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Pediatric Thyroid Disorders: What Pediatricians Need to Know About Diagnosis, Referral, and Surgical Care · Pediatrics in Practice: A CME Podcast

• 0:01
  Dr Mike Smith (Host): Welcome to Pediatrics in Practice, A CME podcast.
• 0:05
  I'm Dr.
• 0:06
  Mike, and with me is Dr.
• 0:07
  Jake Dahl from Children's Mercy.
• 0:10
  Today we'll discuss pediatric thyroid disorders, what pediatricians
• 0:14
  need to know about diagnosis, referral, and surgical care.
• 0:19
  Dr.
• 0:19
  Dahl, welcome to the show.
• 0:21
  I wanna start off with what are some of the, most common pediatric
• 0:28
  thyroid conditions you manage?
• 0:31
  Dr Jake Dahl: so in pediatrics we tend to manage these conditions as a team, And
• 0:35
  so we work very collaboratively with our colleagues in endocrinology, radiology.
• 0:42
  Other specialties to manage both benign and malignant conditions.
• 0:46
  The most common thing we see are just benign nodules, which are just
• 0:50
  little cysts in the thyroid gland that have no real pathology or
• 0:55
  negative impact on the patient's.
• 0:57
  Dr Mike Smith (Host): And so how does a patient enter your care?
• 1:00
  I would assume there's some referral process for you, right?
• 1:02
  Could you describe that for us?
• 1:04
  Dr Jake Dahl: Yeah, so there's a couple of ways that patient's enter our care.
• 1:07
  one of my colleagues in, endocrinology, Dr.
• 1:09
  Mire, has a thyroid nodule clinic, and some patient's
• 1:15
  are referred to that clinic.
• 1:16
  They have a medical evaluation, And then if they are potential
• 1:20
  candidates for surgery, Dr.
• 1:21
  Mire refers them directly to me.
• 1:24
  And then sometimes the exact opposite happens.
• 1:26
  patient's are referred directly to me.
• 1:29
  I will order, basic, laboratory and imaging workup And then refer them to Dr.
• 1:33
  Mitre for his input.
• 1:35
  And then as a team, we discuss, treatment options And then present
• 1:39
  those options to the family.
• 1:40
  Emily.
• 1:41
  Dr Mike Smith (Host): you mentioned most of the cases, luckily, right?
• 1:44
  Are benign nodules.
• 1:46
  what happens with those patient's?
• 1:48
  Do they just go back then to the primary care, or do they even stay
• 1:53
  with you for a treatment plan?
• 1:55
  Dr Jake Dahl: It depends on how big the nodules are And the ultrasound
• 1:58
  characteristics, but the majority of those patient's, we provide reassurance
• 2:03
  And then recommend they follow-up with their, primary pediatrician and
• 2:07
  maybe get a repeat ultrasound every year or so depending on symptoms.
• 2:11
  Dr Mike Smith (Host): Now, when it comes to, more malignant type
• 2:14
  nodules, how often do you see that?
• 2:17
  Dr Jake Dahl: So the incidence of thyroid cancer in children and
• 2:20
  adolescents is actually increasing.
• 2:23
  we're seeing more and more of it, And the majority of the cases we see
• 2:27
  are what are termed differentiated thyroid cancers With papillary thyroid,
• 2:32
  carcinoma being the most common.
• 2:34
  Dr Mike Smith (Host): well, what do you think is going on there?
• 2:35
  Why the rising incident?
• 2:37
  Dr Jake Dahl: the honest answer is we're not sure there's likely
• 2:41
  some component that we're better at diagnosing these, And so we're picking
• 2:46
  up more patient's at an earlier age.
• 2:49
  But the counter to That is that pediatric thyroid cancer
• 2:53
  tends to be more aggressive.
• 2:54
  Tends to have more metastases to, cervical lymph nodes than adult cancer So, It,
• 3:01
  really not well understood, but our team here is working on some research projects
• 3:06
  to help us understand that better.
• 3:09
  Dr Mike Smith (Host): Well, anytime there's a rise in incidence of any
• 3:11
  disease, we're better at diagnosing.
• 3:13
  Right.
• 3:14
  That could always be a part of it.
• 3:15
  But in kids, especially with these aggressive cancers, I'm sure there's
• 3:20
  some research going on trying to figure out, it just we're better
• 3:24
  at diagnosing or it something else?
• 3:26
  Right.
• 3:27
  Dr Jake Dahl: Yeah, and I think that a lot of that, what we're gonna find is
• 3:30
  related to autoimmune thyroiditis and almost every single patient that we
• 3:36
  see with these differentiated thyroid cancers has some level of autoimmune.
• 3:42
  Disease in the pathology background, and I think we just don't understand
• 3:46
  enough about our own immune systems to fully elucidate the mechanism through
• 3:53
  which this autoimmune thyroiditis turns into a differentiated thyroid cancer.
• 3:57
  Dr Mike Smith (Host): Yeah, I definitely wanna talk about that coming up.
• 4:00
  but before we get there, I, I wanna go back to more the
• 4:03
  primary care pediatrician.
• 4:06
  and when they're faced with an abnormal thyroid lab or, on physical exam,
• 4:12
  maybe a thyroid nodule or they've done some imaging and they see it.
• 4:18
  what are some of the steps they need to take first before referring?
• 4:25
  Dr Jake Dahl: So if there's laboratory abnormalities, just getting a
• 4:28
  dedicated thyroid ultrasound.
• 4:30
  is the next step.
• 4:31
  And depending on what that looks like, either a referral to
• 4:35
  endocrinology or myself, if there's abnormalities on ultrasound.
• 4:43
  These are well-characterized abnormalities, such as
• 4:45
  microcalcifications within the nodules.
• 4:49
  Those patient's need an urgent referral to, again, either endocrinology
• 4:54
  or myself for an expedited workup.
• 4:59
  Dr Mike Smith (Host): how does this differ in adults, you know, with
• 5:01
  adults, we know that certain nodules can be cold, as we say, or hot,
• 5:06
  causing hyper or hypothyroidism.
• 5:09
  Is that the same thing in kids?
• 5:10
  Or do they not experience the ups and downs of, thyroid hormone?
• 5:16
  Dr Jake Dahl: So more and more commonly we're seeing that as well, And that
• 5:20
  would fall into our benign disease.
• 5:22
  as I mentioned earlier, these benign colloid cysts, Those are cold nodules.
• 5:26
  Nothing needs to be done.
• 5:28
  We actually see a decent number of hot nodules or nodules that are actually
• 5:33
  just secreting, thyroid hormone.
• 5:36
  without the appropriate endocrinologic HPA access controls, if you will.
• 5:40
  and those patient's actually, most commonly go to our endocrine colleagues.
• 5:45
  They usually get a thyroid uptake scan, which is a nuclear medicine scan
• 5:49
  that will localize the hot nodule.
• 5:51
  And then they come on over to us and we'd usually just remove half the
• 5:55
  thyroid gland for the hot nodules.
• 5:57
  And then the patient's symptoms return to baseline over.
• 6:01
  a course of a couple weeks, but hyperthyroidism is a miserable condition.
• 6:06
  And so these patient's tend to be pretty symptomatic, although the symptoms
• 6:10
  can be vague, And so I think primary care pediatrician should have a low
• 6:14
  threshold to order, TSH, free T four levels, or even a thyroid ultrasound.
• 6:21
  Dr Mike Smith (Host): let's go into autoimmune now.
• 6:22
  You know, you brought this up that This is increasing,
• 6:25
  you're seeing it more and more.
• 6:27
  what signs should prompt earlier testing then, and how does early management
• 6:33
  impact long-term outcomes here?
• 6:35
  if we recognize these autoimmune issues earlier.
• 6:39
  Dr Jake Dahl: Well, I think first that like a lot of thyroid
• 6:43
  conditions, the symptoms.
• 6:45
  Are really so global that they can be hard for anybody, not just a primary
• 6:50
  care pediatrician to diagnose, but you know, signs of, decreased thyroid
• 6:54
  function, lethargy, hair and skin changes, menstrual period changes
• 6:59
  And the appropriate age range.
• 7:01
  All those things that we learned in medical school are true.
• 7:03
  And that should trigger, some basic workup in primary care, very similar to what I
• 7:08
  just said, some basic labs and ultrasound.
• 7:11
  and often what you see in the ultrasound is just a diffusely,
• 7:14
  enlarged, inflamed thyroid gland.
• 7:17
  And as long as those patient's have normal, thyroid function tests.
• 7:22
  We really don't recommend any treatment, but we do know Those are the patient's
• 7:26
  who are at-risk for having hypothyroidism secondary to the autoimmune thyroiditis.
• 7:32
  So they probably do need some type of laboratory surveillance
• 7:36
  and imaging surveillance.
• 7:37
  And then we also know that these are the patient's who.
• 7:41
  Are likely predisposed to having these differentiated thyroid cancers so that
• 7:45
  would trigger the primary care to, do a more thorough neck exam or thyroid
• 7:50
  exam when you're seeing these patient's.
• 7:54
  And if there's any concerning findings, again, just jump to an ultrasound.
• 7:57
  We love
• 7:58
  ultrasound out.
• 8:00
  Dr Mike Smith (Host): in clinical medicine, when you are faced with several
• 8:04
  different symptoms of a patient, it almost seems like it's never a bad idea to do
• 8:09
  a quick check of the thyroid, right?
• 8:11
  maybe go ahead and throw some labs in there, just in case.
• 8:14
  'cause so often we go down these rabbit holes and, a simple
• 8:19
  TSH could have helped us out.
• 8:21
  Right.
• 8:22
  Dr Jake Dahl: I agree.
• 8:23
  but again, these symptoms are vague and it's hard for even
• 8:27
  people who, focus on this area of practice to get these diagnoses
• 8:31
  right.
• 8:31
  All the time.
• 8:32
  Dr Mike Smith (Host): in clinical medicine as a, you know, primary care doctor.
• 8:34
  We need a little sticky note.
• 8:35
  Hey, don't forget thyroid.
• 8:38
  Dr Jake Dahl: yeah, I mean, I don't,
• 8:41
  I don't know how primary care docs.
• 8:44
  keep up with all the things they're supposed to keep up with.
• 8:46
  I can barely keep up with the things in my very limited, practice,
• 8:50
  Dr Mike Smith (Host): well, they are some of our best clinicians, no doubt.
• 8:52
  what clinical or diagnostic factors typically indicate that surgery is gonna
• 8:58
  be necessary for a thyroid condition?
• 9:01
  So.
• 9:02
  Dr Jake Dahl: So for the benign conditions, the most common
• 9:04
  thing is that hot nodule.
• 9:06
  And again, that, that just usually the recommendation is, removing part
• 9:10
  of the thyroid, in kids like a big goiter or diffusely enlarged thyroid
• 9:16
  causing symptoms such as swelling, difficulties, breathing difficulties,
• 9:20
  difficulties with donation is pretty rare, although we do see it.
• 9:25
  In terms of the patient's, with concern for malignancy, once they
• 9:30
  have a thyroid ultrasound that shows concerning nodules, they'll go see our
• 9:35
  friends in interventional radiology for a fine needle aspiration biopsy,
• 9:40
  which is ultrasound guided and done under sedation as an outpatient.
• 9:44
  And then once we have those.
• 9:47
  Results, then we'll talk to the family, about the need for surgery.
• 9:51
  And the way those results kind of fall out is either it's benign, in
• 9:56
  which case we'll probably just repeat an ultrasound in six to 12 months.
• 10:01
  and depending on what the nodule looks like, that may be an ultrasound
• 10:04
  that either endocrinology or eye order and follow-up with, And then
• 10:08
  if it is concerning for malignancy, then we have the discussion about
• 10:13
  surgery in the current state right now for these differentiated thyroid
• 10:18
  cancers, we remove the entire thyroid gland, as well as do a staging, uh.
• 10:24
  What we call central compartment neck dissection.
• 10:27
  So we remove lymph nodes around the thyroid, down the
• 10:31
  tracheal esophageal groove.
• 10:33
  and if there's other lymph nodes on preoperative imaging, then we'll
• 10:37
  do a formal, what we call selective neck dissection, And we can figure
• 10:42
  all this out based on imaging And the FNA biopsies preoperatively.
• 10:47
  For patient's who end up in the gray area.
• 10:49
  So not definitely benign, not definitely malignant.
• 10:53
  That's a real gap.
• 10:54
  because the treatment options are either just remove half the thyroid
• 10:58
  in one surgery, get final pathology.
• 11:01
  If it's malignant, go back and remove the other half And the second surgery,
• 11:05
  which nobody's really excited about,
• 11:07
  or just go ahead and remove the entire thyroid gland.
• 11:11
  And if there's no malignancy, well then the patient got a total thyroidectomy and
• 11:16
  needs thyroid hormone replacement for the rest of their life for no great reason.
• 11:21
  There are some commercially available genetic testing kits that we can
• 11:25
  use to test on that FNA sample.
• 11:27
  but they're only validated in adults and they're only FDA approved in adults.
• 11:31
  So.
• 11:32
  do we trust the results?
• 11:34
  'cause we know the pediatric thyroid cancers behave differently.
• 11:37
  I'm not so sure I do.
• 11:38
  And the other thing is, payers do not want to pay for these genetic tests
• 11:44
  because they're not FDA-approved for patient's under 18 years.
• 11:48
  Dr Mike Smith (Host): Yeah.
• 11:49
  Well, how often are you faced with this question about it?
• 11:52
  Is this malignant?
• 11:54
  Maybe it's not.
• 11:54
  We're not sure.
• 11:55
  How often does that actually happen?
• 11:57
  Dr Jake Dahl: it's pretty common.
• 11:58
  the grading scale that we use, the cytopathologists use for the, FNA analysis
• 12:03
  is, essentially a six point scale.
• 12:06
  And so there's, two ends of it that are really clear
• 12:10
  Dr Mike Smith (Host): and
• 12:10
  then the
• 12:10
  middle you?
• 12:11
  Yeah.
• 12:12
  Dr Jake Dahl: what do you do?
• 12:13
  Dr Mike Smith (Host): Yeah.
• 12:13
  so you, proposed, there's two options there.
• 12:16
  You just, remove the nodule basically and follow-up or remove the whole thyroid.
• 12:20
  what do you usually do in those cases?
• 12:24
  Dr Jake Dahl: I talk to the patient and their family about their options and
• 12:28
  try to guide them through it and help them make the best decision for them.
• 12:34
  Dr Mike Smith (Host): when you think about surgery in general, you know, with AI and
• 12:38
  robots and all this kind of stuff has the surgery you do for thyroid nodules, has
• 12:45
  that changed at all in the past few years?
• 12:48
  Or do you see advancements coming down the line?
• 12:51
  Dr Jake Dahl: well, I think in terms of the major advancement, there's some new.
• 12:56
  Systems available to help us identify parathyroid glands intraoperatively.
• 13:02
  So hypoparathyroidism is one of the most common.
• 13:06
  risks of thyroid surgery for a total thyroidectomy and
• 13:10
  while not life-threatening.
• 13:12
  If you have a permanent hypocalcemia That is not fun, And then you apply that
• 13:17
  to a 12-year-old, 15-year-old, that's something we really, really want to avoid.
• 13:22
  And so the ability to use these new systems to help us identify parathyroids
• 13:27
  and preserve them, is really in advance terms of the robots people.
• 13:33
  Are doing it in adults and they're doing trans axillary
• 13:39
  transoral thyroids in some places.
• 13:41
  Not super common in the us.
• 13:44
  but the expense, and I think the risks for that.
• 13:47
  Higher.
• 13:48
  I can do these surgeries through a two to four centimeter incision in the low
• 13:52
  neck that we close very meticulously and still see all the nerves, blood vessels,
• 13:59
  trachea, everything I need to see.
• 14:01
  And so for right now, I think our traditional surgical approaches are.
• 14:08
  Gonna stay around.
• 14:10
  Now, where I do see an area for innervation is this genetic testing.
• 14:14
  We know what the high-risk genetic mutations are, the drivers of these
• 14:19
  differentiated thyroid cancers.
• 14:21
  And so if we had that information upfront, we can much more accurately counsel
• 14:25
  patient's in families regarding the indeterminate nodules on the FNA biopsy.
• 14:31
  Dr Mike Smith (Host): it's really interesting, isn't it?
• 14:32
  the personalized medicine, understanding that cancers, even though it's the
• 14:37
  same cancer, technically, it could be very different in different
• 14:40
  people and act differently.
• 14:42
  And so that could be very powerful.
• 14:44
  the parathyroids, that's an interesting thing because I don't do what you do.
• 14:48
  I'm a radiologist, I don't do surgery, But when I was a medical student,
• 14:53
  all of the anatomy books made it.
• 14:56
  Very easy to find the parathyroids.
• 14:58
  So I don't know what the problem is, Dr.
• 15:00
  Tall.
• 15:01
  Dr Jake Dahl: They're wrong.
• 15:04
  I like to tell patient's and families that, our patient's
• 15:07
  don't read the textbooks.
• 15:08
  Parathyroids look like little, five millimeter, 10 millimeter drops of fat
• 15:15
  in the neck, and they
• 15:17
  Dr Mike Smith (Host): but that's, the books make 'em
• 15:18
  look like they're headlights.
• 15:21
  Dr Jake Dahl: Let me tell you, they are not headlights.
• 15:23
  They look like fat.
• 15:24
  Sometimes they look like little lymph nodes, and they can be anywhere around
• 15:28
  the thyroid and even inside the thyroid.
• 15:32
  Dr Mike Smith (Host): well That is interesting innovation then, isn't it?
• 15:34
  Because that's gonna help out, I think, or avoid a big side effect of surgery.
• 15:39
  I wanna kind of wrap this up with counseling and, how do you counsel
• 15:44
  families and their pediatricians about all of this, you know, if it needs
• 15:49
  to be surgery, the risk recovery.
• 15:51
  What's your approach to the, counseling aspect of this?
• 15:56
  Dr Jake Dahl: You know, I try to just be honest and straightforward.
• 16:01
  Transparent.
• 16:02
  Well, at the same time, reassuring the patient's and their parents
• 16:05
  that This is a common operation in our hands here at Children's Mercy.
• 16:09
  Myself and my partner, Dr.
• 16:11
  Brown, we do these surgeries together to attending surgeons, both
• 16:14
  fellowship-trained ENT, head and Neck Surgeons, and try to answer
• 16:19
  any of the questions they may have.
• 16:21
  About what they'll experience.
• 16:23
  I'll be honest with you, most patient's are more worried about
• 16:26
  anesthesia than they are the surgery.
• 16:28
  So we talk about that.
• 16:30
  we talk about not taking stitches out because the only
• 16:33
  stitches we use are absorbable.
• 16:36
  And talk about postoperative pain management.
• 16:40
  We do talk about the risks, including risk to the recurrent laryngeal nerves
• 16:45
  And the hypocalcemia amongst other things.
• 16:48
  But I really try to put that in the context of these risks
• 16:51
  are exceedingly rare And we do everything we can to prevent them.
• 16:57
  And you know, if they do happen, we have a great team that
• 17:00
  can help work through them.
• 17:02
  Dr Mike Smith (Host): Very good.
• 17:03
  Dr.
• 17:04
  Dahl, this has been, fantastic information.
• 17:07
  I really appreciate you coming on and sharing your expertise.
• 17:11
  Dr Jake Dahl: Dr.
• 17:12
  Mike, thanks again for having me and allowing me to, share my clinical
• 17:15
  passion with you and your audience.
• 17:18
  If referring pediatricians or other providers in the community
• 17:22
  have questions about the referral process or think they have patient's,
• 17:26
  that need to be seen by our team, they can reach out to us directly.
• 17:29
  all of our contact information is on the Children's Mercy website
• 17:33
  for new patient's, with concern for thyroid cancer goals to get them in
• 17:37
  for an evaluation within two weeks.
• 17:39
  Dr Mike Smith (Host): For more information, you can go to C KC Link.
• 17:44
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• 17:47
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• 17:51
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• 17:55
  This is Pediatrics in Practice, A CME podcast.
• 17:59
  I'm Dr.
• 17:59
  Mike.
• 18:00
  Thanks for listening.