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Head and Neck Cancers

    Table 2. Thyroid Carcinomas in Children continued...

    Treatment of papillary and follicular thyroid carcinoma

    The management of differentiated thyroid cancer in children has been reviewed in detail.[51] Also, the American Thyroid Association Taskforce [68] has developed guidelines for management of thyroid nodules and differentiated thyroid cancer in older adolescents and adults; however, it is not yet known how to apply these guidelines to thyroid nodules in children.[46]

    Surgery performed by an experienced thyroid surgeon is the treatment required for all thyroid neoplasms.[53,56] For patients with papillary or follicular carcinoma, total or near-total thyroidectomy plus cervical lymph node dissection is the recommended surgical approach.[53,58,69] This aggressive approach is indicated for several reasons:

    • Up to 40% of children with differentiated thyroid carcinoma have multifocal disease and a higher recurrence risk if less than a total thyroidectomy is performed.
    • Many children have disseminated disease and require radioactive iodine therapy.
    • Sensitive assays for serum thyroglobulin are used as a marker for active disease and are most useful after total thyroidectomy.[46,51,53]

    However, for patients with a small (<1 cm) unifocal nodule, treatment may involve only a lobectomy.[51,58,70]

    The use of radioactive iodine ablation for the treatment of children with differentiated thyroid carcinoma has increased over the years. Despite surgery, most children have a significant radioactive iodine uptake in the thyroid bed,[53] and studies have shown increased local recurrence rates for patients who did not receive radioactive iodine after total thyroidectomy compared with those who did receive radioactive iodine.[71] Thus, it is currently recommended that children receive an ablative dose after initial surgery.[46,51,56] For successful remnant ablation, serum TSH levels must be elevated to allow for maximal radioactive iodine uptake; this can usually be achieved with thyroid hormone withdrawal for 3 to 4 weeks after thyroidectomy.[46] A radioactive iodine (I-131) scan is then performed to search for residual, functionally active neoplasm. If there is no disease outside of the thyroid bed, an ablative dose of I-131 (approximately 30 mCi) is administered for total thyroid destruction. If there is evidence of nodal or disseminated disease, higher doses (100–200 mCi) of I-131 are required.[72][Level of evidence: 3iDiv] In younger children, the I-131 dose may be adjusted for weight (1–1.5 mCi/kg).[46,73,74] After surgery and radioactive iodine therapy, hormone replacement therapy must be given to compensate for the lost thyroid hormone and to suppress TSH production.[75]

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