September 2019 HSC Section 1 Congenital and Pediatric Problems

Otolaryngology–Head and Neck Surgery 157(4)

Table 2. Relationship of MTNS Components with Final Pathology.

Table 3. Distribution of MTNS with Benign and Malignant Nodules.

Patients, No. (%)

Nodules

n

Mean

SD Min

Max

Benign (n = 36)

Malignant (n = 10)

Variables

P Value

Benign

36 10

5.72

3.03 3.13

1

11 20

Malignant

16

11

Clinical parameters and laboratory tests

Male

10 (27.7) 31 (86.1)

2 (20)

.481 .275 N/A .03 a N/A .391 .006 a .530 .115

Abbreviation: MTNS, McGill Thyroid Nodule Score.

Palpable nodule

10 (100)

Consistency bone hard 0 (0)

0 (0)

TSH . 1.4

11 (30.6)

7 (70)

Radiation history

0 (0)

0 (0)

Family history

1 (2.8)

1 (10)

Ultrasound characteristics

Hypoechoic

5 (13.9) 34 (94.4)

6 (60) 9 (90) 2 (20)

Increased vascularity Shape: taller . wide

1 (2.8)

Calcifications Macro

2 (5.6)

1 (10) 7 (70)

.530 .001 a

Micro

0 (0)

Enlarging . 10%

. .99 . .99 .005 a .143 .283 . .99

3 (8.3) 3 (8.3)

0 (0)

. 30%

1 (10) 6 (60)

Lymphadenopathy

0 (0)

Size, cm 2-2.9

13 (36.1) 11 (30.1) 6 (16.7)

1 (10) 5 (50) 2 (20)

Figure 1. Distribution of cumulative McGill Thyroid Nodule Score (MTNS) score and final pathology.

3-3.9

4 1

FNA Bethesda score

Malignant, %

Sands et al showed that the MTNS is a reliable predictor of risk for malignancy in adults. 12 However, as nodular disease has a tendency to behave differently in the pediatric popula- tion, we looked into the ability to apply this tool to a younger age group. Clinical and Laboratory Features The clinical risk factors that have been associated with increased risk for malignancy include a palpable nodule, 19 history of ionizing radiation therapy, 20,21 elevated thyroid- stimulating hormone, 22,23 male sex, 24 and family history of thyroid cancer. 25 The only statistically significant risk factor in our sample population was a thyroid-stimulating hormone value . 1.4. We were unable to determine whether there is a relationship with bone-hard nodule consistency, as there was no clear documentation in the medical records. Therefore, these clinical findings within the population of children 18 years of age should be interpreted with caution, as the associ- ation has been clearly defined in only adults. 26 We were also unable to evaluate the association of irradiation, as no patient had previously undergone treatment, but this finding has been universally accepted as a major risk factor for developing papillary thyroid carcinoma. 14,20,21,27 The ATA reports that children with a history of radiation therapy presenting with a thyroid nodule are at modest risk for malignancy 14 and, as such, should be approached with a high level of clinical sus- picion. Although it is difficult to assess the impact that each of these factors has on the cumulative MTNS, they are

Nondiagnostic

1

0 0 1 1 1 7

0 0

Benign

15 17

AUS

5.6

FN

3 0 0

25

Suspicious Malignant

100 100

Abbreviations: AUS, atypia of undetermined significance; FN, follicular neo- plasm; FNA, fine-needle aspiration; MTNS, McGill Thyroid Nodule Score;

TSH, thyroid-stimulating hormone. a Statistical significance ( P \ .05).

Discussion

The diagnostic evaluation and management of thyroid nodules in children and adolescents remain a challenge. Multiple risk factors have been identified, including clinical examination and laboratory findings, ultrasound characteristics, and findings on FNAB cytology in adult and pediatric patients. 14,19-36 While historically these have all been used individually to risk stratify nodular disease, this study highlights the need for a modified pediatric MTNS to provide a comprehensive clinical suspicion index to be used in conjunction with clinical judg- ment to support management decisions. This would allow for a more informed discussion with patients when counseling about the risk of malignancy within a given thyroid nodule.

158