Back in the Saddle

Olivia Phillips was not feeling like herself, and she didn’t understand why.

“I was having bad anxiety. I would have nausea all of a sudden and feel shaky, and my mind was all over the place,” says the 14-year-old about her experience last year. “I had always been a happy, cheery, giggling type of girl, but then I just kind of slowed down.”

Her parents were concerned. They knew she had been healthy at her annual pediatric checkup before seventh grade, but the symptoms had been happening in an on-and-off sort of way for several months. Perhaps they were related to typical middle school, puberty, adolescent changes, her parents considered.

Then her dad noticed a lump on Olivia’s throat.

“We both felt bad about missing it,” says Olivia’s mother, Lori Phillips.

The lump turned out to be a thyroid nodule that was overproducing thyroid hormone — a so-called “hot” nodule. Surgery at Monroe Carell Jr. Children’s Hospital at Vanderbilt to remove the nodule and part of her thyroid gland has restored Olivia to her usual self. “I feel pretty great,” she says with a big smile as she sits cross-legged on the couch in her Hendersonville, Tennessee, home.

To care most effectively for patients like Olivia, Children’s Hospital has established the Vanderbilt Pediatric Thyroid Nodule and Cancer Program. The program brings together clinicians from all the specialties that care for patients with thyroid nodules and cancer, among them endocrinologists, surgeons, pathologists, radiologists, interventional radiologists and nuclear medicine specialists. They meet regularly as a team to review and personalize care for patients and to engage in research efforts.

“Children’s Hospital has been taking excellent care of children with thyroid nodules and cancer since its inception, but before last year, clinicians in different disciplines didn’t have an efficient method of collaborating with each other in the care of each patient,” says Ryan Belcher, MD, MPH, assistant professor of Otolaryngology (ENT) – Head and Neck Surgery, lead ENT surgeon on the program team, and Olivia’s surgeon. “We know that, as for other pediatric care that requires multiple disciplines, using a team approach equals better coordination of care and better outcomes for patients.”

Small gland, big impact

The thyroid is a butterfly-shaped endocrine gland located in the front of the neck, just above the collarbone. It produces thyroid hormones, which regulate metabolism, and the hormone calcitonin, which helps control blood calcium levels. In children, thyroid hormones are important for normal growth and development.

“The thyroid gland has an influence on every single organ system in the body,” says Sara Duffus, MD, assistant professor of Pediatrics and the lead pediatric endocrinologist for the Thyroid Nodule and Cancer Program. When the thyroid gland is not functioning properly or is removed, “it can have a huge impact on people’s lives — influencing their energy level and the way they feel on a day-to-day basis,” she adds.

Patients with thyroid disorders such as hypo- and hyperthyroidism, which can usually be treated effectively with medications, continue to be cared for by pediatric endocrinologists and their primary care physicians. The new program is designed for patients who have thyroid nodules, cancer and other thyroid conditions that require care from multiple specialists.

As a regional referral center, Children’s Hospital treats patients who may travel long distances to Nashville.

“Our goal is to really streamline care for patients, to coordinate visits so they can see all of the providers on their team on the same day,” Duffus says. “We want to make sure that we’re coordinating care and making it the least burdensome on families as we possibly can.”

Thyroid nodules are abnormal growths of thyroid cells. They may be discovered during a routine physical exam, by a patient noticing a lump — like Olivia’s family did — or by imaging that is being done for another reason. Typically, patients with a thyroid nodule have no symptoms.

In children under 12, boys and girls are equally likely to have thyroid nodules, but three times as many adolescent girls have nodules compared to boys, Belcher says. And although thyroid nodules are less common in children and adolescents compared to adults, there is a higher risk that they will contain thyroid cancer cells. Thyroid cancer is the second most common solid tumor in adolescent females. (Breast cancer, another hormonally driven cancer, is most common.)

Still, pediatric thyroid cancer is rare, and about 75% of nodules found in children and adolescents are benign (do not contain cancer), according to the American Thyroid Association (ATA).

A nodule is often first evaluated by physical exam, laboratory blood testing and ultrasound imaging. Specific features on the ultrasound — how the nodule looks, its orientation, the blood flow in and around it — may raise concerns that the nodule contains thyroid cancer cells. In that case, a fine needle aspiration biopsy could be recommended.

If cancer is discovered, treatment typically includes surgery followed by radioactive iodine therapy. Differentiated pediatric thyroid cancer has a survival rate greater than 95% over 20-30 years of follow-up, the ATA reports.

Olivia and her parents were relieved when ultrasound imaging did not raise concerns about cancer. “They said it was a complex colloid cyst,” Olivia says, grinning and adding, “I learned some big terminology.”

Bloodwork and an iodine uptake scan supported the diagnosis of a “hot” nodule that was overproducing thyroid hormone, suggesting that removal of part of Olivia’s thyroid would be appropriate.

A beacon for thyroid outcomes and research

Thyroid surgery in children and adolescents should be performed at centers like Children’s Hospital that have a full spectrum of pediatric care, according to ATA guidelines. That full spectrum includes all of the specialists that are part of the Thyroid Nodule and Cancer Program as well as pediatric anesthesia clinicians, child life specialists, nursing care and social support systems focused on children and families, says Monica E. Lopez, MD, MS, associate professor of Pediatric Surgery and the lead pediatric surgeon for the program.

Lopez joined Children’s Hospital last year from Texas Children’s Hospital in Houston, where she helped establish a multidisciplinary thyroid surgery team. In a July 2021 study in the Journal of Pediatric Surgery, Lopez and her colleagues reported that the multidisciplinary team approach resulted in excellent outcomes comparable to high-volume adult thyroid surgery programs.

“The importance of the team cannot be overstated. The complementary expertise and synergy from various disciplines benefit patient care,” Lopez says. “For every patient that is considered for surgery to have an opportunity to have their case discussed and their unique plan of care made by experts who work together routinely and have access to the best evidence-based information really makes a big difference in long-term outcomes.”

Thyroid surgery has the potential to negatively impact the parathyroid glands — four pea-sized glands that lie just behind the thyroid and secrete parathyroid hormone, which controls calcium levels in the bloodstream. If the parathyroid glands are transiently or permanently impacted by thyroid surgery, patients require calcium supplementation up to four times a day.

“That’s not an easy medicine to take, so it’s definitely an outcome we try to minimize,” Duffus says. The program has launched a quality improvement project to implement guidelines for optimizing vitamin D and calcium levels before surgery and then studying outcomes after surgery.

In addition to outcomes that are unique to thyroid surgery, the team will be engaged in broad efforts to follow evidence-based standardized processes and to continuously evaluate outcomes.

“We will be keeping close track of all of our outcomes, not only clinical, but also process metrics, adherence to our guidelines, and what’s happening to patients in the long term. The type and extent of thyroid surgery that a child has first has a critical impact on how they do over time,” says Lopez, who also will be working to standardize procedures and improve care across surgical disciplines in her role as vice chair for Surgical Quality and Evidence-based Programs in the Department of Pediatric Surgery.

“Our goal is to be a beacon for the Southeast and for the United States, to be a leading program for pediatric thyroid clinical outcomes and research,” Belcher says. “It’s ambitious, sure, but we have all the pieces to become a premier national program.”

For Olivia, the remaining half of her thyroid is functioning normally, and she doesn’t have to take medication. In addition to her usual activities like horse riding, church youth group and helping in the church nursery, she was eager after the surgery to start new interests such as karate and voice lessons, school theater club, and running for a student government office.

“She’s a different person this school year,” says her mother.

“Knowing that the anxiety and the way I was feeling last year was from my thyroid, my goal this year was to be more outgoing and to do more things,” Olivia says. “I’m reaching that goal.”

Members of the Vanderbilt Thyroid Nodule and Cancer Program include Belcher, Duffus, Lopez, pathologists Vivian Weiss, MD, PhD, and Huiying Wang, MD, radiologists Rekha Krishnasarma, MD, and Christopher Baron, MD, and nuclear medicine specialists Aaron Jessop, MD, and Chirayu Shah, MD. To make an appointment, call 615-322-3301, or request a referral from your pediatrician.