Preoperative cytology with molecular analysis to help guide surgery for pediatric thyroid nodules

Objectives: To discuss the use of molecular mutation analysis in the surgical management of pediatric thyroid nodules. Methods: This study is a case series with retrospective chart review performed at a tertiary children's hospital. Pediatric patients who presented to the Children's Hospital of Pittsburgh of UPMC with a thyroid nodule and had subsequent fine needle aspiration with positive molecular mutation between November 2009 and February 2012 were identified and charts were reviewed. Patient demographics, presenting signs, lab results, pathologic findings, and surgical outcomes were collected. Results: 5 pediatric patients with positive molecular mutation studies on preoperative FNA were identified. FNA results were categorized as follows: suspicious for follicular neoplasm (n= 2), suspicious for malignant cells (n= 1), and positive for malignant cells (n= 2). The following molecular mutations were identified: BRAF (V600E) (n= 2), PAX8/PPARγ (n= 1), HRAS (n= 1), and RET/PTC (n= 1). A total thyroidectomy was performed on each patient. In all cases the final pathology was positive for malignancy (papillary thyroid carcinoma (PTC), n= 3; follicular variant of PTC, n= 2). Three of five patients had transient postsurgical hypocalcemia. There were no other postoperative complications. Conclusions: This series provides evidence that preoperative FNA with reflex molecular testing in pediatric thyroid nodules can help guide surgical decision making, reduce the need for repeat surgeries, and diminish the risk of complications from a staged procedure.