Differentiated thyroid carcinoma (DTC) is the most common pediatric thyroid cancer, with papillary thyroid carcinoma (PTC) accounting for 90% of the cases. The incidence of DTC is increasing in the United States and worldwide. Thus, I read with great interest the recently published article entitled Pediatric Thyroid Nodules by Drs. Emily Masterson and Zarina Norton in the January 2025 issue of Pediatrics in Review.
In 2015 the American Thyroid Association published management guidelines specifically for pediatric and adolescent patients with thyroid nodules and cancer, which has provided the essential framework for how we approach these patients. Standard treatment includes surgical resection and, in select cases, radioactive iodine (RAI). While overall survival is excellent, less than 20% of patients with lung metastases will have a complete response to RAI. Furthermore, RAI is associated with an increased second malignancy risk. In recent years, we have learned more about the complexity of the molecular profile of pediatric thyroid cancers. PTC in children and adolescents have distinct molecular alterations and fusions are more frequently noted in pediatrics compared to adults with PTC. Fusion positive PTC has been associated with a more invasive behavior, and as we increase our understanding of the unique molecular landscape of pediatric PTC, it is important to understand its impact on clinical behavior and management, particularly in patients with metastatic, advanced, and/or refractory disease. While response to oncogene-specific therapies have been described in children with PTC, further studies are warranted to understand which patients benefit from these targeted therapies, the length of treatment, durability of response, and the effect on RAI avidity. Including the molecular profile into clinical practice may allow for more personalized treatment approaches and potentially impact outcomes for children and adolescents with high-risk or refractory thyroid cancer. Most importantly, we have come to recognize that it takes a multidisciplinary team of specialists in general pediatrics, pediatric oncology, pediatric endocrinology, and head and neck surgery with a specific expertise in thyroid cancer, nuclear medicine, pathology, genetics, and social work to truly improve the care of children, adolescents, and young adults with DTC.
