of levothyroxine prior to a postoperative nuclear scan or radioactive iodine (RAI) treatment. Cytomel has a shorter half-life, minimizing the period in which no suppression or replacement occurs and maximizing the uptake of radionuclide used in the scan or radioiodine therapy.  

• Radioactive iodine (RAI) therapy should be administered to all children and young adults with cervical lymphadenopathy after a total thyroidectomy to reveal and treat all distant metastases in the lungs as mentioned above. 

• A control thyroid scan is usually performed 2-3 weeks after surgery or radioiodine therapy. 

• Thyroid carcinoma has been found to recur up to 33 years after treatment. TSH-suppressive doses (150-200 mcg/d of T4) are thought to decrease recurrence in differentiated carcinomas.

• Patients should receive close follow-up care with pulmonary function tests, chest radiography, CT scans, and thyroid function tests. Thyroglobulin levels should be monitored for indications of medullary carcinoma.

• Postoperative local external beam radiation is not recommended because of a possible carcinogenic effect in children.

• Perioperative antibiotics are often used, and postoperative pain medications are standard, in addition to suppressive or replacement T4.

Author: Mark E Gerber, MD, FACS, FAAP  Clinical Assistant Professor of Otolaryngology, University of Chicago, Pritzker School of Medicine; Section Head, Pediatric Otolaryngology-Head and Neck Surgery, NorthShore University HealthSystem  

Co-Author: Brian Kip Reilly, MD  Assistant Professor of Otolaryngology and Pediatrics, Department of Otolaryngology, Children's National Medical Center, George Washington University School of Medicine  

Pediatric Thyroid Cancer Treatment Overview

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  Treatment for thyroid malignancy is primarily surgical:  Because of the unusual combination of an excellent prognosis and an advanced-stage disease presentation, the initial extent of surgery is controversial. Some recommend that the initial surgical approach should be conservative, while others advocate aggressive management with total thyroidectomy and radioactive iodine (RAI) for all patients. The relative infrequency of thyroid malignancy makes this controversy difficult to resolve.
• Thyroid lobectomy is the initial procedure of choice for most solitary thyroid lesions. This procedure adequately removes the pathologic region but spares enough thyroid tissue to maintain a euthyroid state. The thyroid lobule should be sent immediately for frozen section. If the frozen section confirms carcinoma, total or subtotal thyroidectomy can be completed. If the initial frozen section is indeterminate, one should wait for the final report. If the final pathology finding reveals carcinoma, then a total or subtotal thyroidectomy can be performed at a later date.
• The need for total versus near-total or subtotal thyroidectomy is controversial. Proponents for near-total or subtotal thyroidectomy believe that these procedures decrease the incidence of complications such as recurrent nerve injury and parathyroid devascularization, although the need to identify and preserve these structures remains.  A near-total thyroidectomy with radical lobectomy on the side of the primary lesion and subtotal removal of the contralateral lobe is recommended if the lesion is proven to be or suggestive of carcinoma.
• Although total thyroidectomy has not been proven to decrease recurrence, supporters of this method argue that remaining thyroid tissue may interfere with the use of radioactive iodine (RAI) in the postoperative diagnostic scanning and in the treatment of microscopic regional and distant disease. Residual thyroid tissue also provides a source of thyroglobulin that may postoperatively diminish the specificity of the test as a tumor marker.
• 
  
  Medullary Carcinoma: Total thyroidectomy and central neck dissection are indicated for biopsy-proven medullary carcinoma. Prophylactic total thyroidectomy may be indicated in children with a family history of multiple endocrine neoplasia (MEN) syndrome. Genetic screening is now possible for the MEN2 gene, and prophylactic surgery may be performed in patients as young as 5 years to prevent the occurrence of C-cell hyperplasia or carcinoma.

Neck dissection: Selective ipsilateral neck dissection in pediatric thyroid surgery is indicated for proven or suspected regional lymph node metastasis. During the dissection, lymph nodes in the paratracheal region, tracheoesophageal groove, and lateral areas can be inspected. Suspicious nodes are excised.

• Formal neck dissection has not been shown to improve outcome and has an increased risk of minor surgical complications. The authors advocate the use of total thyroidectomy with selective neck dissection for the treatment of pathologically confirmed thyroid carcinoma.
  
  
  In-patient Post Surgical Care: Serum calcium levels are measured daily for the first 2-4 postoperative days in all patients who have undergone a total or subtotal thyroidectomy. The calcium level usually drops slightly (to about 7 mg/dL) as the remaining parathyroid tissue recovers from surgical trauma. Mild hypocalcemia of this level requires treatment only if symptomatic. Mild symptoms include a positive Trousseau or Chvostek sign, mild cardiac arrhythmia, or perioral tingling. Treatment of these mild symptoms requires only oral calcium combined with vitamin D. Intravenous calcium gluconate is used for a more rapid replacement with severe arrhythmia or impending tetany.
  
  
  Long Term Medications:  Postoperative suppression of TSH with thyroid hormone may decrease recurrence and is more effective in papillary and papillary-follicular carcinomas. 
• Radioactive Iodine Therapy: Radioactive therapy with iodine 131  is indicated to ablate residual normal thyroid and to treat functioning metastases in differentiated thyroid tumors. Because pediatric patients are few and the prognosis is generally excellent, 131I is usually recommended only for patients with extensive unresectable cervical nodal involvement, invasion of vital structures, or distant metastases. Very few instances of solid tumors or leukemia associated with 131I treatment have been reported.
  
  
  Final Thoughts: Surgical complications include recurrent laryngeal nerve injury, hypoparathyroidism, hypothyroidism, and wound infection.
  

  • The most common complication of a total thyroidectomy in children is parathyroid gland injury. In 6-15% of patients, parathyroid gland injury results in permanent hypoparathyroidism.
  • Hypothyroidism in all patients after total thyroidectomy is avoided with thyroid hormone replacement.
  • Hypothyroidism occurs in 6.5-49% of patients who have undergone subtotal thyroidectomy.
  • Secondary operations are more hazardous.
  
  
  AUTHOR: Mark E Gerber, MD, FACS, FAAP  Clinical Assistant Professor of Otolaryngology, University of Chicago, Pritzker School of Medicine; Section Head, Pediatric Otolaryngology-Head and Neck Surgery, NorthShore University HealthSystem 
  
  
  CO-AUTHOR: Brian Kip Reilly, MD  Assistant Professor of Otolaryngology and Pediatrics, Department of Otolaryngology, Children's National Medical Center, George Washington University School of Medicine

New radiation treatment practice recommendations for thyroid disease

New recommendations from the American Thyroid Association (ATA) on outpatient radioiodine (131I) treatment aim to minimize unintended radiation exposure and maximize the safety of patients, their families, and the public. The new ATA recommendations are presented in the April issue of Thyroid, a peer-reviewed journal published by Mary Ann Liebert, Inc

The ATA convened a task force to update radiation safety information related to outpatient 131I therapy to treat hyperthyroidism and thyroid cancer. The new ATA practice recommendations cover a broad range of topics including travel; safety precautions at home, work, and school; personal hygiene; and pregnancy and breastfeeding. 

These recommendations comply with the most up-to-date U.S. Nuclear Regulatory Commission (NRC) regulations, including a recent guidance statement that advises medical professionals administering 131I therapy to ask patients about their intended destination after the treatment and to discourage them from staying at hotels to limit public radiation exposure.

In a Commentary in the February issue of Thyroid, Richard T. Kloos, MD, Professor, The Ohio State University and Secretary/Chief Operating Officer of the ATA, states that the new ATA document "aims to provide simplified, consistent, and safe instructions for care providers and patients."

"The strength of these practice recommendations is that the task force included representatives across the range of disciplines that use radiation to treat thyroid patients. It is essential that our patients receive clear and consistent information from those ordering, administering, and monitoring these treatments," states Gregory A. Brent, MD, Professor of Medicine and Physiology, David Geffen School of Medicine at the University of California Los Angeles and President of the ATA.

More information: The ATA recommendations are available free online at  www.liebertpub.com/thy

Provided by Mary Ann Liebert, Inc

Diagnosing Pediatric Thyroid Cancer: Biopsy

Fine-needle aspiration biopsy: 

• FNAB is the criterion standard in the diagnostic workup of adult thyroid nodules. Several studies report efficacy in the pediatric population.

• High diagnostic accuracy with experienced pathologists improves the selection of pediatric patients for surgery and is an adjunct to guide further management.

• Ultrasonography can be a useful guide for percutaneous needle biopsy when the lesion is difficult to identify with palpation.

• FNAB is often not practical in children younger than 10 years; therefore, excisional biopsy (surgical removal of nodule or tumor mass) under general anesthesia is recommended in this population.

• Using molecular polymerase chain reaction (PCR) studies on FNAB aspirate is mostly beneficial in the clinical research setting. It can be used in a very small number of patients for diagnostic purposes, but it remains expensive.

Significant Histologic Findings Review

Follicular adenoma is the most common cause of solitary nodules of the thyroid in the pediatric population. Adenomas are solitary, well circumscribed, and well encapsulated and are composed of glandular epithelium. Most are histologically follicular but are occasionally papillary.

• Most thyroid cancers (papillary, follicular, anaplastic) originate from follicular cells. Medullary thyroid cancers (25% hereditary vs 75% sporadic) are of C-cell (calcitonin-producing) origin.

• Thyroid malignancies in children are usually well-differentiated papillary or papillary-follicular subtypes, but all histologic types have been observed. 

• Papillary carcinoma lesions, which comprise an estimated 72% of pediatric thyroid cancers, are irregular, solid, or cystic masses that arise from follicular epithelium.

• Microscopically, pediatric thyroid cancer masses or nodules have fronds of epithelium and distinct uniform cells with rare mitoses. Most contain both papillary and follicular components. The cells contain pink, finely granular cytoplasm with large pale nuclei (Orphan Annie eyes) and nuclear grooves. 

• Psammoma bodies (rounded calcified deposits) can be found in approximately 50% of the lesions. 

• Pediatric Papillary Carcinoma has frequent lymphatic and pulmonary metastases.

• Follicular carcinoma lesions, which comprise 18% of pediatric thyroid cancers, are usually encapsulated and have highly cellular follicles and microfollicles with compact dark-staining nuclei of fairly uniform size, shape, and location. Pathologic diagnosis can be made only when invasion of the capsule, adjacent glands, lymphatics, or blood vessels is seen. 

• Pediatric Follicular Carcinoma metastasizes intravascularly to the lungs, brain, and bones. When a portion of the cells in the tumor are found to be oxyphilic (Hürthle cells), it is called a Hürthle cell tumor. These lesions tend to have a less favorable prognosis.

• MTC or Pediatric Medullary Thyroid Cancer arises from the thyroid parafollicular or C cells, which secrete calcitonin and are derived from the neural crest and ultimobranchial body. Hyperplasia of the C cells is thought to represent a precancerous state. 

• Histologically, MTC is composed of columns of epithelial cells and dense stroma that typically stain for amyloid and collagen. The nuclei are hyperchromatic, and mitoses are common. The cells have a fusiform shape and may form a whirling pattern. Calcifications are observed in 50% of these lesions.

Author: Mark E Gerber, MD, FACS, FAAP  Clinical Assistant Professor of Otolaryngology, University of Chicago, Pritzker School of Medicine; Section Head, Pediatric Otolaryngology-Head and Neck Surgery, NorthShore University HealthSystem  

Co-Author: Brian Kip Reilly, MD  Assistant Professor of Otolaryngology and Pediatrics, Department of Otolaryngology, Children's National Medical Center, George Washington University School of Medicine 

Diagnosing Pediatric Thyroid Cancer: Imaging Studies

Imaging studies reveal the malignant potential and the extent of disease, and they provide an anatomical roadmap for surgical planning. The following are the imaging studies with the highest yield.

Ultrasonography:  The safest and most widely available imaging technique, is the first-line screening diagnostic test in all pediatric patients with thyroid nodules. In particular, children with a history of radiation exposure should be observed with serial ultrasonography. 

• Nodules that enlarge even a few millimeters should undergo FNAB.

• Ultrasonography is useful in differentiating solid nodule or mass from cystic lesions and in revealing nonpalpable lesions. Many investigators consider cystic lesions to be benign lesions that represent hemorrhage into, or degeneration of, an adenomatous nodular goiter.

• A solid nodule is more likely to be malignant; however, up to 50% of malignant lesions may have a cystic component, and approximately 8% of cystic lesions represent malignancies.

• Ultrasonography reveals critical information regarding the risk of benign versus malignant disease. Benign features on ultrasound include multiple, solid isoechogenic or nonechogenic lesions and a uniform peripheral halo. Malignant features include a thick irregular halo.

• Color-Doppler sonography may aid in the diagnosis in patients with hyperfunctioning nodules (hot on scintigraphy and usually benign histologically), indicating an intensive vascular flow within a highly vascularized lesion and no visible flow through the remaining suppressed thyroid gland. Color-Doppler sonography is also valuable in distinguishing a cystic lesion (with no vascular flow) from a solid neoplasm (with intranodular flow).

• One of the most helpful capabilities of ultrasonography is guidance of percutaneous needle biopsy.

Radionucleotide scan (scintigraphy): Thyroid scintigraphy is most useful in revealing tissue function in thyroglossal duct cysts (eg, ensuring that thyroid tissue in the normal location is functioning) and in diagnosing ectopic thyroid. However, thyroid scintigraphy has not proven worthwhile in distinguishing malignant from benign disease.

• Classic hot nodules show uptake only in the nodule area of the thyroid and are associated with about a 6% incidence of malignancy. Harach et al (2002) wrote that untreated hot nodules can progress to carcinoma. 

• Surgical treatment is advisable for all children and adolescents with autonomously functioning thyroid nodules because of the risks of hyperthyroidism and thyroid carcinoma.

• Cold nodules are usually benign adenomas, although, in children, a larger number of them are carcinomas. Solid lesions that are cold on scintigraphy are malignant in about 30% of children.

• Total-body radioactive iodine (RAI) scans often reveal pulmonary nodal metastases, which are missed on radiography.

CT Scans

• Noncontrast CT scans can be helpful in patients with substernal extension, local invasion, or lymph node metastasis. 

• At initial evaluation, approximately 20% of children have pulmonary metastasis that can be revealed by either chest radiography or CT scan.

• Children have a much higher incidence of pulmonary involvement (spread to or metastatic thyroid cancer disease) than adults.

• The CT lung findings, which usually consist of diffuse miliary spots and, less often, infiltrating nodules, are often also best noted with RAI scans.

Author: Mark E Gerber, MD, FACS, FAAP  Clinical Assistant Professor of Otolaryngology, University of Chicago, Pritzker School of Medicine; Section Head, Pediatric Otolaryngology-Head and Neck Surgery, NorthShore University HealthSystem  

Co-Author:  Brian Kip Reilly, MD  Assistant Professor of Otolaryngology and Pediatrics, Department of Otolaryngology, Children's National Medical Center, George Washington University School of Medicine 

Living for Today Again!

The radioactive tracer dye is injected into my veins. Now I have three hours to wait until the bone scan to see  if the cancer has spread to my bones. As I sit waiting and thinking about the "what ifs" I am both restless and numb. I've been here before; I am a two time cancer survivor.

I am 47 years old and I have a million things to live for. There are so many people who need me -- my son Jeremy (a traumatic brain injury survivor), my daughter Stevie Joellie (a thyroid cancer survivor), my dog Mr. Max Schnauzer, our extended family and my wonderful circle of friends.  I think of each and everyone of my loved ones and the tears start welling up thinking "No, I am NOT going to get ahead of myself and think the worst."

During  my  last round with cancer in 2008 when I lived through 5 surgeries in one year, numerous blood transfussions, immunosuppressive therapy and chemo I did not allow myself to think about the possibility of my children facing life without their mother as I have. It did cross my mind sometimes, as it does today, but I can't go there, I won't go there, at least not today.....

I pick up a magazine, but I can't concentrate on that either. The latest fad diet or newest spring fashion seems so inconsequential. The housing market, the economy, the war in the Middle East, jury selection in the Casey Anthony trial. I don't care! I have a long, long "To Do" list and I could care less! So I return to my "what ifs" train of thought, yet keep it  light focused on remembering Mr. Max Schnauzers' crazy antics so that I don't become a bawling idiot in the radiology waiting room.

If I were given bad news (let's keep it vague) what would I do?  

I started a list:

• enjoy my children and my dog every moment
• write a book -maybe my autobiography
• publish my poems - I have thousands in binders
• take my children to Puerto Rico -they never been there
• go to Sinatra Park in Hoboken and have a picnic on the 4th of July

I really, really got into my list. I almost forgot about the radioactive tracer flowing through my veins finding it's way to my bones. Eventually, the three hours passed, and it was time for the bone scan. Then the waiting game continues. Waiting for results is always the hardest thing to do. I am thinking that I am not leaving this hospital without an answer today. I am thinking that I may have to hold the radiology department hostage if they tell me that my doctor will call me in a few days. But I didn't have to.

The doctor and the radiology department know me well. I have been here many times before; with my father when he was diagnosed with terminal leiomyosarcoma, with my daughter when she was diagnosed with Stage III thyroid cancer, with my son for routine follow up and with countless other members of our Thyroid Cancer Support Group. They know me and they don't keep me guessing longer than necessary.  I am immensely relieved to hear the bone scan shows no sign of metastatic disease!

I called my kids and told them I'd be home soon. They knew I have been in a lot of pain lately and that I needed a check up but I never told them about the test or about my fears, I don't want them panicked over the "what ifs". They have been through quite enough in their young lives and I want them to be as happy and stress free as they possibly can be, as long as they live. The reality of my medical situation is the same as for every single cancer survivor: I will live the rest of my life with periodic "scares" like this one.

When you are a cancer survivor, the first step is always to rule out a cancer recurrence. Most people with persistent lower back pain woud probably go to their chiropractor first. As a cancer survivor, my first step was to go for a bone scan. But today is not the day to dwell on that. Today is a day I am feeling like an Eagle soaring in the sky!  Later when I talk to a lifelong friend living in St. Thomas I tell her about my list and that she made it on the list.  She asks, "Why don't you come for a visit?"

And that's a good question! How absurd to say, "But I got good news. The cancer has not spread!" I told her I would think about it. And I did! For several days I thought about my list. Was it the "I'm dying" list? That's how I had secretly entitled it in my mind, but should it be the "I'm living" list? I started thinking about how amazing it would be to sit somewhere in Hoboken NJ, sipping on a Margarita watching the 4th of July fireworks like it did so many times before I ever got sick and celebrate the fact that I am living.

Oh, I could come up with an even longer list of reasons  I should stay living in Orlando FL, work more, focus on my "To Do's" But what fun would it be?  What exactly would it all do for me? The work and the "To Do's" will always be here or there and everywhere. It's a choice I have to make about how and where I want to live my life. I am choosing to live where I am the happiest and to enjoy my life today and everyday from this moment on.

I am moving back to New Jersey. I bought plane tickets for April 16th, 2011. I don't have a plan or a place to live for that matter, but my heart is singing and full of hope. I am living today for today and that's good enough for me!

About The Author: Wilma Ariza is the Founder Stevie JoEllie's Cancer Care Fund a Project of United Charitable Programs Inc., a 501(c)(3) Public Charity Tax ID 20-4286082 Progam 102442. In 2008 her daughter Stevie JoEllie was diagnosed with State II Follicular Thyroid Cancer a few weeks after her 21st Birthday. Both her daughter and Wilma are 2 time cancer survivors.

Diagnosing Pediatric Thyroid Cancer: Laboratory Studies

• Thyroglossal duct cysts, the most common developmental thyroid anomaly, carry an increased, albeit small, risk of malignant transformation. This is one of the reasons excision with the Sistrunk procedure (removal of cyst, central hyoid bone, and core from the base of the tongue) is recommended. However, only 8 cases of malignant thyroglossal duct transformation have been reported in the literature.

• Levels of serum triiodothyronine (T3), thyroxine (T4), and thyroid-stimulating hormone (TSH) are usually within reference ranges in malignancy. Therefore, although these blood studies have no predictive value for thyroid cancer, they help shape the differential diagnosis of a child's thyroid mass.

• Antithyroid antibodies are helpful in diagnosing chronic lymphocytic thyroiditis. Thyroglobulin levels may be elevated in differentiated thyroid carcinoma and may help in postoperative monitoring. The thyroglobulin level should not be measured until at least 14 days after fine-needle aspiration (FNA) to prevent an artificial level elevation from the needle instrumentation.

• Traditional screening for both medullary thyroid cancer (MTC) and thyroid C-cell hyperplasia is performed by measuring calcitonin levels before and after pentagastrin stimulation. Screening for multiple endocrine neoplasia 2 (MEN2) is now possible with DNA analysis for specific mutations in the ret protooncogene.

• Serum carcinoembryonic antigen (CEA) should be measured in those in whom MTC is suspected. Unfortunately, a negative value may be found in advanced stages of the disease.

• Obtain a 24-hour urine collection to screen for catecholamines metabolites, as a pheochromocytoma or paraganglioma should be surgically removed before thyroidectomy to avoid a hypertension crisis during surgery.

• Obtain genetic testing at birth in children at risk for MEN2B and no later than age one year in children at risk for MEN2A.

Author: Mark E Gerber, MD, FACS, FAAP  Clinical Assistant Professor of Otolaryngology, University of Chicago, Pritzker School of Medicine; Section Head, Pediatric Otolaryngology-Head and Neck Surgery, NorthShore University HealthSystem  

Co-Author: Brian Kip Reilly, MD  Assistant Professor of Otolaryngology and Pediatrics, Department of Otolaryngology, Children's National Medical Center, George Washington University School of Medicine 

Pediatric Thyroid Cancer: Causes

Thyroid carcinoma is a known sequela of radiation exposure. From the 1920s to the 1960s, external beam radiation was used for treatment of benign lesions (eg, tinea capitis, tonsillar hypertrophy, acne, thymic enlargement, hemangiomas) prior to recognition of its carcinogenic effects.

The Chernobyl disaster in 1986 caused up to a 100-fold increase in the incidence of pediatric thyroid carcinoma in the exposed population. Cases associated with radiation exposure are mostly papillary carcinoma, and those associated iodine-deficient areas are more likely follicular.

Radiation and chemotherapy for other pediatric malignancies also have been implicated in thyroid malignancy. Children who undergo pretreatment radiation therapy prior to bone marrow transplant and children who undergo primary radiation treatments for Hodgkin lymphoma are at increased risk for thyroid cancer. The risk for thyroid cancer is dose dependent.

Congenital hypothyroidism (CH), due to either dyshormonogenesis or an iodine transporter defect, increases the risk of thyroid nodules. Chronic thyroid-stimulating hormone (TSH) elevation increases the risk of neoplastic transformation of thyroid. The benign nodules usually respond to thyroxine treatment. Those that remain or enlarge despite suppression therapy should undergo biopsy.

Thyroglossal duct cysts, the most common developmental thyroid anomaly, carry an increased, albeit small, risk of malignant transformation. This is one of the reasons excision with the Sistrunk procedure (removal of cyst, central hyoid bone, and core from the base of the tongue) is recommended. However, only 8 cases of malignant thyroglossal duct transformation have been reported in the literature.

Author: Mark E Gerber, MD, FACS, FAAP  Clinical Assistant Professor of Otolaryngology, University of Chicago, Pritzker School of Medicine; Section Head, Pediatric Otolaryngology-Head and Neck Surgery, NorthShore University HealthSystem 

Co-Author: Brian Kip Reilly, MD  Assistant Professor of Otolaryngology and Pediatrics, Department of Otolaryngology, Children's National Medical Center, George Washington University School of Medicine 

Pediatric Thyroid Cancer: Clinical Review

Thyroid carcinoma in pediatric patients usually manifests as an asymptomatic neck mass, with a reported incidence of cervical lymphadenopathy that ranges from 35-83%. The neck masses are typically discovered incidentally by parents, patients, or physicians during routine physical examination.

Focal fold paralysis in children with thyroid malignancy is much less common than in adults with thyroid malignancy. Niedziela and Korman (2002) studied 37 children in Poland with thyroid cancer, none of whom presented with vocal cord paralysis or associated hoarseness.

Additionally, unlike adults, young patients with thyroid nodules often do not report pain, tenderness, compression of the respiratory tract, problems with swallowing, or inappropriate fixation of the neck. Even young patients who have lung metastases usually do not report pulmonary symptoms. However, 10-20% of patients present with distant metastasis (most commonly to the lungs) and 70% of patients present with extensive regional nodal involvement.

Many young patients have a family history of thyroid cancer. For example, 25% of medullary thyroid cancer (MTC) cases are hereditary, while over 75% are sporadic. A family history of MTC, pheochromocytoma, or hyperparathyroidism may indicate multiple endocrine neoplasia 2A (MEN2A) or multiple endocrine neoplasia 2B (MEN2B), both of which are inherited in an autosomal dominant fashion.

All family members should be genetically screened for this mutation, especially given its autosomal dominant mode of inheritance. A history of Graves disease, hypothyroidism, or goiter should suggest a benign thyroid disease process, although long-term suppression of Graves Disease with antithyroid drugs may lead to increased risk of malignant thyroid transformation.

Clinical Facts Review

·      Pediatric thyroid carcinoma usually presents with one or more painless firm neck nodules.

·       Most malignant nodules detected in children were 1.5 cm or larger in size.  

·      A soft compressible nodule is less likely to be malignant than a firm one.

·  Tenderness of the nodule suggests hemorrhage into a nodule, a cyst, or an inflammatory process. For     instance, if the skin is warm, erythematous, and diffusely tender, a diagnosis of acute suppurative thyroiditis is most likely and an inflammatory workup should be pursued.

·  Fixation of the mass to surrounding tissues and vocal fold paralysis suggest malignancy, although this process is rare. Lymphadenopathy further increases the likelihood of malignancy.

·      Diffuse thyroid enlargement or multiple nodules are more suggestive of a benign process.

·     Mucosal neuromas of the tongue, palpebral conjunctiva, and lips with marfanoid body habitus may suggest MEN2B syndrome with medullary carcinoma, which often manifests in infancy.

Finally, patients who report a rapid growth rate of cancer may have a poorer prognosis, although that observation is controversial. Pain is rarely associated. Local tenderness is attributed to either thyroid cyst formation or hemorrhage into a rapidly growing nodule. Autoimmune disease, which often results in rapidly enlarging thyroid glands, confounds any associated glandular nodularity for which malignancy must be excluded.

Author: Mark E Gerber, MD, FACS, FAAP  Clinical Assistant Professor of Otolaryngology, University of Chicago, Pritzker School of Medicine; Section Head, Pediatric Otolaryngology-Head and Neck Surgery, NorthShore University HealthSystem 

Co-Author: Brian Kip Reilly, MD  Assistant Professor of Otolaryngology and Pediatrics, Department of Otolaryngology, Children's National Medical Center, George Washington University School of Medicine 

Pediatric Thyroid Cancer: Epidemiology

United States: Thyroid cancer, the most common pediatric endocrine neoplasm, represents 1-1.5% of all pediatric malignancies and 5-5.7% of malignancies in the head and neck. Only 5% of all thyroid cancers occur in children and adolescents. Thyroid nodules occur in 4-7% of the general adult population and in only 1-2% of the pediatric population. These numbers are estimated using a compilation of data from multiple reports.

Paradoxically, despite the lower incidence of thyroid nodules in children, a pediatric thyroid nodule has a greater risk of containing or developing a malignancy. Whereas 5% of nodules in adults are malignant, in the pediatric population, the percentage of malignant nodules is 26.4%. The incidence of malignancy in multinodular goiter is 1-7% and 10-25% in solitary nodules. Pediatric thyroid cancer (3% prevalence) in adolescents is also associated with juvenile autoimmune thyroiditis.

• Papillary thyroid cancer is by far the common thyroid malignancy in children. Although papillary carcinoma is more aggressive in children than in adults, pediatric papillary cancer carries a much better prognosis that adult thyroid cancer.

• Medullary thyroid cancer (MTC), which constitutes 5% of pediatric thyroid malignancies, is usually associated with multiple endocrine neoplasia type 2 (MEN2) in the pediatric population. The inheritance pattern occurs either sporadically or as familial MTC without other associated endocrine abnormalities. MEN2 consists of MTC and pheochromocytoma and either hyperparathyroidism (2A) or mucosal neuromas (2B). MTC associated with MEN2B is more virulent and may occur and metastasize early in infancy.

International: After the Chernobyl nuclear power plant disaster, individuals living in Russia, Ukraine, and Belarus were exposed to significant levels of radioactive iodines, primarily 131I. This radioactivity, which is concentrated in the thyroid gland, has resulted in a substantial increase in pediatric thyroid cancer rates among this cohort of children.

Mortality/Morbidity: Pediatric thyroid malignancies are usually a well-differentiated papillary subtype or the papillary-follicular subtype, but all histologic types have been observed. Children commonly present with advanced disease. At presentation, 70% of patients have extensive regional nodal involvement, and 10-20% of patients have distant metastasis. The lungs are the most common sites of metastasis.

Pediatric patients seem to have higher local and distant recurrence rates than adults, but they tend to respond rapidly to therapy. The prognosis for children is excellent, with mortality rates of less than 10%. Benign tumors such as follicular adenomas should be considered at risk for tumor progression toward follicular thyroid carcinoma, and they must be surgically addressed.

Sex / Gender: Thyroid carcinoma is 2-3 times more common in females. The gender distribution of thyroid carcinoma differs between adults and children. Thyroid cancer is 4 times as common in women as in men. This difference is not seen in individuals younger than 15 years; the girl-boy ratio is as low as 1.5:1. However, in individuals aged 15–20 years, the female-to-male ratio is 3:1. This implies that female sex hormones, especially during puberty, play a significant yet still undefined role in the increased incidence of thyroid cancer in females.

Age:  Age is a major determinant of both the incidence and recurrence of pediatric thyroid carcinoma. Pediatric thyroid carcinoma occurs more frequently in adolescents, although it has been reported in the neonatal period. In children younger than 10 years, identified thyroid lesions are more likely to be malignant. Children younger than 10 years are also more likely to have recurrent cancer.

Author: Mark E Gerber, MD, FACS, FAAP  Clinical Assistant Professor of Otolaryngology, University of Chicago, Pritzker School of Medicine; Section Head, Pediatric Otolaryngology-Head and Neck Surgery, NorthShore University HealthSystem  

Co-Author: Brian Kip Reilly, MD  Assistant Professor of Otolaryngology and Pediatrics, Department of Otolaryngology, Children's National Medical Center, George Washington University School of Medicine 

Introduction to Pediatric Thyroid Cancer

Although a review of thyroid cancer literature contains numerous reports on the subject of pediatric thyroid carcinoma, the low incidence and subsequent lack of prospective randomized trials make drawing absolute conclusions regarding the definitive workup, management, and treatment of this disease difficult.

A detailed understanding of how to perform a comprehensive evaluation of the pediatric thyroid nodule is necessary in order to establish the diagnosis of pediatric thyroid cancer. The incidence of head and neck malignancies, including those of the thyroid, has increased 25% during the past 30 years. 

Although the incidence of thyroid nodules in children is rare before adolescence (1.5%), pediatric thyroid nodules have a 26.4% mean risk of cancer. Some authors have reported an incidence of as high as 36%. Moreover, pediatric thyroid nodules are 4 times more likely to carry a diagnosis of thyroid cancer than adult nodules. Because pediatric thyroid nodules carry this increased risk of malignancy, physicians should perform an expeditious workup.

The recommended diagnostic protocol of thyroid nodules consists of the following steps:

• Child's history, including the prior existence and treatment of a benign thyroid disease
• Clinical examination
• Laboratory tests
• Thyroid ultrasonography
• Fine-needle aspiration biopsy (FNAB)

The beneficial role of scintigraphy is limited, and molecular marker analysis is currently more beneficial in a clinical research setting.

Most childhood thyroid nodules are asymptomatic and are detected by parents or by physicians during routine examination. Only about 50% of children with thyroid carcinoma present with nodular thyroid enlargement as the presenting symptom. Follicular adenoma is the most common cause of solitary thyroid nodules in the pediatric population; however, solitary nodules in children reportedly have a 20-73% incidence of malignancy.

Hurthle Cell Carcinoma 

A monomorphous cell population of Hürthle cells arranged in loosely cohesive clusters and single cells. The cells are polyhedral and have abundant granular cytoplasm with well-defined cell borders. The nuclei are enlarged and have a central prominent macronucleolus.  

A painless non-inflammatory metastatic cervical mass is the presenting symptom in 40-60% of patients. Malignant thyroid  lesions in children with no family history of thyroid cancer are usually papillary and follicular carcinomas. Radiation exposure, which is still used either as therapy prior to bone marrowtransplantation or as a treatment of Hodgkin disease, remains a major riskfactor.

The subsequent diagnostic workup is aimed at determining whether the lesion represents a malignancy. Collected data can be useful in preoperative planning if surgery is indicated. Pediatric and adult thyroid cancers have differing biological behaviors. 

Despite the fact that pediatric thyroid cancer usually presents at an advanced stage, it carries an excellent prognosis for most patients.

Author: Mark E Gerber, MD, FACS, FAAP  Clinical Assistant Professor of Otolaryngology, University of Chicago, Pritzker School of Medicine; Section Head, Pediatric Otolaryngology-Head and Neck Surgery, NorthShore University HealthSystem 

Co-Author: Brian Kip Reilly, MD  Assistant Professor of Otolaryngology and Pediatrics, Department of Otolaryngology, Children's National Medical Center, George Washington University School of Medicine