Metastatic insular thyroid carcinoma in the pediatric patient Kimberly A. Donnellan, MD a, ⁎ , Jeffery D. Carron, MD a , Steven A. Bigler, MD b , Richard O. Wein, MD c a Department of Otolaryngology and Communicative Sciences, University of Mississippi Medical Center, Jackson, MS, USA b Department of Pathology, University of Mississippi Medical Center, Jackson, MS, USA c Department of Otolaryngology-Head and Neck Surgery, Tufts-New England Medical Center, Boston, MA, USA Received 7 January 2008 Abstract Objectives: The clinical history of a pediatric patient with metastatic insular thyroid carcinoma will be reviewed. Previously reported cases will be examined to allow for comparison of prognosis. Methods: A 4-year-old female with the complaint of chronic cough, progressive shortness of breath, and weight loss for 2 months underwent cervical lymph node biopsy. The biopsy revealed metastatic thyroid carcinoma. Preoperative imaging was suspicious for miliary metastatic spread to the lungs. Results: Surgical intervention included total thyroidectomy with bilateral paratracheal and modified radical neck dissections. The right internal jugular vein and recurrent laryngeal nerve were removed at the time of surgery because of gross tumor invasion. Final pathologic finding revealed papillary thyroid carcinoma with insular variant features and bilateral regional metastasis. Postoperatively, the patient underwent radioactive iodine I 131 treatment. Conclusion: Pediatric metastatic insular thyroid carcinoma is an uncommon form of thyroid malignancy requiring aggressive surgical treatment and adjuvant radioactive iodine. © 2009 Elsevier Inc. All rights reserved. 1. Introduction Pediatric thyroid carcinoma is uncommon, comprising less than 3% of all childhood malignancies and only 10% of all thyroid carcinomas [1,2]. Causative factors include prior ionizing radiation exposure, genetic predisposition, dysfunc- tional iodine metabolism, and other endocrinopathies. It has a 2:1 female-male predominance, yet males are more likely to present with distant metastasis at the time of presentation [3,4]. The incidence of well-differentiated thyroid carcino- mas in childhood is slightly higher (85%–90%) than in adults with a different distribution of the histologic subtypes of papillary thyroid carcinoma including most notably follicular and follicular-solid growth patterns [5]. Although there is an increased incidence of regional and distant metastatic at the time of diagnosis as compared to adults, prognosis tends to be favorable [6]. We present the case of a pediatric patient with a locally aggressive thyroid carcinoma with regional and distant metastasis and review the literature on the topic. 2. Case presentation A 4-year-old African American female presented with a 2- month history of nonproductive cough and cervical adeno- pathy. During this time, she experienced a 5-lb weight loss and dyspnea on exertion. She denied hemoptysis, night sweats, nausea, or vomiting. For her symptoms, she was conservatively treated with oral antibiotics but failed to show improvement. The referring facility reported chest radiograph findings suggestive of miliary tuberculosis (Fig. 1). Other- wise, she had been a healthy child with no other pertinent medical history. Her birth mother was reported to be HIV- positive, and she was in foster care without sick contacts or known exposure to tuberculosis. Two consecutive laboratory examinations at our facility revealed both negative results in Available online at www.sciencedirect.com American Journal of Otolaryngology – Head and Neck Medicine and Surgery 30 (2009) 61 – 64 www.elsevier.com/locate/amjoto ⁎ Corresponding author. Department of Otolaryngology and Commu- nicative Sciences, University of Mississippi Medical Center, 2500 North State St, Jackson, MS 39216-4505, USA. Tel.: +1 601 984 5160; fax: +1 601 984 5085. E-mail address: kdonnellan@ent.umsmed.edu (K.A. Donnellan). 0196-0709/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.amjoto.2008.01.002