however , thyroid nodules in children are only found in 3.7% of healthy children aged 1118 years old . compared to adults , these nodules
have an increased risk of being malignant ( 16% in children versus 5% in adults ) [ 46 ] .
thyroid cancer in children is also unusual in that it often presents with advanced disease including lymph node involvement and lung metastasis as compared to their adult counterpart [ 5 , 79 ] .  
multiple modalities are frequently employed in an attempt to characterize thyroid nodules including ultrasound , radionuclide scans , fine needle aspiration ( fna ) , thyroid function tests , and evaluating patient demographics . in the adult population
although these tests are also performed in the pediatric population , these patients frequently undergo partial or total thyroidectomy for diagnosis the aim of this paper is to explore the utility of radiographic imaging and preoperative fine needle aspiration ( fna ) in the evaluation of pediatric thyroid nodules , more specifically , to determine if any of these modalities identifies those thyroid nodules that are at high risk of harboring a malignancy .
a retrospective chart review was performed ( 20042009 ) at a tertiary medical center with a 100% pediatric patient population ( irb approval no .
fifty patients < 21 years of age were identified who underwent partial or total thyroidectomy .
five patients with a family history of multiple endocrine neoplasia ( men ) were excluded , giving a total of 45 patients evaluated in the present study .
patient demographics , preoperative workup , type of procedure performed , and pathology results were reviewed .
forty - five patients underwent either partial or total thyroidectomy ; the majority of patients were female ( n = 41 ) .
there was no difference in the median age at presentation for malignant and benign lesions 15 years ( range of 719 years ) versus 14 years ( range of 821 years ) ( p = .88 ) , respectively .
ninety - one percent of patients underwent preoperative imaging with ultrasound ( n = 31 ) , ct scan ( n = 4 ) , i scan ( n = 2 ) , or ultrasound and a second modality ( n = 4 ) . of the 4 patients who had no preoperative imaging
several nodules ( n = 12 ) were found to have increased vascularity concerning malignancy ; however , these nodules were found to be both malignant ( n = 3 ) and benign ( n = 9 ) .
fna was performed in forty - nine percent of patients ( n = 22 ) .
one fna was interpreted as a follicular lesion but returned multifocal papillary carcinoma on final pathologic evaluation .
nine out of forty - five patients were identified with papillary carcinoma on pathologic examination ( 20% ) .
cervical lymph node involvement was identified in 56% percent of patients ( n = 5 ) at the time of thyroidectomy .
there was no significant difference in the average size of the nodules in patients with malignant or benign disease ( 2.7  cm and 2.9  cm , resp .
total thyroidectomy was performed as the initial procedure in those patients identified with malignancy by fna ( n = 4 ) .
two patients underwent completion thyroidectomy after pathologic examination of their thyroid lobe revealed papillary carcinoma .
both patients underwent preoperative imaging ; the first patient with an ultrasound that showed a vascular nodule , while the second patient had a ct scan that showed a small nodule .
in addition , one patient was diagnosed with papillary carcinoma on an intraoperative frozen section and had a completion thyroidectomy at that time .
one patient had an incidentally found micropapillary carcinoma in the setting of grave 's disease , and one patient with a multinodular goiter had a preoperative fna showing follicular cells , and the final pathologic diagnosis was papillary carcinoma .
these patients did have preoperative imaging that showed nodules .   of those patients with benign disease
( n = 36 ) , 12 ( 33% ) underwent a total thyroidectomy for either an enlarging multinodular goiter or grave 's disease refractory to medical treatment .
sixteen underwent a right lobectomy ( 45% ) , and 8 had a left lobectomy ( 22% ) .
hypocalcemia was the most common postoperative complication , occurring in 8 patients ( 38% ) .
half of these patients ( n = 4 ) experienced symptoms with tingling or paresthesias , whereas the other half ( n = 4 ) were identified with hypocalcemia on routine postoperative labs measurements .
all patients were managed with supplemental oral calcium , and none experienced permanent hypocalcemia / hypoparathyroidism .
the average length of stay was similar for all patients after total thyroidectomy : 1.46 days for those with malignancy ( range 15 days ) and 1.53 days for benign pathology ( range 18 days ) .
thyroid nodules in children represent an uncommon entity but carry a greater risk for malignancy than in their adult counterpart . in the pediatric population ,
this should be limited to an ultrasound examination to determine that if indeed the nodule is within the thyroid gland .
if feasible , given the patients age and anxiety level , a fna should be performed . in those patients who have an inadequate fna , or fna
total thyroidectomy remains the procedure of choice for those lesions identified preoperatively as cancer , while lobectomy should be employed for those lesions in which the diagnosis is uncertain [ 1014 ] .
this facilitates the use of i therapy postoperatively as well as the ability to monitor thyroglobulin levels after treatment for recurrent disease .
overall , thyroid cancer has a very good prognosis with a 98.8% survival at 10 years in children [ 2 , 7 ] .
the female predominance of thyroid nodules noted in our cohort has been previously reported in the literature and is likely secondary to the estrogen sensitivity of the thyroid gland [ 1518 ] .   in our cohort ,
patient age and radiologic imaging bears no impact in determining whether a nodule was malignant or benign .
increased intranodular vascularity is an ultrasound characteristic that has been suggested as an indicator of malignancy [ 19 , 20 ] . in our group , patients were found to have intranodular vascularity suggestive of malignancy ( n = 12 ) however , the lesions returned both benign ( n = 9 ) and malignant ( n = 3 ) .
fine needle aspiration and cytology evaluation in the pediatric patient is controversial [ 5 , 2125 ] .
follicular lesions can not be differentiated as malignant or benign because of the inability of fna to assess capsular invasion .
if the lesion is identified as malignant , the patient should undergo a total thyroidectomy at initial operation versus an initial lobectomy when indeterminate or benign .
if fna identifies the nodule as benign or a cyst , a patient can be followed if the lesion is small and avoid operative intervention . in adults ,
the accuracy of fna can reach 97% , while the pediatric population accuracy only reaches 90% [ 5 , 8 , 21 , 23 , 26 ] . other limitations of fna include sampling error , experience of the cytopathologist , or need for sedation in younger children .
postoperative complications of hypocalcemia and recurrent laryngeal nerve injury are a great cause of concern in patients undergoing total thyroidectomy .
hypocalcemia is largely due to incidental stunning or removal of the parathyroid glands , which may be embedded in the thyroid gland [ 7 , 27 ] .
another risk of total thyroidectomy is recurrent laryngeal nerve injury ( rln ) , resulting in hoarseness , dysphagia , and respiratory failure if a bilateral injury occurs .
permanent rln after total thyroidectomy has been reported as 1% in the literature [ 28 , 29 ] .
we report no instances of rln injury in our group . in our retrospective review ,
we report no instances of major complications , such as rln injury or permanent hypocalcemia , following total thyroidectomy .
transient hypocalcemia is considered to be of moderate risk and is readily managed with oral calcium supplementation . in conclusion , there does not seem to be any component found in the preoperative evaluation of a pediatric thyroid nodule , with the exception of a positive fna to indicate that a lesion is malignant or benign .
our experience suggests that patients can not be risk stratified based on age , size of the thyroid lesion , or characteristics of the lesion by all radiographic imaging techniques .
in addition , postoperative risk to patients undergoing lobectomy or total thyroidectomy remains low and predominantly consists of transient hypocalcemia . at our institution
we have found minimal utility of an extensive preoperative workup in a child with a thyroid nodule .
ct scans have not been shown to be sensitive or specific for determining whether a lesion is cancerous or benign .
therefore , the lifelong risk of cancer associated with ct is not justified ( lifetime cancer risk associated with ct is estimated to be 2/1000 to 3/1000 in children under age 15 ) .
we advocate ultrasound evaluation to determine an intrathyroidal location , an fna if feasible , and then either total thyroidectomy for those with malignancy identified on cytology or lobectomy for those whose diagnosis is uncertain .
 thyroid nodules in children are uncommon but often present an increased risk of malignancy in comparison to their adult counterpart . 
 multiple diagnostic modalities are frequently employed to characterize these nodules including ultrasound , radionuclide scans , fine needle aspiration ( fna ) , thyroid function tests , and evaluation of patient demographics . 
 we chose to evaluate if any of these modalities influence treatment or signify a tendency for a nodule to represent a malignant lesion . 
 a retrospective review of patients < 21 years of age who underwent partial or total thyroidectomy from 2004 to 2009 was performed ( irb no . 
 4695 ) . 
 other than an fna indicating a malignancy , there does not appear to be any value to extensive preoperative imaging , nor can patient risk be stratified based upon age . 
 we conclude that there is minimal utility in an extensive preoperative workup in a child with a thyroid nodule . 
1. Introduction
2. Methods
3. Results
4. Discussion