Patients with distant metastases have a long-term survival that depends, in addition to other factors, on age and the degree of radioiodine uptake in distant metastases.

The overall prognosis in pediatric differentiated thyroid carcinoma (DTC) is excellent. Recurrent disease is frequent, however, and requires additional treatment. We analyzed the probability of recurrence, prognostic factors, treatment, and outcome of juvenile DTC. Methods: Fifty-one DTC patients (32 girls and 19 boys; ≤20 y old; mean age, 16.5 y) were treated with 131 I (radioiodine, or radioactive iodine [RAI]); the median follow-up was 10 y. Patients underwent different initial treatments: 46 patients received total thyroidectomy and RAI, 3 patients received total thyroidectomy, and 3 patients received subtotal thyroidectomy. The probability of recurrence and prognostic factors were tested with the Kaplan-Meier method. Results: Initially, 36 of 51 patients achieved complete remission, 14 of 51 achieved partial remission, and 1 of 51 had progressive disease. By the follow-up, 11 of 51 patients (21.6%) had developed recurrent disease; the median appearance time was 4 y (range, 1-15 y). The probabilities of recurrence were 16.7% at 5 y, 22.3% at 10 y, and 33.3% at 15 and 23 y after the initial treatments. Factors that were strongly predictive of recurrence were age (P 5 0.001), initial treatment (P 5 0.0001), and tumor multifocality (P 5 0.011). Sex, nodal metastases at presentation, distal metastases at presentation, histologic type of the tumor, T stage, and clinical stage had no influence on relapse (P 5 0.180, P 5 0.786, P 5 0.796, P 5 0.944, P 5 0.352, and P 5 0.729, respectively). Patients with recurrent disease, partial remission, and progressive disease were retreated, with either surgery or surgery and RAI, receiving cumulative activities of up to 40 GBq. The overall outcome in our patients was excellent: 90.2% complete remission, 3.92% partial remission, 1.96% stable disease, 1.96% disease-related death, and 1.96% another cause of death. Conclusion: Younger age at diagnosis, less radical primary surgery without subsequent RAI, and tumor multifocality are factors that are strongly prognostic for recurrence. For reducing the rate of relapse and improving surveillance for recurrent disease, total thyroidectomy followed by RAI appears to be the most beneficial initial treatment for patients with juvenile DTC. The use of RAI seems to be safe, with no adverse effects on subsequent fertility and pregnancy or secondary malignancy.

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Recently the American Thyroid Association (ATA) released the third version of one of the most cited differentiated thyroid cancer (DTC) guidelines under the title B2015 American Thyroid Association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer^ [1]. Compared to the earlier versions [2,3], these guidelines are a major departure, as the volume of the text, the number of recommendations and the number of references have increased considerably.We fully understand the effort involving many hours of work that must have been required for the rigorous screening of the literature to produce the evidence tables and the eventual definitions of the recommendations. The document consists of roughly 73,000 words which make up the 101 recommendations and the explanatory text and comments. In the current ATA guidelines, most of the text appears eminently sensible and represents a significant advance from previous DTC-related guidelines published by the ATA as well as other societies, including the 2008 European Association of Nuclear Medicine (EANM) guidelines on 131 I therapy of DTC [4][5][6][7]. For instance, we welcome the clear division of indications for initial 131 I treatment of DTC patients after total thyroidectomy into ablation, adjuvant therapy and therapy. Furthermore, this change in terminology which we strongly support much more clearly delineates the role of 131 I in the care of patients with DTC in other disciplines, especially medical oncology. Considering all the factors that have to be weighed in formulating recommendations this is a huge dedicated effort that has come to fruition.