ATA Guidelines Tools

3 Î The evaluation and treatment of thyroid nodules in children (Figure 1) should be the same as in adults with the exceptions that: • US characteristics and clinical context should be used rather than size alone to identify nodules that warrant FNA. • All FNA in children should be performed under US-guidance. • Preoperative FNA of a hyperfunctioning nodule in a child is not warranted as long as the lesion is removed. • A diffusely infiltrative form of PTC may occur in children and should be considered in a clinically suspicious gland. • Surgery (lobectomy + isthmusectomy) is favored over repeat FNA for most nodules with indeterminate cytolog y. (B) Î A positive mutational test appears highly likely to be associated with malignancy. Conversely, insufficient data exist in children to rely on negative genetic studies to reliably exclude malignancy. Although molecular studies hold promise for complementing the results of FNA, particularly for nodules that yield indeterminate cytology, they have not yet been sufficiently validated in children and cannot be routinely recommended in routine clinical practice until further studies are conducted. (E) Î For patients with autoimmune thyroiditis, evaluation by an experienced thyroid ultrasonographer should be pursued in any patient with a suspicious thyroid examination (suspected nodule or significant gland asymmetry), especially if associated with palpable cervical lymphadenopathy. (B) Treatment of Benign Nodules Î We are unable to recommend for or against the routine use of LT4 therapy for children with benign thyroid nodules. In general, the data support the efficacy of LT4 therapy to reduce the size and risk of subsequent nodule formation but there are no data to weigh this potential benefit against the potential risks of long-term suppression therapy. In patients with compressive symptoms or a history of radiation exposure the benefits of LT4 therapy may be more apparent. (I) Î Benign lesions should be followed by serial US (see Figure 1) and undergo repeat FNA if suspicious features develop or the lesion continues to grow. Lobectomy may be performed in patients with compressive symptoms, cosmetic concerns, or patient/parent preference and should be considered in all apparently benign solid thyroid nodules >4cm, those lesions demonstrating significant growth, or in the presence of other clinical concerns for malignancy. (B) Î For pediatric patients with a suppressed TSH associated with a thyroid nodule, thyroid scintigraphy should be pursued. Increased uptake within the nodule is consistent with autonomous nodular function. Surgical resection, most commonly lobectomy, is the recommended approach for most autonomous nodules in children and adolescents. (A)

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