ATA Guidelines Tools

4 Differentiated Thyroid Cancer Diagnosis Î An annual physical exam is recommended in children at high risk for thyroid neoplasia. Additional imaging should be pursued if palpable nodules, thyroid asymmetry and/or abnormal cervical lymphadenopathy are found on exam. (B) Î In children with a history of radiation exposure to the thyroid, the data show that US can detect small thyroid nodules but the panel is not yet convinced that detection of subclinical disease by US prior to a palpable abnormality on physical exam impacts long-term outcomes. Therefore, routine screening US in high-risk children can neither be recommended for nor against until more data become available. (I) Î Patients at increased risk of developing familial DTC should be referred to centers of excellence so that appropriate evaluation, follow-up, genetic counseling and/or treatment can be undertaken without subjecting patients and families to unwarranted and aggressive therapy. (C) Î The AJCC TNM Classification System should be used to describe the extent of disease in pediatric patients with PTC (Table 2). Children with PTC should be stratified into risk levels (ATA Pediatric Low-, Intermediate-, or High-Risk) based on clinical presentation, tumor size and evidence of regional invasion and metastasis (Table 3). The extent of disease in the neck at diagnosis appears to correlate best with the risk for distant metastasis and/or persistent disease that may require additional treatment. (B) Î Patients found to have disease confined to the thyroid gland, as well as incidental evidence of minimal, microscopic disease to lymph nodes in the central neck (level VI), fall into the ATA Pediatric Low-Risk level (Table 3). The presence of extensive, extra-thyroidal invasion or metastasis defines patients at greater risk for persistent regional or distant metastasis. Patients with these features are categorized within the ATA Pediatric Intermediate- or High-Risk levels (Table 3). Within these categories, additional postoperative staging is warranted to better define which patients may or may not benefit from additional therapy. (B) Î It remains unclear if younger children (<10-15 years of age) are at greater risk for more extensive disease or higher rates of recurrence. Other factors aside from age (treatment approaches, genetic susceptibility, and/or radiation exposure) may interact to modify this risk. However, those studies with a larger proportion of young children show an increased risk of persistent disease/recurrence. In an effort to increase the descriptive nature of these discussions, the committee recommends that "prepubertal" and "pubertal/postpubertal" should be incorporated into future studies to increase uniformity and more accurately represent the potential influence of pubertal development on the incidence and behavior of DTC within the pediatric population. (B)

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