In reply

We thank Drs Machens and Dralle for their letter concerning our article on the unusual presentation of a papillary thyroid carcinoma during childhood. They raise the issue that bronchoalveolar lavage, being an invasive procedure, should only be used under special circumstances. We entirely agree with this notion.
Contrary to what Machens and Dralle suggest, however, it was never our intention to imply that children with suspected thyroid carcinoma should be subjected to a bronchoalveolar lavage. We would advocate a similar diagnostic work-up as Machens and Dralle suggest, which is in agreement with current practice in pediatric oncology. However, in this patient, the bronchoalveolar lavage was performed at a stage that thyroid carcinoma was not yet considered in the differential diagnosis and before the time that fine needle aspiration biopsy from the neck lymph nodes was done. Thus, at the time point of the bronchoalveolar lavage, the patient presented with multiple small lung nodules and this formed the indication for this procedure to be carried out.
In our opinion, there is no role for bronchoalveolar lavage in the diagnostic work-up of thyroid cancer patients, whether they be children or adults, but we wanted to alert the readership that it is possible to diagnose thyroid carcinoma in bronchoalveolar lavage fluid. We considered this an important learning point for physicians who may be in the same situation.
Considering treatment, this was performed exactly as Machens and Dralle suggest. After en-bloc resection, postoperative radioiodine therapy was performed three times. Directly postoperative, there was only a very small spot of remaining thyroid tissue detectable in the thyroid bed, indicative of a successful operation. There was still massive pulmonary infiltration, but thyroglobulin levels dropped from almost 14,000 ug/L before the operation, to 3,664 ug/L during the third iodine therapy. Clearly, this patient needs stringent follow-up to see how the disease will develop over the next decades.