COMMENT ON: REPORT OF ONE CASE OF MALIGNANCY AMONG 17 AUTONOMOUS THYROID NODULES IN CHILDREN AND ADOLESCENTS

We read with interest the paper by Rosario et al. who retrospectively evaluated a series of 17 autonomous thyroid nodules (ATNs) diagnosed in 13 patients aged 9–18 years.¹ All were affected by hyperthyroidism due to thyroid nodule(s) >1 cm in greatest diameter, homogenously ‘hot’ at thyroid scintigraphy while the remaining thyroid parenchyma was suppressed. All patients underwent both fine-needle aspiration of ATNs and surgery. Indeterminate or non-diagnostic cytology was found in three (17.6%) and two (11.7%) nodules, respectively, and benign histology was reported in all but one nodule (i.e. follicular tumour of uncertain malignant potential). Conversely, suspicious cytology was reported in one nodule with malignant histology (i.e. infiltrative follicular variant of papillary thyroid carcinoma); the nodule measured 3.5 cm and exhibited highly suspicious ultrasonography (US) features according to the 2015 American Thyroid Association (ATA) US score.² The authors concluded that the overall incidence of malignancy among ATNs is low in children/adolescents, so subjecting all of them to surgery, as per the ATA guidelines,² represented over-treatment. According to their results, they suggest performing fine-needle aspiration only in ATNs with high suspicious features at US, as already proposed for adults.³ We appreciate the authors' efforts to propose a diagnostic and therapeutic algorithm to be applied in this setting of patients for avoiding unnecessary diagnostic procedures and surgery. However, a critical issue should be highlighted. The aforementioned US criteria for differentiating between benign and malignant nodules are well accepted and applied to ‘cold’ thyroid nodules in adult patients,^{2, 3} but there is insufficient evidence to extend these criteria to ATNs in childhood. We previously reported a 15-year-old girl with an ATN of 3.5 cm in greatest diameter, which turned out to be a papillary thyroid carcinoma, follicular variant, at histopathological analysis after surgery.⁴ In our case, there were no clues to suspect malignancy pre-operatively. The clinical presentation was dominated by the classic signs and symptoms of hyperthyroidism, and US did not reveal any features suspicious for malignancy (i.e. low-risk score according to the 2015 ATA criteria). In conclusion, adopting US-based criteria for malignancy risk assessment of ATNs could be helpful for decision-making in paediatric patients with ATNs, but further evidence is needed. Although the data reported by Rosario et al.¹ are encouraging, we suggest a note of caution until data from larger multicentre series are available.

中文翻译：

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点评：17例儿童及青少年自主甲状腺结节恶性1例报告

评论：17例儿童和青少年自主甲状腺结节恶性病例报告

我们感兴趣地阅读了 Rosario等人的论文。回顾性评估了在 13 名 9-18 岁患者中诊断出的 17 个自主甲状腺结节 (ATN)。¹由于甲状腺结节的最大直径>1 cm，所有患者都受到甲状腺功能亢进的影响，在甲状腺闪烁显像中均质“热”，而剩余的甲状腺实质受到抑制。所有患者均接受了 ATN 的细针抽吸和手术。分别在 3 个 (17.6%) 和 2 个 (11.7%) 结节中发现了不确定或未确诊的细胞学，除了一个结节（即恶性潜能不确定的滤泡性肿瘤）外，所有结节均报告了良性组织学。相反，在一个恶性组织学结节（即乳头状甲状腺癌的浸润性滤泡变体）中报告了可疑的细胞学检查；根据 2015 年美国甲状腺协会 (ATA) 美国评分，该结节长 3.5 厘米，并表现出高度可疑的超声 (US) 特征。²作者得出的结论是，儿童/青少年的 ATN 中恶性肿瘤的总体发病率较低，因此根据 ATA 指南对所有患者进行手术，²代表过度治疗。根据他们的结果，他们建议在美国仅在具有高度可疑特征的 ATN 中进行细针抽吸，正如已经针对成人提出的那样。³我们感谢作者努力提出一种诊断和治疗算法，以应用于这种患者环境，以避免不必要的诊断程序和手术。但是，应该强调一个关键问题。上述用于区分良性和恶性结节的美国标准已被广泛接受并适用于成人患者的“冷”甲状腺结节，^{2, 3}但没有足够的证据将这些标准扩展到儿童时期的 ATN。我们之前报道了一名 15 岁女孩，其 ATN 最大直径为 3.5 厘米，手术后的组织病理学分析结果显示为乳头状甲状腺癌，滤泡性变异。⁴在我们的案例中，术前没有怀疑恶性肿瘤的线索。临床表现以甲亢的典型体征和症状为主，超声未发现任何可疑恶性肿瘤的特征（即根据 2015 年 ATA 标准的低风险评分）。总之，采用基于美国的 ATN 恶性肿瘤风险评估标准可能有助于 ATN 儿科患者的决策，但需要进一步的证据。尽管 Rosario等人报告的数据. ¹令人鼓舞，我们建议在获得更大的多中心系列数据之前保持谨慎。