September 2019 HSC Section 1 Congenital and Pediatric Problems

Canfarotta et al

Table 1. Modified Pediatric McGill Thyroid Nodule Score Template.

Parameter

Result

Points

Clinical parameters and laboratory tests 1. Sex

Male

1 1 1 1 3 3 1 1 1 1 2 1 2 2 2 3 4

______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______

2. Palpable nodule

Present

3. Consistency 4. TSH levels

Bone hard . 1.4 mIU/L

5. Ionizing radiation exposure 6. Family history of thyroid cancer

Present Present

Ultrasound

1. Echogenicity

Hypoechoic

2. Increased vascularity

Present

3. Shape

Taller than wide

4. Calcifications

Coarse calcifications Microcalcifications

. 10% . 30%

5. Enlarging

6. Abnormal lymph nodes

Present

7. Size, cm

2-2.99 3-3.99

4 1

FNA Bethesda score 1. Nondiagnostic

Present Present Present Present Present Present

0

2. Benign

–3

3. Atypia of undetermined significance

3 4 7 8

4. Follicular neoplasm

5. Suspicious for malignancy

6. Malignant

Final score:

Abbreviations: FNA, fine-needle aspiration; TSH, thyroid-stimulating hormone.

of papillary thyroid carcinoma (n = 1, 10%), and follicular thyroid carcinoma (n = 1, 10%). The distribution is propor- tionately similar to that in the Surveillance, Epidemiology, and End Results database for pediatric well-differentiated thyroid cancer for rates of papillary thyroid carcinoma (60%), follicular variant of papillary thyroid carcinoma (22.5%), and follicular thyroid carcinoma (9.5%). 3 For patients with malignancy, 60% had regional lymph node metastases at the time of initial surgery. Male sex was seen at similar rates in benign (27.7%) and malignant (20%) nodules. Nodules were palpable in all 10 cases with malignant histology (100%) and in 31 of 36 cases of benign disease (86.1%). Incidental thyroid nodules were found by computed tomography in 2 cases and ultra- sound examination of the neck in 3 cases. A preoperative thyroid-stimulating hormone value . 1.4 was more com- monly encountered in malignant (70%) versus benign dis- ease (30.6%; P = .03). No patients in our series had nodules characterized as bone hard on examination or a history of therapeutic radiation therapy ( Table 2 ). The ultrasound features associated with benign and malig- nant nodules are compared in Table 2 . Hypoechogenicity ( P = .006), microcalcifications ( P = .001), and abnormal lymph

nodes ( P = .005) were associated with increased risk of malig- nancy. Increased vascularity, shape taller than wide, macrocalci- fications, and enlarging size were not associated with malignant nodules. Nodule size of 2-2.9, 3-3.9, or 4 cm was not associ- ated with increased risk for malignancy. Nodule size was similar in malignant (2.97 6 1.15 cm) and benign disease (3.08 6 0.95 cm). Fine-needle aspiration biopsies (FNABs) were classified according to the Bethesda system as follows: 1 nondiagnos- tic (2.2%), 15 benign (32.6%), 18 AUS (39.1%), 4 SFN (8.7%), 1 suspicious for malignancy (2.2%), and 7 malig- nant (15.2%). The risk for malignancy was 0% for nondiag- nostic and benign aspirates, 5.6% for AUS, 25% for SFN, and 100% in aspirates diagnosed as suspicious or malignant ( Table 2 ). For indeterminate nodules, the mean MTNS was 7.95 for benign and 12.5 for malignant disease ( P = .006). The cumulative MTNS was significantly higher in malig- nant (16 6 3.13) than benign nodules (5.72 6 3.03; P \ .05; Table 3 ). The distribution of MTNSs in relation to final pathology for all nodules and indeterminate nodules is sum- marized in Figures 1 and 2 , respectively. The sensitivity, spe- cificity, and PPV were 100%, 94.4%, and 83.3% for scores 10 and 80%, 100%, and 100% for scores 11 ( Table 4 ).

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