An adolescent with papillary thyroid carcinoma and locally metastatic disease but no distant metastases

Thyroid cancer is rare in the pediatric population, but the incidence appears to be increasing, especially in adolescents. Papillary thyroid carcinoma (PTC), the most common type of thyroid cancer, represents 90% or more of cases in patients ≤18 years of age. Children with PTC are highly likely to present with extra-thyroidal extension and regional lymph node metastases. Despite often having advanced cervical disease at presentation, pediatric patients have very favorable outcomes with long-term survival decades after diagnosis, especially in the absence of distant metastases. Current data suggest that a comprehensive initial surgery performed by a high-volume thyroid surgeon is the most important factor in improving long-term disease-free survival. With the increasing acceptance that routine radioactive iodine (RAI) ablation may no longer be necessary in lower-risk patients who have had surgery by a high-volume surgeon, and given knowledge that patients naïve to RAI can still be effectively followed with serum thyroglobulin (Tg) levels and neck ultrasound (US), ¹³¹I is no longer routinely being given to all children with PTC, even in the presence of lymph node metastases at diagnosis. The use of RAI in pediatric PTC is also evolving due to concerns about possible late effects such as secondary malignancies. In 2015, the American Thyroid Association (ATA) published guidelines specifically for the management of pediatric PTC, and these guidelines try to balance the risks and benefits of ¹³¹I therapy while also advocating that each child be treated at centers of excellence where there are multidisciplinary teams experienced in the management of pediatric thyroid cancer.