Thyroid Cancer: From Emergent Biotechnologies to Clinical Practice Guidelines [ Active ]

PrefaceThyroid cancer evaluation and treatment has enjoyed very little evolution in comparison with other disease management strategies. The standard treatment algorithms for thyroid cancer have varied only in response to major, though infrequent, biotechnological innovations. These resultant algorithm node insertions produced paradigm changes, but there has been little to advance the care of the patient with advanced thyroid cancer—until very recently. Perhaps the reasons for a relative lack of interest and scientific progress are the overwhelming likelihood of benignity among thyroid nodules, the overwhelmingly favorable clinical outcome even if a patient has thyroid cancer, and the overwhelming long time required for clinical follow-up of these cancer patients. Unfortunately, the problem now is that we may be overmanaging low-risk patients, and we have not achieved the clinical responses we would have liked with high-risk patients.

In order to examine emergent biotechnologies, let us first consider historical examples of major innovations for the thyroid cancer patient that shape our current management algorithms and clinical practice guidelines:

•The advent of therapeutic radioiodine in 1942 with radioisotopes approved for use in 1946

 •Improves postoperative treatment

 •Allows radioactive iodine (RAI) scanning and thyroglobulin (TG) measurements to monitor for recurrence

 •Is associated with decreased mortality risk in many patients

•Recent improvements in thyroid surgery technique, minimally invasive procedures, lymph node dissection, and managements of risks

 •Allow primary surgical management of nearly all cases of thyroid cancer and gross cervical recurrence

•Availability of an accurate serum thyroglobulin assay to detect recurrence

•Availability of an accurate serum thyroid-stimulating hormone (TSH) assay to facilitate "suppression therapy" with levothyroxine

•Development of high-resolution thyroid ultrasonography

•Improvements in the fine-needle aspiration technique and cytological analysis

These diagnostic and therapeutic tools account for the majority of procedures we utilize today.

The current age of clinical medicine is witnessing biotechnological innovation at an unprecedented pace. As a result, the recent popularization of clinical practice guidelines (CPG) as a tool to assist clinical decision making has been unable to keep up with the rate of scientific discovery. Many problems have plagued the development and implementation of CPG; most notably, these include disagreement regarding evidence-based medicine methodologies, lack of transparency in the development process, and difficulty evaluating the utility of CPG in order to improve them with future iterations. The purpose of this book is to surf the wave of medical innovation and attempt to predict what CPG will look like based on emergent biotechnologies in the field of thyroid cancer. This premise, that a forward-looking approach to thyroid cancer will improve patient care today, was spawned mainly by two of our collaborative activities: first, the biennial University of Pisa Multidisciplinary Conference on Advances in Management of Malignancies (presided by A.C.), and second, our longstanding interest in the use of molecular markers, namely, galectin-3, in histological specimens from large-needle aspiration biopsies of the thyroid gland.

Our task will be approached in the following manner. First, basic principles of systems biology, molecular and translational medicine, CPG development, and risk stratification forthyroid cancer will lay the foundation to understand subsequent chapters. Thyroid cancer clinical cases will also be presented to instantiate how current CPG contain knowledge gaps and produce uncertainty and impair decision making. Then, a detailed survey of technologically advanced diagnostic procedures and therapeutic interventions will be presented. Each of these chapters will be structured by presenting the current state of the art for each technology, followed by emergent technologies that are not yet approved, though currently under investigation and considered to be very promising. Finally, by critically analyzing the findings of each of the chapters, a futuristic CPG will be constructed based on the potential impact of these emergent biotechnologies. Thus, a synthesis of ideas by prominent world experts in the field of thyroid cancer research and clinical practice will provide an enlightening glimpse into the near future.

We thank each of the authors involved in the production of this book, as their leadership in the care of patients with thyroid cancer has set the stage for dramatic change in clinical outcomes. We also thank Randy Brehm and Jill Jurgenson of Taylor & Francis for their tremendous assistance in the preparation and publication of this book, which has truly been a global project, with contributors representing multiple nations and continents. We hope that readers of this book will avail themselves of the authors' expert opinions and innovative thinking in the care of their patients.