Approach to the Pediatric Patient With Thyroid Nodules

Thyroid nodules in pediatrics carry a higher risk for thyroid carcinoma, and the risk of malignancy in indeterminate thyroid nodules is higher when compared to adults. Despite a substantial increase in the incidence of pediatric thyroid carcinoma since the 1990s, the 30-year disease survival remains >98% in pediatrics. The goal of thyroid nodule management focuses on reducing comorbidity of care while maintaining remission from disease and low disease-specific mortality. In 2014, the Cancer Genome Atlas introduced the concept that molecular subtypes better predict the invasive behavior of papillary thyroid carcinoma compared to pathological classification alone. Recent advancements in the understanding of the genetic landscape of pediatric thyroid carcinoma support the potential utility of incorporating somatic oncogene analysis to evaluate and manage thyroid nodules and thyroid carcinoma. In this Approach to the Pediatric Patient, we review the risk factors of differentiated thyroid carcinoma and present an integrative approach to evaluating and managing thyroid nodules in pediatric patients, incorporating sonographic and cytopathologic findings with somatic oncogene analysis. We illustrate the potential clinical application of knowledge on somatic oncogenic drivers to improve the preoperative accuracy in diagnosing differentiated thyroid carcinoma and present an integrative analysis paradigm designed to individualize the surgical approach of pediatric patients with thyroid nodules and differentiated thyroid carcinoma.