Thyroid Cancer: A Comprehensive Guide to Clinical Management

1021 Pages·2016·73.867 MB·English

by  Leonard Wartofsky, Douglas Van Nostrand (eds.)

Leonard Wartofsky
Douglas Van Nostrand
Editors
Thyroid Cancer
A Comprehensive Guide
to Clinical Management
Third Edition
123
Thyroid Cancer

Leonard Wartofsky (cid:129) Douglas Van Nostrand
Editors
Thyroid Cancer
A Comprehensive Guide to Clinical
Management

Third Edition
Editors
Leonard Wartofsky, MD, MACP Douglas Van Nostrand, MD, FACP, FACNM
Department of Medicine Director
MedStar Washington Hospital Center Nuclear Medicine Research
Georgetown University School of Medicine MedStar Research Institute
Washington , DC , USA and Washington Hospital Center
Georgetown University School of Medicine
Washington Hospital Center
Washington , DC , USA
ISBN 978-1-4939-3312-9 ISBN 978-1-4939-3314-3 (eBook)
DOI 10.1007/978-1-4939-3314-3
Library of Congress Control Number: 2016935400
© Springer Science+Business Media New York 1999, 2006, 2016
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To my past and present students, residents, technologists, staff,
colleagues, and patients, who give me purpose.
Douglas Van Nostrand, MD
Dedicated to the memory of my mentor and colleague, Dr. Sidney
H. Ingbar, and to memory of the authors of the Forewords to the fi rst two
editions of this book, Ernest L. Mazzaferri and E. Chester Ridgway,
good friends and colleagues and highly skilled clinicians in the
management of thyroid cancer. And to all of our patients who struggle
under the cloud of an uncertain future with their malignancies.
Leonard Wartofsky, MD

Foreword to Second Edition
Cancer remains a major health problem for our society as we enter the new millennium. In
2002 there were approximately 550,000 deaths in the United States from cancer, which remains
the second leading cause of mortality in our society behind heart disease. Each one accounts
for approximately 25 % of the deaths in the United States on an annual basis. The most com-
mon cancers to appear in 2005 remain prostate, breast, lung and colon which will generate
between 150,000 and 250,000 new cases this year. Likewise, the most common causes of death
from cancer during this same period will be lung, colon, breast and prostate which will cause
approximately 160,000, 50,000, 40,000, and 30,000 deaths, respectively.
In comparison, thyroid cancer is a relatively uncommon cancer. In 2005 we expect approxi-
mately 26,000 new cases and approximately 1500 thyroid cancer deaths will occur in the same
period. Interestingly, thyroid cancer is the eighth most common cancer in women, similar in
prevalence to ovarian cancer and melanoma. Moreover, American Cancer Society statistics
indicate that thyroid cancer is currently the cancer in women with the greatest rate of increased
incidence. Fortunately, for most thyroid cancers the fi ve year survival rate has always been
outstanding and is continuing to slowly improve. In the 1970s, the fi ve year survival rate for
differentiated thyroid cancer was approximately 92 % and in 2005 it is expected to be 97 %.
This is to be compared with 99 %, 88 %, 63 %, and 15 % for the fi ve year survival rates of pros-
tate, breast, colon, and lung, respectively. Thus, thyroid cancer is important, not only because
it is one of the top 10 cancers in women, but because it is amenable to early diagnosis, accurate
and specifi c therapies, and excellent survival rates. Despite these salutary characteristics of
thyroid cancer, it is problematic to both patients and their physicians because of its high, but
nonfatal, recurrence rates that approximate 30 % for differentiated thyroid cancer over a 40
year followup period. Although not resulting in death, these recurrences result in additional
interventions for the patient and the necessity for long-term followup.
In the second edition of Thyroid Cancer , Drs. Leonard Wartofsky, Douglas Van Nostrand,
and their skilled and expert group of contributing authors have presented a wealth of new infor-
mation on the problem of thyroid cancer. One would hope that all new editions to existing
textbooks would bring as much new information to the subject as Dr. Wartofsky has provided
in his new edition. The number of chapters has increased from 52 to 91. The text is again orga-
nized according to thyroid cancer type: papillary carcinoma followed by follicular carcinoma,
medullary thyroid carcinoma, thyroid lymphomas, and anaplastic cancers. However, new
General Considerations sections on Thyroid Cancer and, in particular, on Nuclear Medicine
aspects of thyroid cancer, now introduce the entire text with improved organization and won-
derfully expanded new information on the molecular pathogenesis, oncogenic determinants
and staging of thyroid cancer. This new edition could serve as a textbook for nuclear medicine
physicians, with the importance of nuclear medicine in thyroid cancer emphasized and
expanded with clearly articulated chapters on radiation exposure, whole-body imaging with
iodine isotopes, and on the emergence of important new isotopic imaging techniques such as
PET scanning of thyroid malignancies. More and more we are recognizing that one basic stan-
dard dose for radioiodine therapy may not be appropriate for all patients, and hence the chap-
ters on “dosimetry” during either thyroxine withdrawal or after recombinant human TSH
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provide convincing rationale and arguments for this valuable method for determining maximal
safe radioactive iodine dosing.
The Thyroid Nodule section has been expanded to emphasize the importance of thyroid
ultrasound as a diagnostically critical element for not only the performance of fi ne needle
aspiration biopsy, but also for the diagnosis of thyroid nodules and followup surveillance of
thyroid cancer patients for recurrence in cervical lymph nodes. Clearly, the newer ultrasono-
graphic modalities and their use by endocrinologists have been one of the reasons why more
thyroid nodules are being detected, which in turn, results in the higher number of thyroid can-
cer cases seen today than fi ve and ten years ago. Doubtless, the above-mentioned observed
improvements in remission and cure rates must relate to this earlier diagnosis.
Recombinant human thyrotropin or Thyrogen®, had just been approved for the diagnostic
followup of differentiated thyroid cancer in 1999 at the time of the fi rst edition of this book. In
the intervening fi ve years recombinant thyrotropin has emerged as one of the most important
discoveries leading to improved diagnosis and followup of thyroid cancer. The new text details
and expands our collective experiences in the use of recombinant thyrotropin as well as illumi-
nates the promise for this reagent in remnant ablation treatment of thyroid cancer, and its dra-
matic potential for augmenting thyroglobulin testing and even its incremental value when
utilized prior to PET scanning. Ongoing prospectively designed studies in the United States
and Europe are providing intriguing results for these indications that will likely alter our man-
agement algorithms for diagnosing and treating thyroid cancer in the future.
Finally, the new edition ends with some very insightful predictions about the future for
nuclear medicine as well as genetic and chemotherapeutic approaches to thyroid cancer. I par-
ticularly liked the very informative last new section on resources for patients including low
iodine diets, and the listings of books, multiple Internet web sites, and recommendations for
patients who have recently been treated with radioactive iodine. Drs. Wartofsky, Van Nostrand,
and their colleagues should be very proud of this new edition and its formidable amount of new
information. The physicians treating thyroid cancer will fi nd this text comprehensive and accu-
rate. The fi eld of thyroid cancer will be enriched and our patients will be the benefi ciaries of
this new second edition of Thyroid Cancer .
E. Chester Ridgway, MD, MACP
Foreword to First Edition
As the 20th century draws to a close, it seems like a propitious time to look back upon the
advances we have made in understanding thyroid carcinoma, since our knowledge today will
certainly serve to light the path of discovery in the next century. Gazing at the world through a
small looking glass focused on thyroid carcinoma seems an appropriate way to begin thinking
about the clinical management of this group of diseases. What are the important things that we
have learned in recent years that form the basis of our current clinical knowledge? How can we
best use that information in the care of our patients? Dr. Leonard Wartofsky’s new and sharply
focused text, Thyroid Cancer , promises to answer this hypothetical set of questions in a suc-
cinct and clinically relevant way.
I t sometimes seems that thyroid carcinoma is a neglected orphan among human cancers,
which is at the root of some important issues. Thyroid carcinomas comprise a diverse group of
malignancies ranging from indolent microscopic papillary carcinomas that pose no threat to
survival to anaplastic carcinomas that are the most vicious carcinomas affl icting humans. Yet,
because of its low incidence, there have been no prospective randomized clinical trials of the
treatment of thyroid carcinoma. Furthermore, none are likely to be done, given the prolonged
survival and relatively low mortality rates associated with the majority of these cancers.
Nonetheless, patients often suffer greatly from this disease: many have serious recurrences and
some die from relentlessly progressive and untreatable cancer. This is a disease that knows no
boundaries, striking young and old alike. Unfortunately, management paradigms derive from
retrospective studies, and few new drugs have been added to our therapeutic armamentarium.
One would thus anticipate a deep void in our understanding of these tumors. Despite these
shortcomings, the 20th century has seen major advances in our understanding of their etiology,
pathophysiology, and management. The good news is that the advances have been rapidly
translated into improved outcomes for many patients with thyroid carcinoma. For example,
data from the National Cancer Institute shows that, although the incidence of thyroid carci-
noma has increased signifi cantly—almost 28 %—since the early 1970s in the United States,
cancer-specifi c mortality rates during this same period have dropped signifi cantly—by almost
21 %. In my view this results from the earlier diagnosis of the cancer, which allows the full
impact of effective therapy, and which I believe has dramatically altered the clinical course of
these tumors.
O ne of the dazzling success stories in medicine in the last half of this century is that with
medullary thyroid carcinoma, a truly orphan tumor affl icting relatively few people. First iden-
tifi ed in 1959 as a discrete entity, this tumor was identifi ed before calcitonin was known to
exist and before the mystery of the multiple endocrine neoplasia syndromes had been com-
pletely unraveled. The pieces of the puzzle fell together at lightning speed over a few decades.
The Ret protooncogene mutations recently identifi ed in this tumor will serve as the portal to
our eventual complete understanding of its biology and are already the keystone to its diagno-
sis in members of affl icted kindreds. Now children with this genetic defect can be identifi ed
with molecular testing well before medullary thyroid carcinoma becomes clinically manifest
or is identifi able by any other test, resulting in thyroidectomy that cures the disease. What a
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