Management of Thyroid Cancer and Related Nodular Disease
http://www.100md.com
《新英格兰医药杂志》
The prognosis for patients with differentiated thyroid cancer is generally very good, with a survival rate of more than 90 percent. However, approximately one third of patients with this diagnosis eventually have a recurrence of their disease. Because of the good prognosis, the indolent nature of this disease, and the behavior of the recurrences, treatment plans for thyroid cancer are derived almost entirely from large retrospective case series and consensus views of good practice. This reliance on the best available (but imperfect) evidence probably will not change, especially because a prospective trial of the role of radioiodine ablation of thyroid tissue remaining after "total" thyroidectomy in improving survival would probably require recruitment of thousands of patients and follow-up for 20 years or more. This type of trial is clearly unachievable, because only 25,000 new cases of thyroid cancer are diagnosed each year in the United States. However, the incidence of thyroid cancer is growing faster than the incidence of any other type of cancer in women in the United States. This growing incidence, which probably reflects earlier diagnosis, has resulted in a growing prevalence of patients with this diagnosis in the general population.
Our understanding of the molecular pathogenesis of thyroid cancer has improved, especially with respect to the relatively small but especially challenging proportion of cases that are inherited or are part of a cancer syndrome. The next objective, which is just starting to be met, is to apply this basic science to diagnosis (especially by refining the diagnostic specificity of thyroid cytology) and to tailor therapies such as radioiodine ablation and intensive follow-up to individual tumor phenotypes. Both the ease and the complexity of management decisions are enhanced by the availability of highly sensitive tumor markers in blood; these include thyroglobulin for papillary and follicular thyroid cancers and calcitonin for medullary thyroid cancer. Both measurements have important and complex technical limitations, and both can identify early recurrences of tumors or residual disease of unclear clinical significance.
New imaging techniques, including octreotide scanning and positron-emission tomography with fluorodeoxyglucose F 18, have an emerging role in both staging and follow-up of thyroid tumors. The cost-effective application of these techniques in the context of parallel technical advances in computed tomography (CT) and magnetic resonance imaging (MRI) is a challenge to all who are involved in the long-term follow-up of patients with thyroid cancer. A further new development is the availability of recombinant human thyroid-stimulating hormone (TSH) and its emerging, but hotly debated, role as an adjunct in radioiodine imaging and treatment of thyroid tumors, as compared with the usual reliance on endogenous TSH secretion induced by thyroid-hormone withdrawal. This new agent, which may be especially useful in stimulating levels of thyroglobulin in the blood, may make more invasive techniques in routine follow-up unnecessary.
All of these advances make the publication of the second edition of Thyroid Cancer timely. The first edition was published in 2000, and developments since then are reflected in the new edition. In particular, Wartofsky has recruited Van Nostrand as his coeditor to facilitate a comprehensive discussion of isotope-scanning procedures and radioiodine ablation, as well as updated sections on ultrasonography, CT, MRI, and other methods of imaging. The second edition retains the format of the first, separating content according to the types of thyroid cancer, with sections on diagnosis, treatment, prognosis, and follow-up for each type. Especially useful are the chapters on "special" situations; these include diagnoses in children and during pregnancy and the treatment of patients with extensive metastases. This format allows the reader to "dip into" the text to address a particular clinical problem with ease. This book includes almost twice as many chapters and contributors as the first edition. I especially enjoyed the addition of patient-focused content, including lists of useful books and Web sites and practical advice regarding radioiodine treatment (although all of this information is focused on North American practice and regulation). Wartofsky and Van Nostrand have built on what was already an important publication to produce an excellent, up-to-date book that is of practical value across all specialties involved in the management of thyroid cancer. It also provides a scholarly overview of the evidence base.
The term "evidence base" is also much heralded by I. Ross McDougall in Management of Thyroid Cancer and Related Nodular Disease. This book, which was written mostly by McDougall, also includes a chapter on pathology written with his colleague, Gerald Berry. McDougall makes no apology for highlighting his own contributions to the field or for presenting his personal views. He states his aspiration to make the book "easy to read, clinically valuable, authoritative, and enjoyable." I believe that he has achieved these aims and has been successful in presenting "all sides of controversial issues." In contrast to the book edited by Wartofsky and Van Nostrand, the layout of McDougall's book makes it less easy to "dip into" to find the answer to a particular clinical question; for example, a single chapter containing 120 pages covers the whole topic of differentiated thyroid cancer. However, I enjoyed the inclusion in the first chapter of a lesson on statistics, as well as the practical illustrations of mathematical and statistical solutions that are placed into context in the other chapters. In making decisions about the management of a disease such as thyroid cancer, we should recognize our personal preferences and biases when interpreting and using less than perfect evidence. I found it refreshing that McDougall does this with such candor, presenting his own views and those of other authorities with an honest approach while also presenting disagreements and areas of uncertainty within the field. I highly recommend this book to clinicians and patients alike.
Jayne Franklyn, M.D., Ph.D.
Institute of Biomedical Research, University of Birmingham
Birmingham B15 2TH, United Kingdom(By I. Ross McDougall, wit)
Our understanding of the molecular pathogenesis of thyroid cancer has improved, especially with respect to the relatively small but especially challenging proportion of cases that are inherited or are part of a cancer syndrome. The next objective, which is just starting to be met, is to apply this basic science to diagnosis (especially by refining the diagnostic specificity of thyroid cytology) and to tailor therapies such as radioiodine ablation and intensive follow-up to individual tumor phenotypes. Both the ease and the complexity of management decisions are enhanced by the availability of highly sensitive tumor markers in blood; these include thyroglobulin for papillary and follicular thyroid cancers and calcitonin for medullary thyroid cancer. Both measurements have important and complex technical limitations, and both can identify early recurrences of tumors or residual disease of unclear clinical significance.
New imaging techniques, including octreotide scanning and positron-emission tomography with fluorodeoxyglucose F 18, have an emerging role in both staging and follow-up of thyroid tumors. The cost-effective application of these techniques in the context of parallel technical advances in computed tomography (CT) and magnetic resonance imaging (MRI) is a challenge to all who are involved in the long-term follow-up of patients with thyroid cancer. A further new development is the availability of recombinant human thyroid-stimulating hormone (TSH) and its emerging, but hotly debated, role as an adjunct in radioiodine imaging and treatment of thyroid tumors, as compared with the usual reliance on endogenous TSH secretion induced by thyroid-hormone withdrawal. This new agent, which may be especially useful in stimulating levels of thyroglobulin in the blood, may make more invasive techniques in routine follow-up unnecessary.
All of these advances make the publication of the second edition of Thyroid Cancer timely. The first edition was published in 2000, and developments since then are reflected in the new edition. In particular, Wartofsky has recruited Van Nostrand as his coeditor to facilitate a comprehensive discussion of isotope-scanning procedures and radioiodine ablation, as well as updated sections on ultrasonography, CT, MRI, and other methods of imaging. The second edition retains the format of the first, separating content according to the types of thyroid cancer, with sections on diagnosis, treatment, prognosis, and follow-up for each type. Especially useful are the chapters on "special" situations; these include diagnoses in children and during pregnancy and the treatment of patients with extensive metastases. This format allows the reader to "dip into" the text to address a particular clinical problem with ease. This book includes almost twice as many chapters and contributors as the first edition. I especially enjoyed the addition of patient-focused content, including lists of useful books and Web sites and practical advice regarding radioiodine treatment (although all of this information is focused on North American practice and regulation). Wartofsky and Van Nostrand have built on what was already an important publication to produce an excellent, up-to-date book that is of practical value across all specialties involved in the management of thyroid cancer. It also provides a scholarly overview of the evidence base.
The term "evidence base" is also much heralded by I. Ross McDougall in Management of Thyroid Cancer and Related Nodular Disease. This book, which was written mostly by McDougall, also includes a chapter on pathology written with his colleague, Gerald Berry. McDougall makes no apology for highlighting his own contributions to the field or for presenting his personal views. He states his aspiration to make the book "easy to read, clinically valuable, authoritative, and enjoyable." I believe that he has achieved these aims and has been successful in presenting "all sides of controversial issues." In contrast to the book edited by Wartofsky and Van Nostrand, the layout of McDougall's book makes it less easy to "dip into" to find the answer to a particular clinical question; for example, a single chapter containing 120 pages covers the whole topic of differentiated thyroid cancer. However, I enjoyed the inclusion in the first chapter of a lesson on statistics, as well as the practical illustrations of mathematical and statistical solutions that are placed into context in the other chapters. In making decisions about the management of a disease such as thyroid cancer, we should recognize our personal preferences and biases when interpreting and using less than perfect evidence. I found it refreshing that McDougall does this with such candor, presenting his own views and those of other authorities with an honest approach while also presenting disagreements and areas of uncertainty within the field. I highly recommend this book to clinicians and patients alike.
Jayne Franklyn, M.D., Ph.D.
Institute of Biomedical Research, University of Birmingham
Birmingham B15 2TH, United Kingdom(By I. Ross McDougall, wit)