Toward Standardized Management of Indeterminate Thyroid Nodules in Pediatric Patients: A Systematic Review and Call for a Comprehensive Risk Stratification Model

Background/Objective: Thyroid nodules are rare in the pediatric population but carry a higher malignancy risk compared to adults. Evaluation and management of cytologically indeterminate nodules vary considerably between institutions and countries. The aim was to systematically review current evidence on the management of indeterminate thyroid nodules in the pediatric population. Methods: A systematic review of the literature was conducted, focusing on cytological classification systems, surgical strategies, and the use of ancillary tools such as molecular testing. Results: Most studies (42.9%) recommend lobectomy for indeterminate thyroid nodules in children; however, considerable heterogeneity in management strategies was observed among institutions. This variability precluded the possibility of conducting a meta-analysis of surgical outcomes. Additionally, a lack of pediatric-specific risk of malignancy (ROM) data for the British Thyroid Association (BTA) and SIAPEC cytological classification systems was noted. Conclusions: We propose the development of a pediatric-specific, multiparametric risk stratification model that incorporates clinical features, biochemical markers, ultrasound characteristics, cytological classification, and molecular profiling. This comprehensive score could help standardize the management of indeterminate thyroid nodules in children and guide clinical decision-making, ranging from observation to total thyroidectomy. Prospective validation in multicenter pediatric cohorts is essential to confirm its clinical utility.