BACKGROUND
Thyroid cancer is the most common endocrine cancer. While only 1.8% of all thyroid cancers occur in the pediatric population (those less than 18 years of age), it is still one of the most common endocrine cancers in the young. In 2015 the American Thyroid Association (ATA) published recommendations for managing thyroid cancer in children. They urged treating pediatric thyroid cancer with a total thyroidectomy. In contrast, recommendations for treating thyroid cancer in adults published around the same time stated that a less invasive lobectomy (removal of only the lobe containing the cancer) was a suitable procedure. The need for more extensive surgery in children was justified because thyroid cancer in youth more often presents with cancer in both thyroid lobes, thus, there may be an increased risk for recurrence with less extensive surgery. Also, youth with thyroid cancer are more likely to develop spread of the cancer beyond the thyroid, both into the lymph nodes in the neck and spread to the lungs.

In the current study, the authors evaluate the trend in lobectomy before and after 2015 to assess the impact of the ATA–pediatric guidelines on the treatment of thyroid cancer in children.

THE FULL ARTICLE TITLE
Stein E et al 2022 The 2015 American Thyroid Association guidelines and trends in hemithyroidectomy utilization for pediatric thyroid cancer. Head Neck 44:1833–1841.

SUMMARY OF THE STUDY
The authors studied a large American cancer database called the National Cancer Database (NCDB) to identify 4776 patients less than 18 years old with thyroid cancer. Established in 1989, the NCDB is a national clinical database that annually captures 72% of newly diagnosed cancers in the US. Of the group with thyroid cancer, 92% of the patients had papillary thyroid cancer, with the remainder having follicular or Hurthle cell cancer. In addition, 3441 of the patients (72%) had surgery before the 2015 ATA guidelines, and 1335 (28%) were treated after 2015.

Overall, only 451 patients (9.4%) had a lobectomy. Patients with follicular and Hurthle cell cytology on biopsy and cancer size less than 1 cm were associated with a lobectomy. Those with papillary cytology and cancer that had spread to lymph nodes in the neck were less likely to have a lobectomy. Interestingly, lobectomy was performed more frequently in areas with an average income greater than $50,353. The authors suggest that this might be due to a concern that patients of lower socioeconomic status might be lost to follow-up after a lobectomy and might potentially be at increased risk for recurrence. Alternatively, patients of higher socioeconomic status may be more likely to question the need for a total thyroidectomy.

Most importantly, the rate of lobectomy after the publication of the 2015 guidelines was 50% greater than would have been predicted based on trends before 2015 (8.4% predicted vs 16.6% actual).

WHAT ARE THE IMPLICATIONS OF THIS STUDY?
Since the release of the 2015 edition of the pediatric ATA guidelines, there has been a significant increase in the proportion of patients undergoing a lobectomy for thyroid cancer. This is true despite the fact that guidelines recommend a total thyroidectomy for most patients, and it suggests that surgeons have begun to take a more conservative and tailored approach to the treatment of thyroid cancer in the pediatric population.

— Phillip Segal, MD

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