9 year-old female with papillary thyroid...
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9 year-old Female with Papillary Thyroid CancerKatie O’Sullivan, M.D.FellowMedicine/Pediatric EndocrinologyThursday, January 16th, 2014
Chief Complaint
Mass on the right side of the neck x 2-3 weeks at 8yr 0 mo
History of Present Illness
Right neck mass identified x 2-3 wksTender x 1 dayTreated with course of steroids and antibiotics
General: Denies fever, fatigue, anorexia, weight loss, night sweats
HEENT: Denies congestion, rhinorrhea, sore throat, dysphagia, hoarseness
No history of radiation exposure
More HistoryMore History……
Birth History:
Neonatal jaundice
Past Medical/Surgical History:
Recurrent otitis media
Allergies:
Cephalosporins
Immunizations: Up-To-Date
Developmental History:
No delayed milestones
Medications:
Clindamycin
Social History:
2nd grade
Lives in Indiana with family, 2 dogs. No exposure to cats.
Family History:
No family history of thyroid cancer.
Review of Systems
Eyes: Negative for visual disturbance.
Respiratory: Negative for cough or shortness of breath.
Cardiovascular: Negative for palpitations or chest pain.
Gastrointestinal: Negative for abdominal pain, nausea, vomiting, diarrhea, constipation.
Genitourinary: Negative for urgency, frequency and enuresis.
Musculoskeletal: Negative for arthralgias, edema.
Skin: Negative for acne, rash, dry skin.
Neurological: Negative for headaches. +intermittent tremulousness.
Psychiatric/Behavioral: Negative for behavioral problems.
Physical Exam
Vital Signs: BP 92/33, P 67, R 17, Wt 36.7kg (85%), Ht 131 cm (70 %), BMI 21.4 (96%)
General: Well-developed, no distress.
HEET: Conjunctiva clear, EOMI, PERRL, nasal turbinates normal, tongue normal, 2+ tonsils.
Neck: supple, trachea midline, small jugulodigastric LN on left and 3 discrete firm, non-mobile LN on the right neck. No palpable thyroid or thyroid nodules.
Axilla: No lymphadenopathy.
CV: RRR, no murmur, no extremity edema.
Pulmonary: CTAB, no crackles or wheezing.
Abdomen: soft, non-tender, non-distended.
Neuro: alert, 2+ patellar reflexes.
Skin: warm, no diaphoresis.
Laboratory/Imaging Studies
Ca 10
137
4
99
27 0.43
1577
CBC: WBC 11.8, Hgb 13, Plt 375
72%PMN, 18.3%Lymph, 6.9%Mono, 2.2%Eos
CT Neck (outside film):• Multiple matted LN extending under the SCM, some
of which had a necrotic center• Bilateral thyroid masses
Next Step: Neck LN biopsy under general anesthesia
Findings: 3-4 hard LN anterior and beneath the right SCM
Procedure: Excision of 2 right-sided LN measuring 1cm and 2cm.
Pathology:Papillary thyroid carcinomaExtra-nodal extension present
Total Thyroidectomy 8/15/2012
Procedure: Total thyroidectomy, right modified radical neck dissection, paratracheal and pretracheal node dissection
Pathology: Papillary thyroid cancer, chronic lymphocytic thyroiditis
Thyroid gland: 2.5cm nodule and widely-invasive cancer in bilateral lobes and isthmus; capsular invasion, positive margins
Lymph Nodes: 32/51 nodes positive
Extranodal extension present
Post-Op
TSH 13.3
FT4 0.85
Ca 7.8
Phos 4.4
PTH 4
Vit D 25-OH 26
Started:LT4 3mcg/kg
(112mcg/d)Calcium carbonate
1250mg po q6hCholecalciferol
2000IU dailyCalcitriol 0.5mcg qd
Next step in management?
Post-Operative Management
Labs 12/2012: Anti-Tg AB 630 IU/mL (nl <22)
Pre-RAI scan: 2.15mCi I-131
RAI ablation 1/2013: 60mCi I-131
Post-therapy RAI scan
6-month post-RAI scan 7/2013: 1.5mCi I- 131
TSH and Free T4 Trend
01234567
Oct
-12
Nov
-12
Dec
-12
Jan-
13
Feb-
13
Mar
-13
Apr
-13
May
-13
Jun-
13
Jul-1
3
Aug
-13
Sep
-13
Oct
-13
Nov
-13
Dec
-13
Date
TSHFree T4
Clinical Questions
How do you determine the prognosis of children with differentiated thyroid cancer?
What is the standard goal thyrotropin for children s/p thyroidectomy for differentiated thyroid cancer?
Well-Differentiated Thyroid Cancer (WDTC) in Children
Accounts for 3-13% of all WDTC
Most common endocrine malignancy in children
Children present with more extensive disease than adults
Mortality is low
Dinauer et al. Curr Opin Onc. 2008.Rachmiel et al. Ped Endo Metab 2008.Shayota et al. Surgery 2013.Zimmerman et al. Surgery 1988.
Calculating Prognosis of Well- Differentiated Thyroid Cancer
Cooper et al. Thyroid 2009.
Shayota et al. Surgery 2013.
Shayota et al. Surgery 2013.
Clinical Questions
How do you determine the prognosis of children with differentiated thyroid cancer?
What is the standard goal thyrotropin for children s/p thyroidectomy for differentiated thyroid cancer?
TSH Suppression Therapy
Adults:
Pediatrics: ???
Cooper et al. Thyroid 2009.
Royal Marsden Hospital – 2000.
Landau et al. European Journal of Cancer 2000.
Royal Marsden Hospital – 2000.
Landau et al. European Journal of Cancer 2000.
Conclusion
WDTC is the most common endocrine cancer in children
Poor prognostic factors for children with WDTC include male gender, larger primary tumor size and presence of distant metastasis
Surgical and RAI therapy in children with WDTC is still controversial
TSH suppression therapy may be beneficial, however the goal TSH has not been well- described in children
Works Cited
Cooper et al. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid 2009;19(11):1-47.
Dinauer et al. Differentiated thyroid cancer in children: diagnosis and management. Current Opinion in Oncology 2008;20:59-65.
Landau et al. Thyroid cancer in children: the Royal Marsden Hospital experience. European Journal of Cancer 2000. 36:214-220.
Rachmiel et al. Evidence-based review of treatment and follow-up of pediatric patients with differentiated thyroid carcinoma. Journal of Pediatric Endocrinology and Metabolism 2006; 19:1377-1393.
Rapkin L and Pashankar FD. “Management of thyroid carcinoma in children and young adults.” Journal of Pediatric Hematology and Oncology 2012; 34(supp 2):S39-S46.
Shayota et al. MeSS: A novel prognostic scale specific for pediatric well- differentiated thyroid cancer: A population-based, SEER outcomes study. Surgery 2013; 154:429-35.
Zimmerman et al. Papillary thyroid carcinoma in children and adults: long-term follow-up of 1039 patients conservatively treated at one institution during three decades. Surgery 1988;104:1157-1166.