By Martin Schlumberger,Institut Gustave Roussy, Villejuif, France. OH Clark, S. Noguchi. Thyroid Cancer; Diagnosis and Treatment. published by Quality Medical Publishing, Inc., St. Louis, Missouri, USA Despite the huge number of meetings, discussions, studies and publications on thyroid cancers, many controversies persist. They are mainly due to the relative rarity of the disease, to the excellent prognosis of most tumors, to the absence of controlled trials and to the frequent absence of significant changes in their outcome resulting from modifications of any treatment and/or follow-up protocol. In this context, two surgeons who are among the leading experts in the field, present the state of the art in the management of thyroid cancer patients. Many aspects remain controversial, and one of the main interests of the book is that the authors provide a well-documented rationale for the various approaches used in their respective Institutions. The book (447 pages) is divided into 19 chapters and 5 parts. It is a combination of clinical and basic data, most of which were acquired in San Francisco and at the Noguchi Clinic, with management strategies and more general ideas that can be applied to other tumor types. The first part of the book is a general overview of thyroid cancer based on the large series of patients treated at the Noguchi Clinic. This is followed by a comprehensive review of the evaluation of thyroid nodules, cytology and histopathology. The description of thyroid cancer according to the extent of disease is more original and particularly relevant; this is the case with the prognostic significance of extra-capsular invasion of lymph nodes and its impact on regional recurrences whatever the initial tumor size. In addition, the controversial prognostic significance of Graves' disease is extensively discussed and data from the Noguchi Clinic strongly argue in favor of a protective effect of this disease on the outcome of thyroid carcinoma. The second part of the book deals with imaging tools and technology. In these chapters, the use of 131-I for total body scintigraphy and for treatment is described as well as the value of ultrasonography, CT scan and MRI. Unfortunately, no follow-up protocol is provided and the respective role of each of these techniques is difficult to appraise. Furthermore, the value of thyroglobulin measurement, the PET scan, and of recombinant human TSH is only partly reported, despite the large number of recent data. In contrast, the authors insist on the role of thallium and sestamibi, despite decreasing interest in most centers. The third part is a detailed description of surgical approaches, including total and partial thyroidectomy, and an extensive rationale is provided for each approach. S. Noguchi then explains surgical options, for both the thyroid gland and lymph nodes, based on data obtained in his clinic. In the fourth part, the management of medullary thyroid carcinoma is presented by JF Moley, an authority in the field. He demonstrates the central role of surgery in the treatment of this disease, including in patients with local and regional recurrences and in those with persistently elevated calcitonin levels; in these patients liver metastases should be excluded before surgery by venous catheterisation for calcitonin measurement and laparoscopy. Then, locally recurrent thyroid carcinoma is discussed, including risk factors and treatment. The rare but difficult case of unresectable thyroid carcinomas is dealt with indicating original strategies combining percutaneous ethanol injection, intraoperative radiotherapy and arterial infusion therapy; remarkable results have been obtained on limited series of patients. Unfortunately, there are very few data on follow-up and on the role of thyroglobulin in patients with papillary and follicular thyroid carcinoma, and even the respective significance of total body scanning with 131-I and of serum thyroglobulin measurement is not discussed. The fifth part presents advances in molecular biology. In the first chapter OH Clark explains with numerous examples how important it is for a surgeon to be educated and trained in the basic sciences and how much this may improve the treatment of thyroid cancer patients. Indeed, these ideas should not be restricted to the thyroid field. Then data on oncogenes and tumor suppressive genes in thyroid carcinoma are extensively described, as well as the role of RET in medullary thyroid carcinoma. Two of his special fields of interest, angiogenesis and TSH suppressive therapy, are then discussed. Studies on angiogenesis may open new fields of research and treatment. TSH suppressive therapy is clearly useful in patients with disease, and OH Clark presents very significant data. However, in patients with no evidence of disease, as demonstrated by reliable modern techniques, it is difficult to think let alone show that suppressive treatment may be beneficial. Such patients represent at least 80% of all patients treated for papillary or follicular carcinoma and unfortunately this point is not addressed. Finally, progress in the field of thyroid cancer is rapid and this may explain why there is no mention of the iodide symporter, despite the fact that it is currently at the center of most scientific discussions concerning papillary and follicular thyroid carcinoma. In conclusion, I strongly recommend the reading of this excellent book to all persons that are involved in the field of thyroid cancer, including surgeons but also thyroidologists, endocrinologists, nuclear medicine specialists, pathologists and even basic researchers. OH Clark, S. Noguchi. Thyroid Cancer; Diagnosis and Treatment. published by Quality Medical Publishing, Inc., St. Louis, Missouri, USA |
