Clinical Oncology RSS feed: Current Issue. Clinical Oncology is published by Elsevier on behalf of The Royal College of Radiologists. To view other college publications, click here Clinical Oncology is an International cancer journal covering all aspects of the clinical management of cancer patients, reflecting a multidisciplinary approach to therapy. Papers, editorials and reviews are published on all types of malignant disease embracing, pathology, diagnosis and treatment, including radiotherapy, chemotherapy, surgery, combined modality treatment and palliative care. Research and review papers covering epidemiology, radiobiology, radiation physics, tumour biology, and immunology are also published, together with letters to the editor, case reports and book reviews. Clinical Oncology is for all those with an active interest in the treatment of cancer. http://www.clinicaloncologyonline.net/?rss=yesElsevier Inc.en © 2010 The Royal College of Radiologists. Published by Elsevier Inc. All rights reserved. Clinical Oncology0936-6555226August 2010 © 2010 The Royal College of Radiologists. Published by Elsevier Inc. All rights reserved. healthpermissions@elsevier.comhttp://www.clinicaloncologyonline.net/article/PIIS0936655510001603/abstract?rss=yesThyroid cancer is rare. However, the incidence is increasing worldwide, and most patients are cured and will have a normal life expectancy. It is therefore vital that this low mortality is complemented by minimal morbidity from treatment. The corollary is that initial management should be optimal and undertaken by well-informed clinicians, for whom this special issue will prove invaluable. It has been written by a small team of experts of international repute, skilfully brought together by Ujjal Mallick. Parathyroid cancer is excessively rare and a particularly welcome inclusion.ForewordClive Harmer10.1016/j.clon.2010.04.002Clinical Oncology 22, 6 (2010)2010-05-17Clinical Oncology2010-05-17226S0936-6555(10)X0006-1393393http://www.clinicaloncologyonline.net/article/PIIS0936655510001913/abstract?rss=yes‘Where is the wisdom we have lost in knowledgewhere is the knowledge we have lost in information?’TS Eliot The treatment of thyroid cancer remains controversial because of its relative rarity, long natural history with generally good outcome, and lack of randomised trials. However, research in thyroid cancer has been progressing rapidly in recent years. This necessitated a revision of the American Thyroid Association’s guidelines , and also publication of special issues such as this which expands on the conceptual basis of some selected aspects of management of this cancer.Thyroid Cancer: Evidence-based Optimal Management and the Search for a CureU.K. Mallick10.1016/j.clon.2010.05.019Clinical Oncology 22, 6 (2010)2010-06-11Clinical Oncology2010-06-11226S0936-6555(10)X0006-1394394http://www.clinicaloncologyonline.net/article/PIIS0936655510001743/abstract?rss=yesAbstract: Thyroid cancer comprises a broad spectrum of diseases with variable prognoses. Although most patients with this disease have excellent overall survival, there are some who do not fare so well. With the worldwide increase in incidence, the need to identify which tumours pose the greatest risk to patients is more acute than ever. This paper will discuss this rising trend in incidence with an analysis of the possible reasons for the increase. In addition, the paper will explore the factors that portend a worse prognosis for the individual patient. Finally, the limitations of the current staging systems will be discussed, with particular emphasis on why they are not as informative in the management of patients with thyroid cancer.Thyroid Cancer Epidemiology and Prognostic VariablesJ.A. Sipos, E.L. Mazzaferri10.1016/j.clon.2010.05.004Clinical Oncology 22, 6 (2010)2010-06-04Clinical Oncology2010-06-04226S0936-6555(10)X0006-1395404http://www.clinicaloncologyonline.net/article/PIIS093665551000097X/abstract?rss=yesAbstract: The incidence of well-differentiated thyroid cancer has seen a worldwide increase in the last three decades. Whether this is due to a ‘true increase’ in incidence or simply increased detection of otherwise subclinical disease remains unclear. The treatment of thyroid cancer revolves around appropriate surgical intervention, minimising complications and the use of adjuvant therapy in select circumstances. Prognostic features and risk stratification are crucial in determining the appropriate treatment. There continues to be considerable debate in several aspects of management in these patients. Level 1 evidence is lacking, and there are limited prospective data to direct therapy, hence limiting decision-making to retrospective analyses, treatment guidelines based on expert opinion and personal philosophies. This overview focuses on the major issues associated with the investigation of thyroid nodules and the extent of surgery. As overall survival in well-differentiated thyroid cancer exceeds 95%, it is important to reduce over-treating the large majority of patients, and focus limited resources on high-risk patients who require aggressive treatment and closer attention. The onus is on the physician to avoid treatment-related complications from thyroid surgery and to offer the most efficient and cost-effective therapeutic option.Management of Thyroid Nodules and Surgery for Differentiated Thyroid CancerN.G. Iyer, A.R. Shaha10.1016/j.clon.2010.03.009Clinical Oncology 22, 6 (2010)2010-04-09Clinical Oncology2010-04-09226S0936-6555(10)X0006-1405412http://www.clinicaloncologyonline.net/article/PIIS0936655510001640/abstract?rss=yes‘I keep six honest serving men(They taught me all I knew)Their names are what, and why, and whenAnd how, and where, and who.’ Kipling wrote this poem to accompany ‘The Elephant’s Child’ in 1902 , and his formula of ‘what, why, when, how, where and who’ provided the basic structure of reporting style in the early 20th Century . Asher subsequently stated that ‘most scientific enquiry is based on these six monosyllables’ , so–‘Who should treat thyroid cancer?’.Who Should Treat Thyroid Cancer? A UK Surgical PerspectiveN. Sharma, K. Boelaert, J.C. Watkinson10.1016/j.clon.2010.04.006Clinical Oncology 22, 6 (2010)2010-06-14Clinical Oncology2010-06-14226S0936-6555(10)X0006-1413418http://www.clinicaloncologyonline.net/article/PIIS0936655510001639/abstract?rss=yesAbstract: Risk assessment is the cornerstone of contemporary management of thyroid cancer. Following thyroid surgery, an initial risk assessment of recurrence and disease-specific mortality is made using important intra-operative findings, histologic characteristics of the tumor, molecular profile of the tumor, post-operative serum thyroglobulin and any available cross-sectional imaging studies. This initial risk assessment is used to guide recommendations regarding the need for remnant ablation, external beam irradiation, systemic therapy, degree of TSH suppression, and follow-up disease detection strategy over the first 2 years after initial therapy.While this initial risk stratification provides valuable information, it is a static representation of the patient in the first few weeks post-operatively that does not change over time. Depending on how the patient responds to our initial therapies, the risk of recurrence and death may change significantly during follow-up. In order to account for differences in response to therapy in individual patients and to incorporate the impact of treatment on our initial risk estimates, we recommend a re-stratification of risk at the 2-year point of follow-up. This re-stratification provides an updated risk estimate that can be used to guide ongoing management recommendations including the frequency and intensity of follow-up, degree of ongoing TSH suppression, and need for additional therapies.Ongoing management recommendations must be tailored to realistic, evolving risk estimates that are actively updated during follow-up. By individualizing therapy on the basis of initial and ongoing risk assessments, we can maximize the beneficial effects of aggressive therapy in patients with thyroid cancer who are likely to benefit from it, while minimizing potential complications and side effects in low-risk patients destined to have a full healthy and productive life after minimal therapeutic intervention.Contemporary Post Surgical Management of Differentiated Thyroid CarcinomaH. Tala, R.M. Tuttle10.1016/j.clon.2010.04.005Clinical Oncology 22, 6 (2010)2010-06-02Clinical Oncology2010-06-02226S0936-6555(10)X0006-1419429http://www.clinicaloncologyonline.net/article/PIIS0936655510001731/abstract?rss=yesThe first reports of radionuclide therapy for thyroid disease used 130I, but 131I rapidly became the favoured radionuclide with beta- and gamma-ray emissions and a half-life suitable for therapy . Although thyrotoxicosis was the initial indication for 131I therapy, reports on its use in the treatment of differentiated thyroid cancer (DTC) soon followed.Radioiodine Therapy in Differentiated Thyroid Cancer: a Nuclear Medicine PerspectiveS.E.M. Clarke10.1016/j.clon.2010.05.003Clinical Oncology 22, 6 (2010)2010-06-01Clinical Oncology2010-06-01226S0936-6555(10)X0006-1430437http://www.clinicaloncologyonline.net/article/PIIS0936655510001755/abstract?rss=yesAbstract: Background: Differentiated thyroid carcinoma (DTC) with rising thyroglobulin (Tg) level and negative radioiodine whole body scan results has been observed in follow-up studies. The management of this condition remains controversial. Most studies support blind 131I treatment while others oppose this approach.Aims: To assess the effects of 131I therapy for DTC with rising Tg and negative scan results.Selection criteria: Randomised controlled clinical trials, prospective controlled clinical trials and any trials using 131I treatment or no treatment for Tg-positive and radioiodine-negative disease were included in this review.Results: Due to the lack of any suitable randomised or prospective controlled trials in this area, it was not possible to undertake a meta-analysis. Eighteen trials were retrieved for further overall assessment. Of 438 patients from 16 studies who were treated empirically with 131I for Tg-positive and radioiodine-negative disease, 267 (62%) displayed pathological uptake in the thyroid bed, lungs, bone, mediastinum and lymph nodes. In studies in which data were available for serum Tg levels during thyroid-stimulating hormone (TSH) suppression therapy or TSH withdrawal, 188 of 337 patients (56%) showed a decrease in serum Tg. Of 242 patients from five studies who received no specific treatment for Tg-positive and radioiodine-negative disease, 106 (44%) showed spontaneous normalisation and a significant decrease in serum Tg.Conclusions: The currently available evidence is insufficient for reliable assessment of the potential of 131I treatment for DTC with elevated Tg and negative scan results. A decrease in serum Tg in 62% of patients with DTC with elevated Tg and negative scan results suggests that 131I therapy has a therapeutic effect for more than one-half of patients when the Tg level is considered an index of tumour burden. However, considering that 44% of patients with DTC with elevated Tg and negative scan results showed spontaneous normalisation and a significant reduction in serum Tg without any specific treatment, 131I therapy should be individualised according to clinical characteristics. Other diagnostic techniques are strongly recommended for patients with Tg-positive and radioiodine-negative disease. If these diagnostic results are positive, treatment options such as surgery, external radiotherapy and tumour embolisation should be considered. If diagnostic results are negative, one course of 131I treatment may be considered in high-risk patients with serum Tg >10ng/mL after TSH withdrawal or >5ng/mL under recombinant human TSH stimulation. No further 131I therapy is indicated for patients with a negative post-therapy radioiodine scan.Management of Differentiated Thyroid Cancer with Rising Thyroglobulin and Negative Diagnostic Radioiodine Whole Body ScanM. Chao10.1016/j.clon.2010.05.005Clinical Oncology 22, 6 (2010)2010-06-21Clinical Oncology2010-06-21226S0936-6555(10)X0006-1438447http://www.clinicaloncologyonline.net/article/PIIS0936655510001664/abstract?rss=yesAbstract: The recent availability of molecular targeted therapies leads to reconsideration of the treatment strategy in patients with distant metastases from differentiated thyroid carcinoma who are resistant to radioiodine therapy, and in patients with metastatic medullary thyroid carcinoma. In patients with progressive disease, treatment with kinase inhibitors should be offered, preferably in the context of a prospective trial.Molecular Targeted Therapies for Patients with Refractory Thyroid CancerC. Chougnet, M. Brassard, S. Leboulleux, E. Baudin, M. Schlumberger10.1016/j.clon.2010.04.008Clinical Oncology 22, 6 (2010)2010-05-31Clinical Oncology2010-05-31226S0936-6555(10)X0006-1448455http://www.clinicaloncologyonline.net/article/PIIS093665551000124X/abstract?rss=yesAbstract: The management of differentiated thyroid cancer involves a combination of surgery, thyroid stimulating hormone suppression and radioactive iodine for most patients. In a small subset of patients, external beam radiotherapy is also used. However, its role remains controversial and there are no randomised controlled trials to guide practice. In this overview we review the evidence from the published literature for the use of external beam radiotherapy in the management of differentiated thyroid cancer and discuss the indications for which it is most commonly used. The technique of external beam radiotherapy, including the emerging role for intensity-modulated radiotherapy, will also be discussed.External Beam Radiotherapy for Differentiated Thyroid CancerC. Powell, K. Newbold, K.J. Harrington, S.A. Bhide, C.M. Nutting10.1016/j.clon.2010.03.012Clinical Oncology 22, 6 (2010)2010-04-28Clinical Oncology2010-04-28226S0936-6555(10)X0006-1456463http://www.clinicaloncologyonline.net/article/PIIS0936655510001263/abstract?rss=yesAbstract: For patients with metastatic differentiated thyroid carcinoma that progresses despite standard therapies, systemic cytotoxic chemotherapy has traditionally been a limited option. Historically, phase II studies and small retrospective series have failed to identify highly effective drugs or regimens, in part by failing to recruit sufficient numbers of patients. Doxorubicin remains the single most effective cytotoxic chemotherapy for the treatment of metastatic disease, although complete responses are rare, partial responses limited and toxicity considerable. Newer agents, such as pemetrexed, may be of benefit and potentially better tolerated. Newer approaches to treatment as well as trial design and recruitment, emphasising the role of thyroid cancer patients in early drug trials, may yield advances in patient benefit.Cytotoxic Chemotherapy for Differentiated Thyroid CarcinomaS.I. Sherman10.1016/j.clon.2010.03.014Clinical Oncology 22, 6 (2010)2010-05-10Clinical Oncology2010-05-10226S0936-6555(10)X0006-1464468http://www.clinicaloncologyonline.net/article/PIIS0936655510001615/abstract?rss=yesAbstract: The American Thyroid Association guidelines on thyroid nodules and differentiated thyroid cancer, published in 2009, provide valuable recommendations based on current evidence. Inevitably, controversies and uncertainties will continue to challenge clinicians and patients. On topics where evidence is not clear-cut, judgement may be coloured by pre-existing practises and the structure of the health service in each country, so one has to be aware of the pitfalls of transferring recommendations to one’s own practise.2009 American Thyroid Association Guidelines on Thyroid NodulesP. Perros10.1016/j.clon.2010.04.003Clinical Oncology 22, 6 (2010)2010-05-31Clinical Oncology2010-05-31226S0936-6555(10)X0006-1469471http://www.clinicaloncologyonline.net/article/PIIS0936655510001718/abstract?rss=yesIn view of the significant amount of work that has been carried out in the field of management of differentiated thyroid cancer (DTC) over the last few years, members of a task force set up by the American Thyroid Association (ATA) undertook a painstaking critical analysis of the current published literature and revised the 2006 guidelines. The task force included experts from Europe, so the American and European guidelines are now more closely aligned .The Revised American Thyroid Association Management Guidelines 2009 for Patients with Differentiated Thyroid Cancer: an Evidence-Based Risk-Adapted ApproachU.K. Mallick10.1016/j.clon.2010.05.001Clinical Oncology 22, 6 (2010)2010-06-25Clinical Oncology2010-06-25226S0936-6555(10)X0006-1472474http://www.clinicaloncologyonline.net/article/PIIS093665551000172X/abstract?rss=yesAbstract: Medullary thyroid carcinoma (MTC) accounts for 5–8% of all thyroid cancers. MTC is mainly sporadic in nature, but an hereditary pattern [multiple endocrine neoplasia type 2 (MEN 2)] is present in 20–30% of cases, transmitted as an autosomal-dominant trait due to germline mutations of the RET proto-oncogene. About 98% of patients with MEN 2 have germline mutations in exons 5, 8, 10, 11, 13, 14, 15 or 16 of the RET gene. The primary treatment of both hereditary and sporadic forms of MTC is total thyroidectomy and removal of all neoplastic tissue present in the neck. The therapeutic option for lymph node surgery should be dictated by the results of presurgical evaluation. After total thyroidectomy, measurements of serum calcitonin (CT) and carcinoembryonic antigen are of paramount importance in the postsurgical follow-up of patients with MTC as they reflect the presence of persistent or recurrent disease. Complete remission is demonstrated by undetectable and stimulated serum CT measurement.On the contrary, if serum CT is detectable under basal conditions or becomes detectable after stimulation, the patient is probably not cured, but imaging techniques will not demonstrate any disease until serum CT approaches levels >150pg/ml. The tumour metastasises early to both paratracheal and lateral cervical lymph nodes. Metastases outside the neck may occur in the liver, lungs, bones and, less frequently, brain and skin. Surgery is the main treatment for local and distant metastases whenever feasible. Systemic chemotherapy with dacarbazine, 5-fluorouracil and doxorubicin (alone or in combination) has shown very limited efficacy, achieving only partial responses in the range of 10–20% and of short duration. Several kinase inhibitors are currently under evaluation and preliminary results are promising.Familial cases must be identified by searching for RET proto-oncogene mutations in the proband and in family members. Carriers of the RET gene are candidates for prophylactic thyroidectomy at different ages depending on the risk associated with the specific RET mutations.Medullary Thyroid CarcinomaF. Pacini, M.G. Castagna, C. Cipri, M. Schlumberger10.1016/j.clon.2010.05.002Clinical Oncology 22, 6 (2010)2010-06-07Clinical Oncology2010-06-07226S0936-6555(10)X0006-1475485http://www.clinicaloncologyonline.net/article/PIIS0936655510001251/abstract?rss=yesAbstract: Anaplastic thyroid carcinoma ranges from 1.3 to 9.8% of all thyroid cancers globally. Mutations, amplifications, activation of oncogenes and silencing of tumour suppressor genes contribute to its aggressive behaviour, and recent studies (e.g. microarrays, microRNAs) have provided further insights into its complex molecular dysregulation. Preclinical studies have identified numerous proteins over- or underexpressed that affect critical cellular processes, including transcription, signalling, mitosis, proliferation, cell cycle, apoptosis and adhesion, and a variety of agents that effectively inhibit these processes and tumour growth. In clinical studies of 1771 patients, 64% were women, the median survival was 5 months, and 1-year survival was 20%. The variables associated with survival in some series included age, tumour size, extent of surgery, higher dose radiotherapy, absence of distant metastases at presentation, co-existence of differentiated thyroid cancer and multimodality therapy. However, considerable bias exists in these non-randomised studies. Although more aggressive radiotherapy has reduced locoregional recurrences, the median overall survival has not improved in over 50 years. Newer systemic therapies are being tried, and more effective combinations are needed to improve patient outcomes.Anaplastic Thyroid Carcinoma: Pathogenesis and Emerging TherapiesR.C. Smallridge, J.A. Copland10.1016/j.clon.2010.03.013Clinical Oncology 22, 6 (2010)2010-04-26Clinical Oncology2010-04-26226S0936-6555(10)X0006-1486497http://www.clinicaloncologyonline.net/article/PIIS0936655510001652/abstract?rss=yesAbstract: Parathyroid carcinoma is a rare endocrine malignancy. The reported incidence is from 0.5 to 5% of primary hyperparathyroidism cases in various series. The cause is unknown, but clinical correlations with different genetic syndromes exist. Mutations in the HPRT2 gene seem to play a significant role in the pathogenesis of this disease. Men and women are equally affected, usually in the fourth or fifth decade of life. Most patients will present with signs and symptoms of hypercalcaemia. Cases of non-functioning carcinoma are exceedingly rare. Surgical resection is the most effective method of treatment and palliation. A significant proportion of patients will experience recurrence, and will need further surgical and, eventually, medical management of hypercalcaemia. The disease is progressive but slow growing. Most patients will require multiple operations to resect recurrent disease. The main cause of morbidity and mortality is the sequela of uncontrolled chronic hypercalcaemia rather than tumour burden. The current paper will review the epidemiology, pathogenesis, clinical presentation and diagnostic work-up of this disease. Surgical management in different scenarios is reviewed in detail, followed by other types of treatment and management of incurable disease.Parathyroid CarcinomaB. Givi, J.P. Shah10.1016/j.clon.2010.04.007Clinical Oncology 22, 6 (2010)2010-06-01Clinical Oncology2010-06-01226S0936-6555(10)X0006-1498507http://www.clinicaloncologyonline.net/article/PIIS0936655510001627/abstract?rss=yesThyroid cancer is relatively rare and, as a result, each thyroid cancer multidisciplinary team deals with a relatively small number of new cases on an annual basis. In many centres, a single clinician specialises in the management of this disease, and there may be no conveniently located work colleague with whom to discuss difficult cases or controversial issues.Thyroid Cancer Forum-UK (TCF-UK): a Free, Independent, Multidisciplinary Education Resource and Peer Support Organisation for ConsultantsL. Moss10.1016/j.clon.2010.04.004Clinical Oncology 22, 6 (2010)2010-05-20Clinical Oncology2010-05-20226S0936-6555(10)X0006-1508511http://www.clinicaloncologyonline.net/article/PIIS0936655510001597/abstract?rss=yesI write this in March 2010, almost 10 years after I was diagnosed with thyroid cancer. Looking back, so much has happened since then, much of which has been very positive, but my family and I were devastated by my diagnosis at the time. It was a very busy time in my life. I was working with my husband in his very busy dental practice, our son was 12 years old and would soon be preparing for important examinations at school, and my father was chronically ill.Thyroid Cancer: Doctor–Patient PartnershipK. Farnell10.1016/j.clon.2010.04.001Clinical Oncology 22, 6 (2010)2010-06-04Clinical Oncology2010-06-04226S0936-6555(10)X0006-1512513