Report of a family with inherited medullary carcinoma of the thyroid and phaeochromocytoma

Concurrent Pheochromocytoma, Paraganglioma, Papillary Thyroid Carcinoma, and Desmoid Tumor: A Case Report with Analyses at the Molecular Level

Reports on the association of papillary thyroid carcinoma with paraganglionic or desmoid tumors have appeared infrequently. The former setting usually affects middle-aged females; the latter is typical of familial adenomatous polyposis. We report the case of a 69-yr-old man in whom two abdominal masses had been instrumentally detected following an access of abdominal pain. Save for a moderate hypertension, he was asymptomatic and an impalpable thyroid nodule was detected by ultrasonography. A high urinary noradrenaline output and cytology of the masses raised the suspicion of pheochromocytoma. At laparotomy, an adrenal pheochromocytoma and a paracaval paraganglioma were excised. Subsequently, hemithyroidectomy was performed, and histopathology revealed papillary microcarcinoma. A nodule of desmoid tumor was also removed from the abdominal wall. An analysis of RET, APC, and TP53 gene mutations, and of RET and NTRK1 gene rearrangements, yielded negative results. No in vitro transforming activity was detected in the tumor DNA when assayed in transfection experiments. The lack of a consistent family history also made unlikely the possibility of identifying the putative germline defect by linkage analyses. Should this unusual aggregation of tumors represent a new entity, a number of genetic alterations have now been excluded.

Multiple endocrine neoplasia syndromes

The multiple endocrine neoplasia (MEN) syndromes are characterized by autosomal dominant inheritance with a high degree of penetrance but varying expression. This review gives a classification of these syndromes and a short summary of the historical background. The pathogenesis of the disease and its possible origin in the APUD cell system are discussed together with the mechanisms underlying normal and ectopic hormone production by MEN tumors on the basis of recent findings in molecular endocrinology. The natural history and the clinical manifestations of the different syndromes are described. The sensitivity and discriminative capacity of the tests used to detect the syndromes in an early stage are compared. The choice of therapy and criteria for the timing and extensiveness of treatment are also considered. Lastly, problems associated with the ethical and legal aspects of screening, central registration, and monitoring of relatives at risk are described.

Phaeochromocytomas in 72 patients: clinical and diagnostic features, treatment and long term results

Phaeochromocytomas were diagnosed in 72 patients in Hammersmith, Belfast and Newcastle between 1955 and 1976. Fourteen were found unexpectedly at autopsy while 58 were diagnosed in life. Associated lesions included neurofibromatosis (7 patients), medullary carcinoma of the thyroid (3), renal artery stenosis (2) and cerebellar haemangioblastoma (1). The clinical features were similar to those reported by others. Hypertension was found in all but one of the patients and was sustained only in 17 per cent, paroxysmal only in 48 per cent and sustained with superadded paroxysms in 33 per cent. Hypertension was significantly greater in the women than in the men.

Diagnosis was confirmed chemically in all patients and urinary vanylmandelic acid (VMA) was elevated in all but one. Tumours were localized correctly by various radiographic techniques and by selective venous sampling in over 80 per cent of patients. The tumours were in adrenals in 59 patients (bilateral in 6) and at extra-adrenal, intra-abdominal sites in 13.

The tumours were removed surgically from those in whom they were diagnosed in life. Before 1967 3 of 17 patients died after operation (18 per cent). Since then patients have been prepared with alpha blockade and have received infusions of plasma, blood or dextran after removal of the tumours. One of 41 patients so treated has died after operation (2 per cent). Phaeochromocytomas were diagnosed and treated in pregnancy in 4 patients, all of whom survived. Two of the fetuses died.

Five tumours diagnosed in life were malignant and 2 recurred (40 per cent). Fifty-three were benign and 2 of these recurred locally (4 per cent).

All but 2 patients (who could not be traced) were followed completely from 1 to 20 years after operation and 3 died during this period. Two-thirds of the patients were alive after 10 years.

Paroxysmal hypertension was abolished by operation, but sustained hypertension often persisted and required drug therapy.

It is concluded that at least one-third of phaeochromocytomas are not diagnosed in life and that a high index of suspicion is required to bring them to light. If they are diagnosed and treated by present methods, the prognosis is good.

Medullary thyroid carcinoma and pheochromocytoma accompanied with nodular hyperplasia in multiple endocrine neoplasia type 2

Three patients with familial multiple endocrine neoplasia type 2 underwent total adrenalectomy and subsequently near-total or total thyroidectomy. The overt pheochromocytomas were present bilaterally in two patients and unilaterally in another patient. In addition, multiple nodules measuring a few mm in diameter were demonstrated in all adrenal medullas examined. All patients exhibited bilateral medullary thyroid carcinomas which varied in size from a few minute nodules accompanied by the microscopic C-cell hyperplasia to distinct large tumors. The thyroid C-cell hyperplasia appeared to be confined to the upper and middle thirds of the lateral lobe, and micronodules of the C-cell hyperplasia enlarged to coalesce, forming one large carcinoma mass. On the other hand, nodular hyperplasia of the chromaffin cells was distributed diffusely throughout the adrenal medulla and each nodule appeared to develop individually into a large pheochromocytoma. These findings suggested that, at least in the family members at a high risk for multiple endocrine neoplasia type 2, the development of both medullary thyroid carcinoma and pheochromocytoma was always preceded by a multicentric nodular hyperplasia. On the basis of the pathogenesis of these tumors, the most rational surgical approach was presented.

APUD cells and the apudomas. A concept relevant to anaesthesia and endocrinology

A variety of cells found in the pituitary and pineal glands, sympathetic nervous system and adrenal glands, the gut, pancreas, thyroid (C-cells), chemoreceptors (type I-Cells), lungs (P-cells), skin (melanocytes) and the urogenital tract have a common origin from the neural crest. These cells are programmed for neuro-endocrine function and, as a group, can be regarded as one of the physiological control systems. They secrete a variety of amine and peptide hormones and have common cytochemical characteristics from which the term APUD cell is derived. Tumours of these cells are referred to as 'apudomas' and may synthesise not only their own hormones but also those which are normally produced by other APUD cells. The relevant physiological properties of some of the peptides which have been described relatively recently are discussed and the principal clinical syndromes produced by the APUDomas are described.

Thyroidectomy for non-familial medullary carcinoma

Two cases of non-familial medullary carcinoma of the thyroid which had thyroid tissue remaining after initial thyroidectomy were shown to contain residual, intra-glandular carcinoma at reoperation. This observation, the distribution of C cells in the normal thyroid gland and the lymph node spread of this carcinoma have led to the proposal of a bilateral 90 per cent upper pole thyroidectomy including the superior parathyroids for cases of non-familial medullary carcinoma. This operation removes all the C-cell-bearing area and leaves a small thyroid remnant at the lower pole for preservation of the inferior parathyroid glands. The operation is discussed with reference to these factors.

Primary malignant tumours of the thyroid: the relationship between histological classification and clinical behaviour

One hundred and seventy-nine primary malignant tumours of the thyroid seen at The London Hospital between 1945 and 1972 were classified by the system of Woolner et al. (1961) and Hazard (1964). The distinct pathological and clinical features of the differentiated primary carcinomas and the similarities and differences between malignant lymphoma and anaplastic carcinoma were confirmed. This study showed the 'benign' behaviour of more than half the 'differentiated' papillary and follicular carcinomas when treated by thyroid lobectomy and the very malignant nature of anaplastic carcinomas and lymphomas whatever their treatment. The behaviour of medullary carcinoma was closer to that of the other differentiated tumours than to the undifferentiated varieties. Our patients were not thought to have been exposed to known goitrogens or previous thyroid irradiation.