P1.044: Pediatric Thyroid Nodule Management Patterns and Outcomes in a Regional Clinical Research Consortium

Background: The management of pediatric thyroid nodules was historically based on adult paradigms involving total thyroidectomy, central neck dissection, and radioactive iodine (RAI), which effectively cure disease but incur morbidities. In 2015, the American Thyroid Association developed guidelines for children recommending lobectomy for benign and indeterminate nodules and selective use of RAI. We sought to characterize the contemporary management of pediatric thyroid nodules and post-operative outcomes.

Methods: This multi-institutional retrospective cohort study included patients < 21 years with thyroid nodules who underwent biopsy and index thyroid surgery between 2013-2023 at seven institutions in an established regional clinical research consortium. Data on preoperative nodule pathology, surgical and adjuvant treatments, and outcomes were collected via chart review. Differences in categorical variables were assessed with Chi-square tests.

Results: There were 269 patients with a median age at surgery of 16.0 years. Preoperative Bethesda classifications were 3.4% nondiagnostic, 28.6% benign, 24.1% indeterminate, and 44.0% malignant. Preoperative molecular testing use varied across Bethesda classifications, including 3.9% of benign, 32.8% of indeterminate, and 12.8% of malignant nodules (p < 0.001). Table 1 displays the surgeries performed based on Bethesda classification. Lobectomies accounted for 32.0% of all operations before 2015 and 49.1% after (p=0.10, Figure 1).

Postoperative hypocalcemia occurred in zero lobectomies and 25 thyroidectomies (17.9%) with five patients requiring treatment beyond 6 months. Nerve damage occurred during 3 lobectomies (2.3%) and 5 thyroidectomies (3.6%) with 3 patients requiring subsequent intervention. Eight unanticipated 30-day readmissions occurred, half involving hypocalcemia. Node dissection was associated with higher risk of hypocalcemia (13.8% vs. 5.5%, p=0.019) and nerve damage (5.7% vs. 0.7%, p=0.016).

Sixty-six of 138 patients with cancer received RAI entailing 50.0% (3/6) of those with follicular carcinoma, 48.4% (62/128) of papillary, and 25.0% (1/4) of medullary. RAI use was more common after thyroidectomy than lobectomy (39.3% vs. 8.6%, p< 0.001). Six (9.0%) patients reported a side effect from RAI.

Thirteen patients had recurrence at a median of 247 days after surgery with rates of 25.0% (1/4) for those with medullary carcinoma, 16.7% (1/6) for follicular, and 8.6% (11/128) for papillary. Recurrence rates did not differ between patients who did and did not previously receive RAI (12.1% vs. 6.9%, p=0.30). Three patients with initial benign surgical pathology (2/21 with hyperplasia and 1/48 with follicular adenoma) later developed a cancer, at a median of 871 days. Thirty-eight patients underwent another thyroid-related procedure, of which 24 were completion thyroidectomies. All patients were alive at a median follow up of 3.1 years.

Conclusion: Within the consortium, 79% of patients with benign thyroid nodules and 73% with indeterminate nodules underwent lobectomy rather than total thyroidectomy, and half of patients with cancer underwent postoperative RAI. These data reflect the contemporary paradigm to decrease the extent of treatment and associated morbidity.