Clinical Thyroidology® for the Public

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An evaluation of the management of thyroid nodules in children

Clinical Thyroidology for the Public

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Thyroid nodules are an abnormal growth of thyroid cells that form a lump within the thyroid. Thyroid nodules can be benign (not cancer) or malignant (cancer). While thyroid nodules are very common in adults, occurring in up to 50% of individuals, they are uncommon in children. However thyroid nodules have a higher rate of cancer in children than in adults. Further, thyroid cancer in children tends to be more aggressive and can be more advanced compared to in adults. The American Thyroid Association (ATA) developed guidelines in 2015 for the management of pediatric (childhood) thyroid nodules. The purpose of this study is to analyze the management of thyroid nodules in children and understand the clinical practice variations or differences when comparing clinical practices to the 2015 ATA guidelines.

Al Maawali A et al 2020 The thyroid nodules in kids study (ThyNK study): An evaluation of clinical practice variation. J Pediatr Surg 55:950–953. PMID: 32081357.

A study of pediatric patients presenting with a thyroid nodule at a single pediatric center from 2007 to 2017 was performed. Patients up to 18 years of age with a solitary or dominant thyroid nodule were identified using a chart-based patient registry at the British Columbia Children’s Hospital. Age at presentation, mode of referral, presenting symptom, and relevant history were collected. Blood thyroid function tests (blood tests used to measure how well the thyroid gland is working) done before surgery, thyroid ultrasound, neck imaging with a computed tomography (CT), thyroid scan, and thyroid biopsy results were reviewed.

The ATA pediatric guidelines for thyroid nodules were reviewed and variations from the ATA recommendations were identified.

A total of 86 patient records were reviewed. The average age at presentation was 14.4 years and 59 (68.6%) were female. Of all patients presenting with thyroid enlargement (86 patients), a total of 44 thyroid biopsies were completed. Thyroid stimulating hormone (TSH) was the most commonly ordered blood test at presentation. Of the 47 patients (55%) who had thyroid surgery, 14 (30%) had thyroid cancer. Of these 47 patients who underwent surgery, 7 patients (15%) did not have a neck ultrasound prior to thyroid surgery and 12 (26%) did not have a biopsy before surgery. All patients with a low TSH had a thyroid scan completed. One patient with high/normal TSH did not have a pre-surgery biopsy completed. Patients with thyroid cancer were treated with lobectomy (removal of 1 thyroid lobe) or total thyroidectomy (removal of the entire thyroid) based on specific cancer type/ pathology. Variations from the ATA pediatric guidelines were associated with complex presentations, surgical decisions to perform surgery without biopsy results or imaging and uncommon diagnoses.

The ATA pediatric guidelines provide valuable recommendations for the management of thyroid nodules in children, however there are limitations. The rate of cancer in children is indeed higher than in adults. Variations from the ATA guidelines exist because of complexity of cases and differences amongst patients.

— Priya Mahajan, MD


Thyroid nodule: an abnormal growth of thyroid cells that forms a lump within the thyroid. While most thyroid nodules are non-cancerous (Benign), ~5% are cancerous.

Thyroid Ultrasound: a common imaging test used to evaluate the structure of the thyroid gland. Ultrasound uses soundwaves to create a picture of the structure of the thyroid gland and accurately identify and characterize nodules within the thyroid. Ultrasound is also frequently used to guide the needle into a nodule during a thyroid nodule biopsy.

Thyroid scan: this imaging test uses a small amount of a radioactive substance, usually radioactive iodine, to obtain a picture of the thyroid gland. A “cold” nodule means that the nodule is not functioning normally. A patient with a “cold” nodule should have a fine needle aspiration biopsy of the nodule. A “functioning”, or “hot”, nodule means that the nodule is taking up radioactive iodine to a degree that is either similar to or greater than the uptake of normal cells. The likelihood of cancer in these nodules is very low and a biopsy is often not needed.

Thyroid biopsy: a simple procedure that is done in the doctor’s office to determine if a thyroid nodule is benign (non-cancerous) or cancer. The doctor uses a very thin needle to withdraw cells from the thyroid nodule. Patients usually return home or to work after the biopsy without any ill effects.

TSH: thyroid stimulating hormone — produced by the pituitary gland that regulates thyroid function; also the best screening test to determine if the thyroid is functioning normally.