Thyroid Cancer: A Comprehensive Guide to Clinical Management

Leonard Wartofsky, MD, past president of the American Thyroid Association, and a panel of world-class clinicians critically review all aspects of thyroid cancer from pathogenesis to prognosis, including management and treatment. Organized for rapid access by busy physicians, the book covers both differentiated tumors (papillary carcinoma and follicular carcinoma) and undifferentiated cancers (anaplastic carcinoma, lymphoma, and medullary carcinoma), as well as miscellaneous and unusual cancers of the thyroid. For each tumor type the authors succinctly discuss the key aspects of their clinical presentation, cytology, diagnosis, nuclear isotope scanning evaluation, imaging by MRI or CT, monitoring, surgery, pathology, post-operative care, and prognosis. Authoritative and evidenced-based, Thyroid Cancer: A Comprehensive Guide to Clinical Management provides in one place everything that physicians treating thyroid cancer patients need to know.

Thyroid cancer, an uncommon disease, accounts for only about 1 percent of new cancers diagnosed each year. In contrast, benign thyroid nodules are common, with 5 to 10 percent of women having one or more palpable lumps in the thyroid. The challenge facing the clinician is therefore to distinguish the small proportion of patients with thyroid cancer from the larger number with benign, nodular enlargement of the gland. Opinions differ widely as to how best (and most cost effectively) to examine patients with thyroid enlargement in whom the diagnosis of thyroid cancer is a possibility. Once the diagnosis of thyroid cancer has been made, the next challenge is to determine the optimal approach to treatment to improve the prognosis in what is usually, in the case of differentiated thyroid cancer, a forgiving and relatively "benign" disease. Because of the rarity of thyroid cancer and its typically good prognosis, there have been no prospective studies of treatment options for the common forms of the disease. This, in turn, means that there is debate about the optimal use of surgery and radioiodine to treat differentiated thyroid tumors as well as about the most appropriate means of follow-up to detect recurrent or residual disease.

These controversies are highlighted in Thyroid Cancer: A Comprehensive Guide to Clinical Management. The book brings together the views of experts (many from the Washington, D.C., area) in a wide range of specialties involved in the treatment of patients with thyroid cancer. The book does not attempt to reach a consensus regarding some of the debated issues, and conflicting opinions are appropriately expressed. Relatively little space is devoted to the assessment of patients with one or more thyroid nodules, although the use of fine-needle aspiration to obtain specimens for cytologic examination clearly emerges as the first step. More coverage of the debate on this topic would have been useful, since a "lump in the thyroid" is such a common clinical problem and is managed in a variety of clinical settings. What is surprising is that suppressive therapy with thyroxine appears in the diagnostic workup in the first figure in the book, even though evidence of its lack of specificity and sensitivity is presented in the text. Clearly, this is a question that will benefit from more detailed cost-benefit analysis.

The remainder of the book is conveniently divided into sections, each devoted to a particular type of thyroid cancer and covering etiology, epidemiology, pathology, treatment, and follow-up. Although this arrangement results in some repetition among sections (and leaves some of them very short), it does allow the reader to focus quickly on a specific cancer during consultations. Particularly helpful is the pragmatic approach adopted by the chief contributor to the discussions of surgery, Orlo Clark, who outlines his own policy for thyroid lobectomy and total thyroidectomy if the diagnosis of thyroid cancer is known or suspected from the results of preoperative cytologic examinations. The sections on pathology are also useful, although unfortunately the excellent illustrations of cytopathological and histopathological specimens are not in color.

Even though thyroid cancer is uncommon, a number of factors have made it a high-profile disease. Not the least of these factors is the public and professional concern about the effect of radiation exposure, particularly from nuclear testing or accidental release, on the risk of thyroid cancer. This topic is well reviewed in Thyroid Cancer: A Comprehensive Guide to Clinical Management, which presents up-to-date information on radiation exposure from the Nevada test site and from the disaster at Chernobyl. Other areas of topical interest are also well covered and include the rapid advances in our understanding of the genetic basis of medullary carcinoma of the thyroid, which have revolutionized our approach to family screening for these sometimes inherited tumors.

We still have much to learn about this group of diseases. Still needed are an understanding of the pathogenesis of the other differentiated thyroid cancers, a more efficient means of securing a preoperative diagnosis from cytologic investigation, optimization of surgical and radionuclide therapy, and better post-treatment follow-up with imaging and tumor markers such as thyroglobulin. This information will accrue with further laboratory investigation of this group of diseases and an understanding of the cell biology, as well as with careful audit of the long-term outcome of patients treated according to defined protocols. This book illustrates the importance of the multidisciplinary approach available in major medical centers for the care of patients with thyroid cancer. The wide-ranging and topical nature of this book will interest those working in many fields of medicine. It should be essential reading for trainees in endocrinology, pathology, imaging, nuclear medicine, surgery, and oncology, as well as for specialists in those fields.

Jayne Franklyn, M.D., Ph.D.
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