Diana Deason

196 statements · 4 topics

Adrenal Tumors · guest expert Sarcoma (Ewing/Rhabdo) · guest expert Soft Tissue Sarcoma (lymph nodes) · guest expert

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The most recent recommendations from the ATA are that all of these indeterminate lesions be resected. And the reason that they have recommended that, which is different than the recommendations for adults, so the reason that children are recommended to have resection for their indeterminate lesions is their risk of malignancy is higher than adults.

quote · Adrenal Tumors

For the pediatric population, we can't use size cutoffs as they do in adults. And so we use ultrasound characteristics in the clinical context to decide whether or not something should be biopsied and warrant FNA.

quote · Adrenal Tumors

I do routinely use a nerve monitor in my practice, knowing that it will not decrease my risk of nerve injury, but I do find it helpful in identifying the nerve, especially in patients with bulky cervical disease.

quote · Sarcoma (Ewing/Rhabdo)

When children actually do present with a thyroid cancer, they're more likely to have an extension outside of the thyroid. They're more likely to have regional lymph node involvement. And distant metastasis.

quote · Sarcoma (Ewing/Rhabdo)

Sporadic medullary thyroid cancer is unusual in children, so the current recommendations are not to do routine calcitonin monitoring in every patient that presents with a thyroid nodule.

quote · Soft Tissue Sarcoma (lymph nodes)

About 30% of patients at some point may develop hypothyroidism. So it's important for patients that even if they've undergone just a lobectomy, that their thyroid function is monitored.

quote · Soft Tissue Sarcoma (lymph nodes)

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Diana's statements about Adrenal Tumors 49 statements

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Thyroid Disorders

Statement Risk factors for thyroid nodules and cancer include previous exposure to radiation or alkylating agents, such as treatment for Hodgkin's lymphoma, leukemia, or CNS tumors. Open

Statement Some thyroid conditions and thyroid cancers have familial predisposition, including MEN syndromes, PTEN hamartoma tumor syndromes, and APC-associated polyposis syndromes. Open

Statement Thyroid nodules are less common in children than adults, but when detected in children, they are more likely to be malignant. Open

Quotation Thyroid nodules are less common in children than adults, when they're detected, they're more likely to be malignant. Open

Quotation When children actually do present with a thyroid cancer, they're more likely to have an extension outside of the thyroid. They're more likely to have regional lymph node involvement. And distant metastasis. Open

Statement When children present with thyroid cancer, they are more likely to have extension outside of the thyroid, regional lymph node involvement, and distant metastasis compared to adults. Open

Statement If TSH is suppressed, a nuclear thyroid scan should be obtained to identify hyperfunctioning nodules, which do not need to be biopsied if they are going to be resected. Open

Statement Suspicious ultrasound features for thyroid malignancy include hypoechoic mass, irregular margins, increased blood flow, microcalcifications, or association with abnormal lymph nodes. Open

Statement In pediatric patients, size cutoffs used in adults (1 cm) cannot be applied for biopsy decisions; ultrasound characteristics and clinical context determine whether FNA is warranted. Open

Quotation For the pediatric population, we can't use size cutoffs as they do in adults. And so we use ultrasound characteristics in the clinical context to decide whether or not something should be biopsied and warrant FNA. Open

Quotation The current recommendations for patients with papillary thyroid cancer because of the risk of bilateral disease, which is seen in up to 30% of patients, multifocal disease, which is seen in up to 65% of pediatric patients. Open

Statement Total or near-total thyroidectomy is recommended for papillary thyroid cancer due to risk of bilateral disease (up to 30%), multifocal disease (up to 65%), increased risk of recurrence with lobectomy alone, and ability to optimize for radioactive iodine and use thyroglobulin as a tumor marker. Open

Quotation I do routinely use a nerve monitor in my practice, knowing that it will not decrease my risk of nerve injury, but I do find it helpful in identifying the nerve, especially in patients with bulky cervical disease. Open

Statement Nerve monitoring is used routinely during thyroidectomy, and while it does not decrease the risk of nerve injury, it is helpful in identifying the recurrent laryngeal nerve, especially in patients with bulky cervical disease. Open

Statement There is no evidence to support prophylactic lateral neck dissection in thyroid cancer; lateral neck dissection is performed only when lateral nodes are pathologically positive. Open

Statement After total thyroidectomy, PTH levels less than 10 to 15 in recovery indicate higher risk for hypocalcemia, prompting initiation of calcium replacement or calcitriol. Open

Statement Low-risk papillary thyroid cancer patients (disease confined to thyroid, no nodal involvement, T1B N0) require only thyroglobulin surveillance with TSH suppression to 0.5-1, ultrasound at 6 months postoperatively, then annually for 5 years. Open

Statement Intermediate-risk patients (extensive central neck disease or any lateral neck disease) and high-risk patients (extensive regional disease, local invasion, or distant metastases) may require radioactive iodine postoperatively. Open

Statement Follicular lesions represent about one-third of thyroid FNA results and are indeterminate specimens. Open

Statement Current ATA recommendations are that all indeterminate (follicular) lesions in children be resected, typically with lobectomy and removal of the isthmus. Open

Quotation The most recent recommendations from the ATA are that all of these indeterminate lesions be resected. And the reason that they have recommended that, which is different than the recommendations for adults, so the reason that children are recommended to have resection for their indeterminate lesions is their risk of malignancy is higher than adults. Open

Statement For follicular lesions of undetermined significance, the risk of malignancy in adults is 5-15%, but in pediatric literature it is approximately 28%. Open

Statement For follicular neoplasms, the reported malignancy rate was 15-30%, but more recent data suggests it is between 50% and 60% in children. Open

Statement Frozen section cannot distinguish follicular adenoma from follicular carcinoma, but can identify papillary components. Open

Quotation A frozen section will not be able to tell you a follicular adenoma from a follicular carcinoma. Open

Statement For follicular carcinoma with significant vascular invasion or tumor greater than 4 cm, completion thyroidectomy is recommended; smaller tumors with minimal vascular invasion can be monitored. Open

Statement About 30% of patients who undergo lobectomy may develop hypothyroidism at some point, so thyroid function monitoring is important even after partial thyroidectomy. Open

Quotation About 30% of patients at some point may develop hypothyroidism. So it's important for patients that even if they've undergone just a lobectomy, that their thyroid function is monitored. Open

Statement TSH suppression goals vary by ATA pediatric risk level: low-risk patients have a TSH goal of 0.5-1, while high-risk patients have a TSH goal of less than 0.1. Open

Statement For benign thyroid nodules greater than 4 cm, the sensitivity and specificity of FNA is decreased, so it is important to follow these lesions with repeat ultrasound in 6-12 months and repeat biopsy if enlarging or developing suspicious features. Open

Statement Inadequate FNA specimens occur in roughly 1-3% of cases and should be repeated in 3-6 months to avoid picking up atypia from trauma of the initial FNA. Open

Statement Sporadic medullary thyroid cancer is unusual in children, so routine calcitonin monitoring is not recommended for every child with a thyroid nodule. Open

Quotation Sporadic medullary thyroid cancer is unusual in children, so the current recommendations are not to do routine calcitonin monitoring in every patient that presents with a thyroid nodule. Open

Statement For medullary thyroid cancer, if initial calcitonin level is greater than 500, imaging should be performed to exclude metastatic disease, including CT of neck and chest, MRI or CT of abdomen (looking at liver), and bone scan. Open

Statement MEN 2A patients can develop medullary thyroid cancer, pheochromocytomas, and hyperparathyroidism. Open

Statement MEN 2B patients can develop medullary thyroid cancer, pheochromocytomas, mucosal neuromas, and a Marfanoid habitus with elongated features and joint laxity. Open

Statement MEN 2B patients with RET 918 mutation present with thyroid cancer very early, as young as 3 months of age, and require thyroidectomy before 1 year of age. Open

Quotation There are reported cases of having medullary thyroid cancer as young as 3 months in the MEN2B group. Open

Statement MEN 2A high-risk patients (most commonly RET 634 mutation) should have total thyroidectomy before age 5, with surveillance starting at age 3 including calcitonin, CEA, and ultrasounds; if calcitonin or ultrasound abnormalities develop, thyroidectomy should be performed at that time. Open

Statement If calcitonin levels exceed 40 in MEN patients undergoing surveillance, central neck dissection is recommended at the time of thyroidectomy. Open

Statement Children under age 10 have increased risk of complications from thyroidectomy, including hypoparathyroidism and nerve injury, due to smaller anatomy and smaller parathyroid glands. Open

Statement For MEN 2A moderate-risk patients, total thyroidectomy is recommended when serum calcitonin becomes elevated or if parents do not want to proceed with frequent surveillance. Open

Statement MEN 2A moderate-risk patients do not tend to develop pheochromocytomas until their twenties or above, so screening begins at age 16; MEN 2A high-risk patients begin pheochromocytoma screening at age 11. Open

Statement For prophylactic thyroidectomy in MEN patients, if performed before calcitonin levels exceed 40, central lymph node dissection is not necessary. Open

Statement After thyroidectomy for medullary cancer, if calcitonin levels are undetectable or normal, surveillance includes physical exam and neck ultrasounds every 6 months for 1 year, then annually. Open

Statement If postoperative calcitonin levels are greater than 150, imaging should be performed to detect metastasis, including CT neck and chest, MRI or CT abdomen, bone scan, and MRI of pelvis and axial skeleton. Open

Statement Systemic therapy for medullary thyroid cancer (tyrosine kinase inhibitors, external beam radiation) has significant side effects and is reserved for patients with progressive disease not treatable with surgery, not for all patients with elevated calcitonin. Open

Statement For Graves' disease in young children, thyroidectomy is often preferred over radioactive iodine due to concerns about risks of secondary malignancies from radioactive iodine. Open

Statement Some pediatric patients with papillary thyroid cancer present with diffuse infiltration of the thyroid rather than a discrete nodule, often with clinically suspicious lymph nodes, which is a characteristic more common in children. Open

Diana's statements about Sarcoma (Ewing/Rhabdo) 49 statements

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