Pediatric Thyroid Cancer: An In-Depth Look at the ATA’s Guidelines

For the first time the American Thyroid Association (ATA) has published guidelines for managing thyroid nodules and thyroid cancer in children. 

Although previous guidelines have addressed the diagnosis and treatment of thyroid nodules and thyroid cancer in adults, none have addressed management of these conditions children.

The new guidelines provide what the authors believe to be contemporary, rational and optimal medical practice. Based on the latest evidence available in the literature and the expert opinion of the ATA’s task force, the guidelines are not meant to replace individual decision-making, the wishes of the patient or family or clinical judgment but rather to improve overall care and eliminate overtreatment.

“What I find notable about these inaugural guidelines is that they represent the first time that there has been a consensus document developed by an international panel of experts to address specifically the unique issues in children with benign and malignant thyroid tumors,” said Steven Waguespack, MD, chair of the task force and professor and deputy department chair of the Department of Endocrine Neoplasia and Hormonal Disorders at the University of Texas MD Anderson Cancer Center in Houston.

Weighing Benefits, Risks of Therapy

The “Management Guidelines for Children with Thyroid Nodules and Differentiated Thyroid Cancer” has been published in the latest issue of Thyroid, and it covers a broad range of topics, including the use of ultrasound and fine-needle aspiration for cellular analysis.¹ The guidelines address how to evaluate and manage benign thyroid nodules based on the current body of scientific knowledge.

Recommendations for assessing, treating and monitoring children and adolescents with differentiated thyroid cancer (DTC) cover all aspects of disease management, from preoperative staging to surgical management. 

The recommendations also address the role of radioactive iodine (RAI) therapy and the goals of thyrotropin suppression. Rather than a one-size-fits-all treatment strategy, the guidelines propose a broader scope of therapeutic options for pediatric patients with DTC. 

The goal is to limit the use of aggressive therapy when it is unlikely to offer benefit, according to the guidelines. Recently, studies have suggested that there has been an increase in all-cause mortality for survivors of childhood DTC, predominately due to second malignancies in children treated with RAI therapy.

The guidelines state that the treatment of children with DTC is evolving. In recent years, there has been a move away from intensive therapy in which all children received total thyroidectomy. Today, personalized therapy is considered optimal, and all treatment plans are individualized and based on preoperative and postoperative staging as well as continuous risk stratification.

Chairman of the task force, Gary L. Francis, MD, PHD, a pediatric endocrinologist and chief of the Division of Endocrinology and Metabolism Center for Endocrinology, Diabetes and Metabolism at Virginia Commonwealth University in Richmond, said these new guidelines were needed because thyroid cancer presents and behaves differently in children, as compared with adults. The overall disease-specific mortality is about 2%, he explained. 

“Most children have disseminated disease at diagnosis, and in previous decades, because of that, they got treated with total thyroidectomy, lymph node dissection and radioactive iodine, just as adults with metastatic disease would,” Francis said.

“However, over the last 20 years, we have learned that this treatment has a high risk for complications that we would like to avoid. In order to do that, we need to treat children with an individualized approach based on risk stratification.” 

Differences in Adult vs. Pediatric Thyroid Cancer

The task force found that thyroid cancer is increasing among adolescents aged 15 to 19 years, and it is now the eighth most frequently diagnosed cancer among children in this age group and the second most common cancer among girls.

In light of this evidence, the task force recommends that “prepubertal” and “pubertal/postpubertal” be incorporated into future studies. This move could help increase uniformity and more accurately represent the potential influence of pubertal development on the incidence and behavior of DTC within the pediatric population, according to the task force.