This guide to thyroid nodules for pediatricians covers risk factors in the young, an important benchmark for potential malignancy in kids, tips on performing a hands-on neck exam, and best practices for workup as well as follow-up. Includes a useful flowchart for patient management, starting from the point of nodule detection.
today, I'm going to be speaking to you guys about pediatric thyroid modules. Um, I think some of my colleagues have already spoken on obstructive sleep apnea and neck masses, and I wanted to sort of draw attention to this area of our practice and sort of present to you some information that I hope you guys will find useful within pediatrics just to begin hiding awareness about these and and sort of, how we work them up. I have no disclosures. So at the end of this session, I hope that you will be able to understand some background information on pediatric thyroid nodules as well as the associated cancer risk. Um, identify those Children who have elevated risk of developing thyroid nodules and and and potentially cancer, and in particular, discussed the work up of pediatric thyroid nodule. Xas are laid out by our sort of like source document that incorporates all the evidence, which is the 2015 80 a pediatric guidelines. Um, there are no more recent ones, but hopefully there should be some in development for 2021 that I will gladly bring to you so pediatric dire. Not just a little. A little background. There's wide variability in the prevalence among Children. Their estimates from 0.55% in this obviously is less than in our adult patients. We think some of this has to do with high resolution ultrasound with increasing prevalence. Were just detecting more of them. Um, there are studies that have been done both in Texas and also actually in the wake of the recent, um nuclear accident in Japan following the tsunami. Andi. These also shows sort of wide variability anything from 0.55%. Um, regardless of the prevalence of thyroid nodule that's greater than one centimeter in a child is more likely to harbor malignancy than nodule in adults. And I'll keep returning to that point and harping on it just to sort of drive at home. So in a child, we estimate that at one centimeter, nodule with certain features that I'll talk about later carries a 22 to 26% chance of malignancy versus a 5% chance of a nodule in an adult. Um, keep in mind that nodules can represent another benign entities, and I listed those here multi Nagy Alert Glider, How she Moto's Thyroid I dissed cysts, Um, particular adenomas Bertholle cells. You guys can see that as well as the sort of wide breath of, um, malignant entities that will get a little bit into. So here again, this is again just hammering home to the same point, which is that within a nodule of any size that the incidents of, ah, cancer in a child Sorry, There, there. 125% present in Children, a supposed present in 10 to 15% of adults. And again here, the risk is 26% of harboring malignancy. Most of these air papillary, thyroid carcinomas and, thankfully, the survivals quite high. And so a lot of our guidelines focused on how to optimize this on but to sort of not miss an opportunity for a cancer that is ultimately survivable in most cases, eso a lot of our data about the prevalence of cancer and these novels comes from a couple of studies. But this is one of the larger studies looking at 125 kids and they looked at, um, Children and adults with modules that are greater than one centimeter who ultimately ended up getting pathologic diagnosis. Eso here again, just the same exact point, which is that those looking at Children adults About 22% of those Children had thyroid cancer, compared to 14% of the adult group. This is for all modules off one centimeter greater. There were certain characteristics that seem to correlate more the number of modules again. This is because papillary cancers can be multifocal, um, and the size of the nodule. We do know that the size the nodule tends toe have significant spent, but other characteristics are also important, and I'll talk a little bit about those, Um, generally just want to talk about pediatric cancer and thyroid cancer in general. So this year, data, which is some of the best data that we have documented doubling in both adult and pediatric thyroid malignancy incidents between 1975 2012. Um, it's difficult. There's a lot of theories as to why this might be the case. Sort of increased survivability of childhood cancers is one theory. We know that there is an increased risk and, uh, kids who undergo treatment for lymphoma and other people who have undergone radiation therapy for their cancers. Um, there's also thought to be some hormonal influences and azi related to obesity that might increase proliferation in the thyroid gland. Um, and I think this is sort of was fascinated to me when I learned this, and I wasn't aware Oops, that it's the second most common tumor and adolescent girls next to Hodgkin's lymphoma. And I think, you know, we think when we see next masses and certainly is an e m T, we, you know, diagnosed a fair amount of lymphoma through exceptional biopsy, certainly lymphoma, leukemia or the first thing that comes to mind. But I think a very important key and one of the takeaways, I hope is that when you see a neck mass, it can also be a lateral implant. It can also actually be a thyroid. Malignancy does, actually in the lymph nodes of the neck. So keeping this on your differential on being aware, um, I'll go a little bit into the types of thyroid cancer, but not to belabor so papillary thyroid cancer, by far the most common in the pediatric group. These air usually multifocal, which again relate to the fact that if they're in the presence of multiple modules, um, tend to carry an increased risk of harboring malignancy. 10 to 25% of these kids will have pulmonary method presentation. This does not necessarily confer poor prognosis of than adults, but the chance of pulmonary test is inversely related to age and increases with tumor size, extra guy, royal extent and burden of neck disease. A rare bone Mets in these kids. Some of this is just pathology slides that we study for our boards, but it shows these sort of typical characteristic orphan Annie eyes in the path that we see. Um, follicular thyroid carcinoma. This is rare accounts for approximately 10% of cases. Generally, these air less aggressive, um, fewer distant Mets, less advanced disease in a lower rate of recurrence. Um, and unlike in popular the mutation profiles not well studied, we can get a little bit into cancer genetics, but mainly for the purposes of discussing with you some syndromes where you might be more inclined to see thyroid cancers. So I think one of the more important questions and and ones that the guidelines seek to answer is, Why do we treat the why do we treat kids? Definitely. Why does there need to be guidelines when you know it's a you know, relatively rare and stable again. Not not among Children. Um, the psychologic. So a couple of the reasons that the guidelines address and then I'll get into and that as I address the guidelines, societal logic risk. So again, if a child does have a nodule, they have a much higher risk of having a carcinoma. Um, there's increased metastases, and these metastases in some subtypes of thyroid carcinoma do carry increased risk. Um, there's a higher complication rate when we operate on them, and some of it has to do with the anatomy. And some of it has to do with the centers in which these air done, Um, the recurrence rate. Uh, because of the lifetime, you know, these kids are going to potentially recur, and you want to minimize the morbidity associated with their initial treatment because it changes, it changes how we manages the recurrences, and it changes the survivability. So, you know a child in your office and sort of this is this is the gateway, right? This is where you first see a child, and you're doing your thyroid examination or even your lateral neck exam. I just wanted to go over a little bit of this sort of ways that I do. And I think, you know, going through both medical school and residency, there were seven different ways. I was taught that behind the neck over the head I just want to go over some general things that I used in my principles. So normally I want to get a very good look at the child. Just, you know, as you were doing your systemic evaluation both in the chin neutral position, which I think is important and looking up, Um, I do look at the neck with swallowing, and that's because a lot of times Children referred to me with that road lost duct cysts or other entities that sort of correlate with swallowing. And I want to figure out, Are they attached the thyroid? Are they at the hyoid bone? I generally start working my way down from the thyroid cartilage. I could feel the apex, the Adam's apple, and then I know Okay, the cry quite cartilage is inferior to that. I feel little nubbin with my thumb, and then just below that is the isthmus. And then I just move my fingers out laterally from there. Once I've located the isthmus, I think this is part of a comprehensive neck exam feeling again. Lymph nodes Because, actually, one of the ways that these Children present is actually with lymphedema. Apathy, not just a nodule that you'll feel within the thyroid gland itself. Um, and this is more for the purposes of some of our teachings. But these these lymph node mets can present in level six. That's the central compartment, so most of the time the lymph nodes that you're feeling, you may think it's a thyroid nodule. It's actually lymph node in the central next. And then if these lateral jugular die gastric chains so you feel a nodule or you don't feel a nodule, or you think that the thyroid appears large. What is the first thing that you should dio? So they're things you could certainly dio before, even referring them to our us, And that is to get some routine thyroid function studies TSH free T 43 and you can even consider calcitonin. But that's only in the family. If there's a family history of Megyeri thyroid carcinoma or the personal P 10 tumor syndrome, and I'll get a little bit into those, um, in hyper functioning modules, you can proceed with an I won 23 skin, meaning If you have TSH that's low and a hyper thyroid nodule or hyper functioning nodule. What you believe to be a hyper function nodule you can order, and I won 23 scan, or at least refer to us order, and I won 23 scan. But if there's no hyperthyroidism, nuclear scans are not recommended as an initial evaluation. This is perhaps the most valuable thing that you can get in the initial evaluation of a thyroid nodule. Eso ultra challenge should be performed prior to surgery, but more importantly, any time is a suspicion of a thyroid nodule. Ultrasound, ultrasound, ultrasound. Andi. I think I wanna also belabor this point, which is that it's not just a thyroid ultrasound but actually an ultrasound of the whole neck. Because again, um, lymph node management is important for us. So if a child has a lateral lymph node, that may change our decision making around whether or not we're going to pursue a central neck dissection. So really, um, ultrasound and in your ordering of the ultrasound. It should read a thyroid ultrasound slash comprehensive neck ultrasound. Um, ultrasound characteristics rather than the size alone, will dictate whether or not we decided to pursue. Or you decide to pursue an F in A so you can obtain the ultrasound prior to performing exceptional lymph node biopsy. Well, that's for us. But what I what? I guess I'm trying to say there is that the FDA will be our guide post. So what is the most common presentation of, ah, thyroid malignancy? Asymptomatic Mass noted by the patient or provider? Some of the ones that are referred to us actually, you can actually see sort of just looking at the child, especially in a child who is not overweight. You can see sort of very prominent nodule. And I've been surprised, you know, a lot of the times he's come to our attention because they're visible to the family. Um, incidental, serendipitous discovery. You know, child came to you just with some, you know, swollen lymph nodes in the setting of the U. R I and you image. You got an ultrasound of the neck and it showed some thyroid modules. The most common presentation, though for a malignancy is a persistent cervical in Fadden apathy that then prompts imaging of the thyroid. So symptomatic enlargement. And then, of course, there seem baseline, high risk patients. Um, not all thyroid matches or novels, and I sort of alluded to this earlier. So you have to think about ectopic diamos, vascular anomalies and Ira glass of Texas. And certainly we're thinking about those when we see them. Are there high risk groups who might benefit from perspective screening for thyroid nodules and thyroid cancer? So do you Do all these kids require? Um, F in A And the answer? Of course I do. All these kids require ultrasound. The answer, of course, if they don't have symptoms and you haven't detected and the answer is no. But there are certain Children who do warrant ultrasound and and they fall into these categories. So Children with iodine deficiency who come from IDA and efficient areas prior radiation exposure. Of course, you know, thankfully, we live in a time where that that that is not as prevalent, but certainly in in a history of prior malignancy. History of answers He didn't thyroid disease. Hashimoto's decker Vince thyroid itis or designated genetic syndromes, and I'll talk a little bit more about thes inheritable. Forms of thyroid cancer account for 5 to 10% of thyroid malignancy, and so sometimes these are in a in A in a permutation of symptoms related to one of these syndromes. And again, previous primary malignancy treated radiation therapy. So Hodgkin's lymphoma, leukemia or primary CNS malignancy. So I wanted to talk a little bit about the tumor predisposition syndrome because these Children are under your care for other reasons on DSO. Certainly these Children are those that would warrant a thyroid ultrasound screening because of a very high rate of malignancy compared to their non affected piers. Um, there are more syndromes than this, but just as the ones that are sort of most common and that you may see in your practice Gardner syndrome, this is a mutation in the adenomas public posts coli jean autism, a dominant inheritance and manifest with G I tract polyps. These Children, um, 16% risk of papillary thyroid cancer, and all of them are in age under 35 years. And is it just sort of a picture of jog your memory? Thes kids also have numerous this plastic potentially this plastic regions along their colon. So they're also seeing G i for routine colonoscopy, um, Cowden syndrome and it's cousin benign. I'm gonna put you this. I'm sorry, but Nyon Riley Ruvalcaba syndrome. But we generally refer to these as the P 10 syndromes. So these air syndromes characterized by Homer Thomas, which are these sort of soft tissue subcutaneous growth, Um, and they carry an increased thyroid cancer risk as well. And these are some of the things you might see. So 7.3% have particular carcinoma, 6.3 papillary and 1% mentally, um, Carney complex. And this is again a little schematic to help you remember the manifestations in this one. So this is abnormalities and skin pigmentation. You see this variegated colors off pigmentation, cardiac mix, Omagh's adrenal cortical disease and Schwann Oma. So, um, if these Children are in your care, certainly they require thyroid ultrasound. Or if you suspect that they've been referred to genetics evaluation, that this is a group of kids who would also won't benefit from thyroid ultrasound. And of course, the men syndromes. I spend less time on this because the legendary Carson was actually form a very, very small group of the pediatric thyroid carcinomas. But certainly, um, those parathyroid hyperplasia hyper calc Mia's mucosal neuroma mark annoyed body habit. It's the men. Two A and two B syndromes are those which are sort of certainly Children who are going to already be usually monitored for for development of thyroid cancer and often will undergo prophylactic, uh, thyroid ectomy. So this is another one that I wanted. Um, another point. I wanted the harp on, which is again. Thyroid modules and differentiated thyroid carcinoma will develop in cancer survivors, and it's not to a negligible degree. So the peak incidents of these carcinomas air about 15 to 25% years after their initial exposure to radiation. Children who survived Hodgkin's lymphoma have a 28 fold increase in their thyroid carcinoma. Risk and radiation therapy at a younger age with doses 20 to 29 gray, which is generally what falls within the therapeutic range, have greatest risk females exposed to neck radiation therapy. Less than 10 have a 17.3% incidence of differentiated thyroid carcinoma at 50 years old. But so I want thio sort of transition away just from background risk of thyroid carcinoma and syndromes associated with it to the guidelines themselves. Because I think they form the basis for a lot of our practice but also I think are really helpful in the primary care setting for having, um, you know, our pediatric colleagues just understand how we think about it. Andi, what are our algorithm is for working them up and also enables you as the pediatrician to sort of start some of this work up and think about where they are and that algorithm. So we talked a little bit about the delineation of high risk groups, and certainly the guidelines laid those out for us. I'll talk now a little bit about the optimal evaluation of a nodule and sort of where it goes into into these guidelines. I will talk less about pre and post op stage because I don't think it's as relevant in the, you know, primary care setting. Um, I do think it's critical to optimize their initial surgical care, and part of that has to do with the last point, which is care in teams of dedicated pediatric sub specialists. Um, I think many of you guys realize this, but we we, um For every child to present for the thyroid model who ultimately undergoes F in A, we present them within our multidisciplinary thyroid conference. And that involves a pediatric endocrinology, um, radiation oncology, oncology on bond. Thyroid surgeons are both general surgery and e m t on bond. In this setting, we we basically discuss, you know, the optimal management, citing guidelines and sort of coordinate their care. Um, and a lot of the evidence supports just better outcomes in the settings because it's not just the initial surgical management, but, of course, monitoring the calcium post operatively, making sure that their vocal cords or mobile both pre and post up. So there's a lot of sort of nuance and coordination. Uh, that goes into sort of caring for these kids. So I just wanted to highlight that, And that's certainly a ah focal point of the guidelines. So this is sort of the meat of it, and I It's so weird cause I can't see you guys faces, but please feel free to put any questions you have in the chat function. But I'm going to just spend a little time on this mind numbing slide, and I apologize for how mind numbing it. Iss Um So I think the first thing is that you have a nodule. This module has been identified either because you see it or because they've got an ultrasound or because they're in one of these cancer groups that you've identified because of co morbidity is that the child has or they had a prior malignancy. So you see a solitary a thyroid nodule detected by imaging or physical examination. The next step on diff there was an interactive future. Ask you guys, but the next step would be getting your thyroid study your thyroid function studies. So is TSH suppressed? Are they hyper thyroid or states? It s h not suppressed. If we suspect Ah, hyper functioning nodule and TSH is suppressed, We're going to refer to nuclear thyroids. Integra fee. Um, and this is something that you can order or you can refer to endocrinology to order. Um, certainly they probably be seeing endocrinology anyway because they have a hyper functioning nodule that's affecting their thyroid function. More often than not, their TSH is not suppressed. The child is you thyroid. They have normal thyroid function or their Hypo Thyroid. Um, and in this case, this brings a survey next part of the work up, which is the F in a under ultrasound guidance. And this is really important. And I want to highlight one of the research that we have, um, that has been so valuable to us, which is basically the same day F in a clinic that I send patients to and that some of our pediatric providers that they were able thio obtain an ultrasound. Um, same day under, uh, sorry. Obtain an f in a same day under ultrasound guidance. And we do this in Children as young as six years old. Um, and sometimes younger. Um, this F in a in turn, guides our initial management, and I'll go into those categories. Um, but this is sort of where we take over their care and sort of the tissue will then guide our future future endeavors. And I can return to the slide after we've discussed. Um, this is a study. Done it. Boston Children just talking about na jewels biopsied in their association with cancer. Ric. So what aspect of a nodule, or concerning enough that they warned F in A In adults, it's a It's a quote unquote simple size cut off, meaning any nodule greater than one cent? I mean, you're gonna biopsy and Children. It's a little less straightforward because it's not size alone that determines the risk of having ah, carcinoma Onda again. We talked about the baseline risk being higher for all sizes. So there were certain features that did correlate, so calcifications were one of them. And I think a skilled ultra stenographer is pretty important and certainly doing it in place that sees a lot of these. The other thing that was important with cystic contents. So, um, the more solid the lesion, the more likely it is to harbor malignancy. So obviously, if you have a higher component that cystic, the less likely it is to harbor malignancy. So the two things that they saw in these 136 modules that correlated were cystic, um, solid component and calcifications as being highly correlated. And then this is sort of a cheat, right? This final cytology correlated. So when you get an F in A, thankfully that does correlate with what it actually is. If the gland is ultimately removed and subject to Pepe Logic analysis. So who should get the F in a, um after they and we talked a little bit about this but high poke OIC masses, That just means that there's more solid here, you see, sort of a lesion sort of pushing out towards thyroid with a regular margins. Calcifications. You can see a lot of calcifications here calcifications along the border here, um, taller rather than wide on transfers view. I never fully understood why this was the case. If this is something to do with the pattern of growth or the vascular charity, I'm not totally certain on that, but that that is something that we know to be correlated, though not to a significant degree. Um, this is just a slide for interest. So basically, there is a form. So this is a child who has a diffuse the sclerosing variants of papillary thyroid carcinoma. You'll see that they don't actually have a single distinctive nodule, but they actually have this diffuse lee infiltrated form of a carcinoma. And I think this just sort of highlights for me the importance of having skilled ultra stenographers and and, uh, radiographic radiologist who could interpret these and help you help us interpret these to know, to spot these sort of secrets. So I wanna go back to key points in the evaluation of pediatric thyroid nodule. So the evaluation and treatment of thyroid knowledge and Children should be the same as adults, with the exceptions that ultrasound characteristics and clinical context should be used rather than size alone to identify nah, jewels that warrant F in a. So let's say you've ordered the F in a, um it comes back, and it's, you know, it's less than a centimeter. But it has these certain concerning characteristics which might include calcifications, which might include a being significantly solid and or regularly margins. Or, if you're not sure, we're happy to see them and sort of make that determination of whether or not they need this F in a all Effendy and Children should be performed under ultrasound guidance. This again is because there are a lot of Children who have cystic lesions, and it's really important to sample the solid portion of lesion. Otherwise, you're subject to, you know, a decent, false negative rate. Um, preoperative f in a hyper functioning nodule is not warranted that again goes back to our thyroid function. Diffuse Lee infiltrated form of popular thyroid carcinoma, current Children and should be considered in a clinically suspicious gland. Clinically suspicious gland is one which is diffuse Lee tender, rubbery, hard and which has those ultrasound characteristics. Um, we don't have to talk about that last point or this, um, so I wanted to just pause and and see before I get into any further detail what questions you guys had, if any, you could write them in the chat function. I can't see you the way I'm accustomed to seeing people on Zoom get a minute or two, right? All right, I will go into the next section here. So the takeaways from this first part and then I will go into a little bit more detail. Um, pediatric thyroid care should be formed in a multi disciplinary coordinated fashion Thyroid nodule zehr uncommon in Children. But when present are more frequently malignant and that I know I've really tried toe hammer that home most thyroid cancers and Children present as a nodule or a lump in the neck. Stephanie of suspicious nonfunctioning modules should be performed under ultrasound guidance prior to surgical resection in most Children in comprehensive neck ultrasound to evaluate cervical nodes should be done. You see this little check should be done in conjunction with thyroid ultrasound when working at solid thyroid modules, Um, consider evaluation for a cancer predisposition syndrome, which can occur in Children with well differentiated thyroid cancer. So generally, all these Children are now seeing geneticists because there's a lot of information that we're learning about those who have, Um, there's a lot of genetics that are known about the adult population, so there's more and more emphasis on getting these Children to see if those mutation profiles match in pediatrics patients to help improve their treatment outcomes. Um, I have a question here. Is there a size limit of, ah, nodule to go forward with F in a um so I think anything over one centimeter for sure. Um, if you get an ultrasound and its sub centimeter and but there are certain concerning features and those are calcifications a regular margins, those were completely solid. Those air reasons to sort of pursue Unefon a or the minimum refer to us, and we can sort of talk to our radiology colleagues and review it in our thyroid conference. The source images. Um, so what do we use? Let's say we get Unefon A. Now, this is This is sort of our guide post, and unfortunately, this actually hasn't been validated in Children. So while in adults, we know that these categories match up fairly well toe what they turn out to be in the operating room after we've removed the thyroid. We don't know as much in the Pedes population, So a non diagnostic or inadequate sample actually carries in 1 to 4% risk of malignancy. This is an adult. I would suspect that a non diagnostic sample and Children would carry a higher risk reason being Is that just the higher baseline prevalence, but nine thankfully carries a 0 to 3% risk of malignancy. A Tippee of undetermined significance or flushed as we call with the religion of undetermined significance carries a 5 to 15% chance, Um, and concerning suspicious for particular neo plasm 15 to 30 and then, of course, suspicious for malignancy 60 to 75 97 99. These these decisions sort of died. Our, um, these these categories do guide our management even though they have not been validated necessarily. And Children eso What do we do in each of these categories? I feel that this may not be as beneficial, but I'll go through it very quickly. And then I'll talk a little bit about the surgical complications, which you guys are more heavily managing but psychopath benign. So all benign lesions should be followed by serial examination ultrasound. So let's say you refer to us. They do have path that's benign. We typically do follow those with ultrasound every 6 to 12 months. And again, the guideline slide, which I can make available to you guys if you'd like, um, provides the basis for that. The purpose for that is to see if there's changes in size or change in the ultrasound appearance. Things that are bad, of course, grow, and they tend to grow even over a gradual setting. And any change in size certainly warrants Unefon a. Especially, you know, rapid growth, Of course. Um, we do consider low back to me in certain cases of benign lesions. So if they're compressive, child's having difficulty swallowing, you could see here. This is a very you know, obviously compressive Lee large nodule that may or may not be benign. Cosmetic concerns. Nacho is greater than four centimeters. So this is something taken from the adult literature on this, and that's because of the high false negative rate and the modular. That's large, but this is not a hard and fast rule. It's something that we consider an offer as an option because it's the only way to definitively determined, um, lesions with significant interval growth. Or, you know, family feels that they do not want to monitor for the duration of this child's life. You know, they want to at least get the low about that. That is something that we do consider and we talk about in our conference. What or not that's in the best interest. Um, indeterminant, Um, this is controversial and Children, and I feel like maybe beyond the scope of this talk, but at a minimum, these Children should undergo another. Another biopsy, um, determination of for completion direct. So let's say we remove the nine nodule, Um, and it comes back with the following pathologic results. So if it's molecular, almost always, they'll have a completion thyroid ectomy. Unless it's this minimally invasive form. Papillary, certainly a completion thyroid ectomy and Majal area completion. Thyroid ectomy Malignant To these kids, um, if they have an F in A that indicates that they have a malignant lesion or suspicious for malignant lesion, um, total thyroid ectomy is has a lot of evidence to support that it's the best in terms of preventing recurrence, lowering morbidity associated with re operation, um, and decreasing persistent recurrent disease. We could talk more about that, but again, I think beyond the scope, this is about our lymph node management. I wanted to really more just focus on some of the complications and highlight the fact that even though we do this routinely, there are risks associated with it, and we don't. We don't take it lightly, especially in the pediatric population, where, um, they have a slightly higher risk of having these issues. So hyper parathyroid is, um, this is primarily due to d vascular ization of the of the hype of the parathyroid glands, intra operatively or their inadvertent removal, um, or stunning and and that has to do with just a temporary loss of blood supply, the way we sort of guard against this? Is that intra operatively where, of course, a identifying the parathyroid. But we're also doing intra operative p th measurements. So at the end of the surgery before we're about to close, we tend to measure, um, the child's up intact parathyroid hormone. And depending on that, if it's critically low, we will find and re implant a gland within another tissue we do. It's called auto implantation. Then the reason for that is because we want to make sure they don't suffer that The blood supply, which may have been compromised while it's sitting in the thyroid gland, is then, um, sort of in tactically reimplanted, either in the sternal plateau, mastered muscle or nearby were able to sort of improve the outcomes. Faras ensuring blood supply to that land, um, total thyroid ectomy has no correlation to increase grand removal. Meaning low back to me versus I Reject me has a lot more to do with the technique in terms of finding and locating aan den. This just talks a little bit about re implantation, and it's a little riskier into a because sometimes the parathyroid are involved. Of course, in the tumor syndrome, we're currently radial nerve injury so preoperative we were always evaluating these kids for, um, you know, they're vocal fold mobility. We have monitoring size five and above. So that means usually from all of our adolescent patients were able to actually monitor their vocal fold function. Um, there is data that suggested does not reduce the rate of recurrent laryngeal nerve injury. But I will tell you that there is not a surgeon I know who doesn't use this technology in the o. R. Um, to sort of help guide us. Um, we can certainly identify the nerve, but it really helps and give us a measure of security when we're able to stimulate it, especially in cases where the cancer is a fairly adherent. This gets into postoperative staging, which I also think is less important for you guys. Um, so I wanted to just return to the guidelines and highlight one or two more things and then open to questions for you and tell you a little bit more about our resources. We have in the way of F in a, um, and multi disciplinary care. So, um, here again, it's the FDA. Under ultrasound guidance, we talked a little bit about these categories. Benign. So I think this is the most commonly the scenario that you might be seeing your clinic. You know, they had one benign ultrasound, doctor, I have thio repeat the ultrasound like my whole life, and the answer is yes. So if if you know, if you follow them for two or three years and they're stable, the truth is you can lengthen this interval. Um, but I think a fair fair to say that even benign nodules and Children should be followed. Um, if there are changes in the nodule or or any suspicious findings on a subsequent ultrasound repeat F in a is both low morbidity and high yield for us, um, inadequate or non diagnostic. This is a difficult decision here because again of the higher baseline rate of malignancy and kids, but generally at a minimum, um, ultrasound in F in a in 3 to 6 months. Um and so yeah, these air. And then we could talk a little bit more about these categories. What questions do you have for me? Actually, don't let me tell you a little bit. Some of the resources we have, but so I just wanted to tell you guys sort of. This is our team. Um, and also just let you know a little bit about how you refer to us. I think e think some of you this may have been shared with you guys before, but we're able to fit at least within e n t for any issue. Not just these thyroid issues were able to see kids within 72 hours now.