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Original article
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Follicular Adenoma of the Thyroid Gland in Children
C. Festen1, B. ]. Otten2, C. A . van de Kna3
'ivdiatrir Surgical Center, ^Department of Pediatries and '"Department of Pathology, University Hospital Nijmegen, The Netherlands
.a-- I,
Introduction
1
Summary
Folliciilar adenoma is the most frequent cause of a
solitary thyroid nodule in children. We reviewed our own patient
material and the literature and discuss etiology, available diagnostic
methods, differential diagnosis, natural course and clinical manage
ment. In spite of the fact that the great majority of solitary thyroid
nodules are benign, the treatment strategy is completely dominated by
the risk for malignancy.
Key words
Thvroid - Adenoma - Child
Résumé
La cause la plus fréquente d’un nodule thyroïdien
solitaire chez l’enfant est l’adénome folliculaire. Nous avons revu nos
patients atteints d’une nodule solitaire de la thyroïde et la littérature et
discutons l’étiologie, les méthodes diagnostiques disponibles, le
diagnostic différentiel, le cours naturel et le traitement clinique de cette
maladie. Malgré le fait que la majorité des nodules solitaires de la
glande thyroïde soit d’un caractère bénin, le protocole thérapeutique
est complètement dominé par le risque de malignité.
Mots-clés
Glande thyroïde - Adénome - Enfant
Zusammenfassung
Das follikuläre Adenom ist die häufigste Ursache
eines solitären Schildtlrüsennodus bei Kindern. Wir haben unsere
Patienten und die Literatur überprüft und diskutieren die Ätiologie,
che diagnostischen Möglichkeiten, die Differentialdiagnose, den Verlauf
und die Therapie dieser Erkrankung. Die Mehrheit der solitären
Schilddrüsennodi ist gutartig. Jedoch wird das therapeutische Vor
gehen beherrscht durch die Frage der Malignität.
Schlüsselwörter
Schilddrüsenadenom - Kindesalter
Surgery does not play an important role in the
treatment of diseases of the thyroid gland in children. Besides
remnants of the thyroglossal duct and an exceptional case of
goitre, which does not regress adequately on medical treatment, a
solitary thyroid nodule is the most frequent indication for surgery.
The interest in solitary thyroid nodules is dominated by the risk
for malignancy. Nevertheless, only a small proportion of solitary
nodules turn out to be malignant and the majority are benign
lesions. In the group of benign lesions, which present as a solitary
nodule, wore than half are follicular adenomas. Reviewing the
literature on follicular adenoma, it is striking that hardly any
thing is known about follicular adenomas, especially in children.
Based on our patient material and the available literature we
discuss the etiology, diagnostic methods, differential diagnosis,
clinical course and management.
Material and methods
In the period from January 1976 till January 1992 in
the Pediatric Surgical Center and the Department of Pediatrics 5 patients
were seen with a solitary thyroid nodule which, after excision and
histologic examination, proved to be a follicular adenoma (Table 1). Age
ranged from 11 months till 18 years. There were 4 girls and 1 boy. Three
adenomas were in the left and two hi the right thyroid lobe. The mother
and a niece of one of the girls (Case 2) and the lather of the boy (Case 1)
were treated in the past also for a thyroid nodule. The mother of another
girl (Case 5) was treated for hyperthyroidism.
T4 and basic TSH values were normal in all patients, In
the boy (Case 1) a slight hyperresponse to TRH stimulation was found,
suggesting subcliriical hypothyroidism. In the boy and two girls (Cases 1,2,
3) normal values for thyreoglobuline and low molecular weight iodinated
material were found, making an inborn error of thyroid hormone synthesis
unlikely. Thyroid scanning showed a cold nodule in all A fíne needle
aspiration in one of the girls (Case 5) revealed follicular cells, without signs
of malignancy.
With the exception of Case 4 who, had a subtotal
thyroid lobectomy, in all the others a total thyroid lobectomy was
performed. There were no postoperative complications. Three patients
(Cases 1,2, 5) on histologic examination were shown to have two nodes in
the resected lobe.
Two patients, one boy and one girl (Cases 1 and 2) after
respectively 10 and 24 months presented with a second node on the other
side and underwent a total thyroid lobectomy on that side. After the first
operation the boy (Case 1) had an elevated basic TSH, but all the other
patients had normal values for thyroid function tests.
No patient received thyroid suppression therapy
Discussion
Received December 10, 1993; revised, accepted July 1, 1994
Em* J Pediatr Surg 5 (1995) 262-264
© Hippokrates Verlag Stuttgart - Masson Editeur Paris
Although solitary thyroid nodules in children are
much less common than in adults (12), there is a considerably
higher risk of malignancy (20). In the literature the reported
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C. Fes ten et al
Eur I Pediatr Surg 5 (1995)
The surgical literature unanimously advises op
erative excision. Because of the risk of malignancy and the
limited value of frozen-section diagnosis during operation (19),
enucleation as was proposed (1) does not seem a wise option. At
least a subtotal thyroid lobectomy should be done, which gives
the opportunity of studying the node with its environment. To
avoid a later reoperation a total thyroid lobectomy seems prefer
able. Although thyroid suppression preoperatively is controver
sial (8), several authors recommend postoperative suppression
therapy as recurrence prophylaxis (1, 21). The mean recurrence
rate after benign lesions of the thyroid is reported to be 5% (1).
Although some authors advised suppression therapy as a routine,
others only do so in case of an elevated TSH-level (21). In
accordance with the literature in our patients follicular adenomas
were found predominantly in girls and diagnosis was made
around puberty. However, we saw one girl 11 months of age.
Three adenomas were left-sided and two on the right. In three
patients on histologic examination two nodes were identified in
the resected thyroid lobe. All the nodes were cold on scanning.
Four patients had a total thyroid lobectomy and one patient a
subtotal thyroid lobectomy. There were no postoperative compli
cations.
Our patients did not receive suppression therapy.
Two patients developed a second adenoma in the other thyroid
lobe, respectively ten and twenty-four months alter the first
operation. In one of them there was an elevated TSIi level
postoperatively; in all the others we found normal values,
Conclusions
Although most solitary thyroid nodules are be
nign, there is a definite risk for malignancy. With the exception of
clear signs of malignancy, like irregular hard consistency, defini
tive adherence to the trachea, cervical lymphnodes or a lesion of
the recurrent laryngeal nerve, it is as a rule impossible to make a
clinical distinction between benign and malignant lesions. Thy
roid function tests are mostly normal with exception of elevated
calcitonin levels in medullary carcinomas. Ultrasonography is of
limited value except in case of cysts. If scintigraphy with 9UmTCpertechnetate indicates a cold nodule, the scanning is repeated
with Iodide 123. Although both warm and hot nodules are
described in carcinoma, especially cold nodules have a higher
risk for malignancy. FNA is an inexpensive and specific method
in the diagnosis of malignancy, but in many cases of follicular
adenoma versus follicular carcinoma there remains some doubt.
The reliability of FNA depends on the skill of the aspirator and
the experience of the pathologist. Most authors prefer excision of
all thyroid nodules.
Enucleation of the node is only mentioned to be
condemned. Frozen-sec:tion examination during operation is of
limited value in the differentiation of the follicular adenoma and
follicular carcinoma. Because of the risk for malignancy a total
thyroid lobectomy should preferentially be done in spite of a
greater chance of complications (7), because the complication
rate is significantly higher when on the same side a reoperation is
necessary. Postoperative thyroid suppression therapy is contro
versial but seems worthwhile when TSH-levels are elevated.
Autonomous hot thyroid nodules in children deserve operation
merely because of the risk for thyrotoxicosis (2).
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C. Festen, M. D.
Professor of Pediatric Surgery
Pediatric Surgical Center University Hospital Nijmegen
PO-Box 9101
0500 HB Nijmegen
The Netherlands

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