Thyroid Disorders
With Dr. Diana Deason · hosted by Dr. Todd Ponsky · StayCurrentMD
Cued at 26:10 · stops at 26:55 · press play
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
More about thyroid nodules
same diagnosisOnly a few other public items share this diagnosis — nothing to add yet.
Only a few other public items share this expert — go deeper there →
Video
Pediatric Surgical Oncology Research Collaborative (PSORC): Studying Rare Pediatric Tumors
56 s · Published May 2026
Video
Update Course Rewind 2025: Hirschsprung + ARM: Rare but Real
1 min · Published May 2026
Video
Update Course Rewind 2025: Hirschsprung + ARM: Rare but Real
1 min · Published May 2026
Video
Pooling Patients to Study Rare Pediatric Tumors: An Introduction to PSORC
56 s · Published May 2026
Video
The fetal frontier: A review of current and emerging fetal therapies for genetic diseases
44 s · Published May 2026
Video
Indocyanine green assists with sentinel lymph node mapping in pediatric and adolescent patients
1 min · Published May 2026
What the experts said
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.
Some thyroid conditions and thyroid cancers have familial predisposition, including MEN syndromes, PTEN hamartoma tumor syndromes, and APC-associated polyposis syndromes.
Thyroid nodules are less common in children than adults, but when detected in children, they are more likely to be malignant.
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.
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.
Suspicious ultrasound features for thyroid malignancy include hypoechoic mass, irregular margins, increased blood flow, microcalcifications, or association with abnormal lymph nodes.
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.
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.
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.
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.
After total thyroidectomy, PTH levels less than 10 to 15 in recovery indicate higher risk for hypocalcemia, prompting initiation of calcium replacement or calcitriol.
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.
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.
Follicular lesions represent about one-third of thyroid FNA results and are indeterminate specimens.
Current ATA recommendations are that all indeterminate (follicular) lesions in children be resected, typically with lobectomy and removal of the isthmus.
For follicular lesions of undetermined significance, the risk of malignancy in adults is 5-15%, but in pediatric literature it is approximately 28%.
For follicular neoplasms, the reported malignancy rate was 15-30%, but more recent data suggests it is between 50% and 60% in children.
Frozen section cannot distinguish follicular adenoma from follicular carcinoma, but can identify papillary components.
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.
About 30% of patients who undergo lobectomy may develop hypothyroidism at some point, so thyroid function monitoring is important even after partial thyroidectomy.
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.
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.
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.
Sporadic medullary thyroid cancer is unusual in children, so routine calcitonin monitoring is not recommended for every child with a thyroid nodule.
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.
MEN 2A patients can develop medullary thyroid cancer, pheochromocytomas, and hyperparathyroidism.
MEN 2B patients can develop medullary thyroid cancer, pheochromocytomas, mucosal neuromas, and a Marfanoid habitus with elongated features and joint laxity.
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.
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.
If calcitonin levels exceed 40 in MEN patients undergoing surveillance, central neck dissection is recommended at the time of thyroidectomy.
Children under age 10 have increased risk of complications from thyroidectomy, including hypoparathyroidism and nerve injury, due to smaller anatomy and smaller parathyroid glands.
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.
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.
For prophylactic thyroidectomy in MEN patients, if performed before calcitonin levels exceed 40, central lymph node dissection is not necessary.
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.
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.
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.
For Graves' disease in young children, thyroidectomy is often preferred over radioactive iodine due to concerns about risks of secondary malignancies from radioactive iodine.
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.