Evolving trends in pediatric thyroid nodules and cancer management

Differentiated thyroid cancer (DTC) is the most common form of pediatric thyroid cancer, yet its management has been largely based on evidence from adults. Recent advances in science and clinical studies of pediatric DTC, particularly in papillary thyroid carcinoma, the predominant subtype, now form the basis of emerging paradigms and revised guidelines. The potential of malignancy in thyroid nodules, as defined by current ultrasound risk stratification systems, has been evaluated in pediatric patients, enabling evidence-based indication for fine-needle aspiration biopsy. Observational studies comparing the effect of different interventions on prognosis, complications, and quality of life, challenge traditional surgical approaches in favor of potentially less extensive initial resection. Recognition of distinct underlying oncogenic drivers has not only paved the way for discoveries in the biology of pediatric thyroid cancer but has also advanced the era of targeted systemic therapy for progressive and metastatic pediatric DTC. Certain genome alterations, particularly oncogenic gene fusions that are more common in pediatric DTC, can now be targeted with small-molecule inhibitors, offering more effective therapy for metastatic disease with fewer and less severe adverse effects. This review offers an evidence-based summary of these data and the evolving trends in the diagnosis and management of pediatric DTC.