Familial medullary thyroid carcinoma and C cell hyperplasia

Incidental thyroid C cell hyperplasia: clinical significance and implications in practice

Incidental C cell hyperplasia (CCH) following thyroidectomy for other indications may rarely be encountered, which may raise concerns about its clinical significance and proper management. CCH can be classified as physiological (reactive) or neoplastic. Reactive CCH has no malignant potential and can be observed in association with many other thyroid diseases (including differentiated thyroid cancer); in contrast, neoplastic CCH should be considered as a preneoplastic stage in the spectrum of C cell disease, ultimately leading to the development of medullary thyroid cancer (MTC). Neoplastic CCH is commonly observed in patients with germ-line mutations in the RET oncogene (commonly in families with a history of hereditary MTC, i.e. familial MTC or multiple endocrine neoplasia type 2 (MEN2)). CCH should be considered in patients with hypercalcitoninemia without nodular thyroidopathy. Total thyroidectomy, which is commonly performed for the majority of thyroid diseases, is an adequate treatment and achieves cure, even in patients with neoplastic CCH. There is no role for cervical lymph node dissection in patients with pure CCH. In conclusion, reactive CCH has no malignant potential, in contrast to neoplastic CCH. Total thyroidectomy achieves cure of patients with CCH.

Thyroid safety in patients treated with liraglutide

During the last years, various novel anti-diabetic drugs have considerably enriched the therapeutic armamentarium for subjects with Type 2 diabetes. In the meantime, much interest has recently been focused on the potential cardiovascular and oncological adverse effects of these new therapies. As to glucagon-like peptide 1 (GLP-1) analogs, medullary thyroid tumors were reported to be more common in rodent toxicology studies with liraglutide, although the relevance of this finding in humans has been questioned. Analyses of sequential changes in calcitonin levels in several thousands of subjects did not reveal a relationship between liraglutide therapy and plasma calcitonin. Furthermore, no medullary thyroid cancer has been detected in humans taking liraglutide. Nevertheless, the long-term consequences of sustained GLP-1 receptor activation in the human thyroid remain unknown and deserve further investigation.

2012 European thyroid association guidelines for genetic testing and its clinical consequences in medullary thyroid cancer

Twenty-five percent of medullary thyroid cancers (MTC) are familial and inherited as an autosomal dominant trait. Three different phenotypes can be distinguished: multiple endocrine neoplasia (MEN) types 2A and 2B, in which the MTC is associated with other endocrine neoplasias, and familial MTC (FMTC), which occurs in isolation. The discovery that germline RET oncogene activating mutations are associated with 95-98% of MEN 2/FMTC syndromes and the availability of genotyping to identify mutations in affected patients and their relatives has revolutionized the diagnostic and therapeutic strategies available for the management of these patients. All patients with MTC, both those with a positive familial history and those apparently sporadic, should be submitted to RET genetic screening. Once an RET mutation has been confirmed in an index patient, first-degree relatives should be screened rapidly to identify the 50% who inherited the mutation and are therefore at risk for development of MTC. Relatives in whom no RET mutation is identified can be reassured and discharged from further follow-up, whereas RET-positive subjects (i.e. gene carriers) must be investigated and a therapeutic strategy initiated. These guideline recommendations are derived from the most recent studies identifying phenotype-genotype correlations following the discovery of causative RET gene mutations in MEN 2 eighteen years ago. Three major points will be discussed: (a) identification of patients and relatives who should have genetic screening for RET mutations, (b) management of asymptomatic gene carriers, and (c) ethics.

Familial thyroid cancer: a review

Thyroid carcinomas can be sporadic or familial. Familial syndromes are classified into familial medullary thyroid carcinoma (FMTC), derived from calcitonin-producing C cells, and familial non-medullary thyroid carcinoma, derived from follicular cells. The familial form of medullary thyroid carcinoma (MTC) is usually a component of multiple endocrine neoplasia (MEN) IIA or IIB, or presents as pure FMTC syndrome. The histopathological features of tumors in patients with MEN syndromes are similar to those of sporadic tumors, with the exception of bilaterality and multiplicity of tumors. The genetic events in the familial C-cell-derived tumors are well known, and genotype-phenotype correlations well established. In contrast, the case for a familial predisposition of non-medullary thyroid carcinoma is only now beginning to emerge. Although, the majority of papillary and follicular thyroid carcinomas are sporadic, the familial forms are rare and can be divided into two groups. The first includes familial syndromes characterized by a predominance of non-thyroidal tumors, such as familial adenomatous polyposis and PTEN-hamartoma tumor syndrome, within others. The second group includes familial syndromes characterized by predominance of papillary thyroid carcinoma (PTC), such as pure familial PTC (fPTC), fPTC associated with papillary renal cell carcinoma, and fPTC with multinodular goiter. Some characteristic morphologic findings should alert the pathologist of a possible familial cancer syndrome, which may lead to further molecular genetics evaluation.

Thyroid pathology in PTEN-hamartoma tumor syndrome: characteristic findings of a distinct entity

BACKGROUND

Phosphatase and tensin homolog deleted on chromosome ten (PTEN)-hamartoma tumor syndrome (PHTS) is a complex disorder caused by germline inactivating mutations of the PTEN tumor suppressor gene. PHTS includes Cowden syndrome (CS), Bannayan-Riley-Ruvalcaba syndrome (BRRS), and Proteus-like syndromes. Affected individuals develop both benign and malignant tumors in a variety of tissues, including the thyroid. This study is to better characterize and describe the thyroid pathology within the different entities of this syndrome, and examine whether there is an association between specific thyroid findings and different PTEN mutations.

METHODS

Twenty patients with known PTEN mutations, and/or clinical diagnosis of PHTS, and thyroid pathology were identified: 14 with CS and 6 with BRRS.

RESULTS

Thyroid pathology findings were as follows: multiple adenomatous nodules in a background of lymphocytic thyroiditis (LT) in 75%, papillary carcinoma in 60%, LT alone in 55%, follicular carcinoma in 45%, C-cell hyperplasia in 55%, and follicular adenomas in 25%. Within the papillary carcinoma group, there were 6 microcarcinomas, 5 follicular variants, and 1 classical type.

CONCLUSIONS

There were no morphologic differences between the thyroid findings in CS and BRRS. Also, there was no correlation between specific PTEN germline mutations (exons 5, 6, and 8) and pathologic findings. Distinctive and characteristic findings in PHTS include multiple unique adenomatous nodules in a background of LT, and C-cell hyperplasia; it is vital that pathologists recognize the classical histologic features of this syndrome to alert clinicians to the possibility of this syndrome in their patients.

Multiple endocrine neoplasia type 2

Multiple endocrine neoplasia type 2 (MEN 2) is an autosomal dominant cancer syndrome with major components of medullary thyroid carcinoma (MTC), pheochromocytoma and hyperparathyroidism. The disease is caused by germline mutations of the RET proto-oncogene. Subtypes of MEN 2 include MEN 2A, MEN 2B and familial MTC (FMTC) which differ in pattern of additional lesions or--in FMTC--lack of pheochromocytoma. In 2009, after extensive review of the literature, the guidelines of the American Thyroid Association made several recommendations regarding clinical and genetic diagnostic testing and treatment options. In this article, the recently published literature is reviewed and concerns regarding future perspectives are added. In particular, a critical handling of rare DNA variants and double mutations is necessary. Up to now, mutation-specific risk profiles and mutation-associated treatment recommendations are unavailable. We emphasise the need for approved centres for treatment of patients affected by MEN 2, not only adults but young children as well. As a high level of skill is required for endoscopic adrenal-sparing surgery, surgeons should declare their expertise before operating such patients. Registry-based follow-up should be mandatory including documentation of short- and long-term outcome in order to provide valid data for future counselling of patients with MEN 2.

Clinical features and genetic predisposition to hereditary nonmedullary thyroid cancer

BACKGROUND

Approximately 5% of the nonmedullary thyroid cancers are hereditary. Hereditary nonmedullary thyroid cancer may occur as a minor component of familial cancer syndromes (familial adenomatous polyposis, Gardner's syndrome, Cowden's disease, Carney's complex type 1, Werner's syndrome, and papillary renal neoplasia) or as a primary feature (familial nonmedullary thyroid cancer [FNMTC]). The goal of this article was to review our current knowledge on the hereditary nonmedullary thyroid cancer.

SUMMARY

Epidemiologic and clinical kindred studies have demonstrated that FNMTC is a unique clinical entity. Most studies suggest that FNMTC is associated with more aggressive disease than sporadic cases, with higher rates of multicentric tumors, lymph node metastasis, extrathyroidal invasion, and shorter disease-free survival. A hereditary predisposition to nonmedullary thyroid cancer is well established, but the susceptibility genes for isolated FNMTC have not been identified. However, additional susceptibility loci for FNMTC have been recently identified in classic isolated cases of FNMTC (1q21, 6q22, 8p23.1-p22, and 8q24).

CONCLUSIONS

More studies are needed to validate chromosomal susceptibility loci and identify the susceptibility genes for FNMTC. The discovery of the predisposing genes may allow for screening and early diagnosis, which could lead to improved outcomes for patients and their families.

Multiple endocrine neoplasia type 2

Multiple endocrine neoplasia type 2 (MEN 2) is an autosomal dominantly inherited tumor syndrome subclassified into three distinct syndromes: MEN 2A, MEN 2B and familial medullary thyroid carcinoma. In MEN 2 families, medullary thyroid carcinoma, pheochromocytomas and parathyroid adenomas occur with a variable frequency, also depending on the specific genetic defect involved. In 1993, the responsible MEN2 gene was identified. The genetic defect in these disorders involves the RET proto-oncogene on chromosome 10. The germline RET mutations result in a gain-of-function of the RET protein. Extensive studies on large families revealed that there is a strong genotype-phenotype correlation. In this review, guidelines for early diagnosis, including MEN2 gene mutation analysis, and treatment, including preventive surgery, periodic and clinical monitoring, have been formulated, enabling improvement of life expectancy and quality of life. Identification of the RET protein has also provided new insights into its function, and the specific pathways it effects involved in cell proliferation, migration, differentiation and survival. In the near future, identification of biological tumor markers will enable target-directed intervention and may prevent and/or delay progression of both primary and residual tumor growth.

Familial thyroid carcinoma: a diagnostic algorithm

Thyroid carcinomas derived from follicular cells are the most common endocrine malignancies, and papillary thyroid carcinoma (PTC) is the most common type. Although, the majority of papillary and follicular thyroid carcinomas (FTCs) are sporadic, familial forms have been described in recent years. Familial syndromes are classified into familial medullary thyroid carcinoma and familial nonmedullary thyroid carcinoma. Multifocal papillary carcinoma is the most frequent presentation of familial nonmedullary thyroid carcinoma, and based on clinico-pathologic findings it is divided into 2 groups. The first includes familial syndromes characterized by a predominance of nonthyroidal tumors, such as familial adenomatous polyposis, PTEN-hamartoma tumor syndrome, Carney complex type 1, and Werner syndrome. The second group includes familial syndromes characterized by a predominance of NMTC, such as pure familial (f) PTC with or without oxyphilia, fPTC with papillary renal cell carcinoma, and fPTC with multinodular goiter. Medullary thyroid carcinoma is derived from calcitonin-producing C cells. The familial form accounts for 20% to 25% of cases, and is usually a component of multiple endocrine neoplasia (MEN) IIA or IIB, or presents as pure familial medullary thyroid carcinoma syndrome. C-cell hyperplasia is the precursor lesion of these heritable syndromes. Some characteristic morphologic findings should alert the pathologist of a possible familial cancer syndrome, which may lead to further molecular genetic evaluation.

Familial non-medullary thyroid carcinoma: an update

Familial thyroid cancer can arise from follicular cells (familial non-medullary thyroid carcinoma (FNMTC)) or from the calcitonin-producing C-cell (familial medullary thyroid carcinoma). This is usually a component of multiple endocrine neoplasias (MEN) IIA or IIB, or as pure familial medullary thyroid carcinoma syndrome. The genetic events in the familial C-cell-derived tumors are known and genotype-phenotype correlations are well established. In contrast, the case for a familial predisposition of non-medullary thyroid carcinoma is only now beginning to emerge. Although the majority of papillary (PTC) and follicular thyroid carcinomas (FTC) are sporadic, familial tumors account for over 5% of cases. The presence of multifocal papillary carcinoma is a common feature of FNMTC. The familial follicular cell-derived tumors or non-medullary thyroid carcinomas encompass a heterogeneous group of diseases, including diverse syndromic-associated tumors and non-syndromic tumors. Based on clinico-pathologic findings, FNMTC is divided into two groups. The first includes familial syndromes characterized by a predominance of non-thyroidal tumors, such as familial adenomatous polyposis (FAP), PTEN hamartoma tumor syndrome (PHTS), Carney complex type 1, and Werner syndrome. The second group includes familial syndromes characterized by a predominance of NMTC, such as pure familial (f) PTC with or without oxyphilia, fPTC with papillary renal cell carcinoma, and fPTC with multinodular goiter. Some characteristic morphologic findings should alert the pathologist of a possible familial cancer syndrome, which may lead to further molecular genetic evaluation.

Differential expression of galectin 3 in solid cell nests and C cells of human thyroid

AIMS

To provide new insights into characterising solid cell nests and gain information that might help distinguish between solid cell nests and C cells.

METHODS

Thyroid tissue specimens from patients who had undergone prophylactic thyroidectomy for familial medullary thyroid cancer were immunostained for calcitonin, carcinoembryonic antigen, and galectin 3.

RESULTS

Solid cell nests displayed a strong and diffuse staining for carcinoembryonic antigen and galectin 3, but not for calcitonin. C cells located at the periphery of solid cell nests and in neighbouring follicles expressed both calcitonin and carcinoembryonic antigen but not galectin 3. These three markers were positive in medullary thyroid carcinoma.

CONCLUSION

Galectin 3 immunoreactivity permits a better characterisation and differentiation between solid cell nests and C cells, avoiding the misidentification of two biologically and clinically different thyroid structures.

False-positive results of basal and pentagastrin-stimulated calcitonin in non-gene carriers of multiple endocrine neoplasia type 2A

Direct DNA analysis permits accurate identification of gene carriers in kindred members with multiple endocrine neoplasia type 2A (MEN 2A). The aim of this study was to assess the specificity of basal and pentagastrin stimulated calcitonin levels in 3 family members with MEN 2A. For this purpose 53 members of 3 consecutive families with MEN 2A were evaluated in a university medical center. Serum calcitonin, basal and stimulated, was determined by a commercial RIA. RET protooncogene analysis was carried out by automatic DNA sequencing and adequate digestion of PCR amplified products for exons 10 and 11. Two distinct mutations in the RET protooncogene were identified. A T-->A transition at position 1783 (codon 618) in exon 10 was detected in one family, and a G-->A replacement at position 1832 (codon 634) in exon 11 in the others. In non-gene carriers we obtained 6.6% of false-positive results for basal calcitonin and 15.4% for the pentagastrin provocative test. We conclude that the specificity of basal and pentagastrin-stimulated calcitonin is rather limited and RET protooncogene analysis must be the first line screening procedure in order to identify gene carriers.

Immunostains for collagen type IV discriminate between C-cell hyperplasia and microscopic medullary carcinoma in multiple endocrine neoplasia, type 2a

At a light microscopic level, the separation of C-cell hyperplasia and microscopic medullary carcinoma of the thyroid (MCT) is difficult, and it ultimately rests on the finding of C cells outside of the thyroid follicular basement membranes (FBMs). To date, this has required ultrastructural examination for proper documentation. The assessment of thyroidectomy specimens from patients with multiple endocrine neoplasia, type 2a (MEN2a), a hereditary condition in which there is widespread C-cell hyperplasia (CCH) and multifocal MCT, presented an opportunity to the authors to assess the entire range of C-cell abnormalities. Total thyroidectomy specimens from 17 patients with MEN2a were examined. In addition to hematoxylineosin (H&E) stains, representative tissue sections were labeled for chromogranin A and collagen type IV (CIV), using the avidin-biotin-peroxidase complex (ABC) method. All patients in the study had multifocal C-cell proliferation that was both diffuse and nodular. Fifteen had microscopic MCTs, which were multifocal in eight instances. Three patterns of C-cell proliferation were recognized in CIV immunostains. The first was characterized by complete investment of C-cells by a continuous rim of CIV, corresponding to FBM and confirming an intrafollicular localization; hence, the diagnosis of CCH was made in such cases. The second pattern was distinctive and was typified by defects in the CIV layer; constituent C-cells assumed an extrafollicular location. These images yielded a diagnosis of micro-MCT. The latter findings were also accompanied by focal reduplication of basement membrane that was apparently tumor derived, producing a micronodular or microlobular configuration. The third pattern represented a combination of the first two, with C-cell nodules that were bounded by CIV and clearly situated in an intrafollicular location; however, focal reduplication of basement membranes was also evident in these cases. The biological significance of the third pattern of CIV staining is uncertain, but it may reflect the presence of a preinvasive proliferation of C-cells that is distinct from "usual" CCH in MEN2a.

From medical history and biochemical tests to presymptomatic treatment in a large MEN 2A family

An extensive study was published in 1959 in the Netherlands on a large family, which initially attracted attention because of a family history of attacks of shaking. Clinical investigation revealed phaeochromocytomas in four family members. In 1975, the family was identified to be a MEN 2A family, and since then, the members were examined annually using measurement of catecholamine metabolites in 24-h excreted urine and C-cell stimulation tests. In 1993, the RET proto-oncogene on chromosome 10q11 was found to be associated with MEN 2A and a specific mutation in this gene was identified in the family. In this family, 32 MEN 2A patients were detected. Since screening started in 1975, no patient died of phaeochromocytoma; however, two patients died of metastasized medullary thyroid carcinoma (MTC) (mean age 46 years). Twelve patients were operated on for phaeochromocytoma, and 13 for MTC. The results of DNA-analysis revealed the failures of the biochemical tests to identify affected family members. Six disease gene carriers with normal C-cell stimulation test results appeared to have small multifocal MTCs. Two carriers with normal excretion levels of catecholamines had a small phaeochromocytoma. DNA-analysis enables the unambiguous diagnosis of MEN 2A gene carrier-ship, allowing presymptomatic surgery for MTC.

Clinical screening as compared with DNA analysis in families with multiple endocrine neoplasia type 2A

BACKGROUND

Multiple endocrine neoplasia type 2A (MEN-2A) is characterized by medullary thyroid carcinoma in combination with pheochromocytoma and sometimes parathyroid adenoma. Missense mutations in the RET proto-oncogene are associated with MEN-2A. Their detection by DNA analysis allows the identification of carriers of the gene, in whom the risk of medullary thyroid carcinoma is 100 percent. We compared the reliability of biochemical tests with that of DNA analysis in identifying carriers of the MEN2A gene.

METHODS

Starting in 1975, we screened 300 subjects in four large families with MEN-2A for expression of the disease, using measurements of plasma calcitonin after stimulation with pentagastrin or calcium and urinary excretion of catecholamines and catecholamine metabolites. We tested for carrier status by DNA analysis, including linkage analysis, and more recently by analysis of mutations in the RET gene.

RESULTS

Of 80 MEN2A gene carriers (in 61 of whom carrier status was proved by DNA analysis), 66 had abnormal plasma calcitonin values and medullary thyroid carcinoma. Fourteen young carriers had normal results of plasma calcitonin tests. In 8 of these 14, thyroidectomy revealed small foci of medullary thyroid carcinoma; the remaining 6 have not yet been operated on. Of the other 220 family members, 68 were found by DNA analysis not to carry the MEN2A gene. None of these 68 subjects had medullary thyroid carcinoma or pheochromocytoma; 6 had elevated plasma calcitonin concentrations and underwent thyroidectomy but had only C-cell hyperplasia.

CONCLUSIONS

Unlike biochemical tests, DNA analysis permits the unambiguous identification of MEN2A gene carriers.

C-cell hyperplasia associated with chronic lymphocytic thyroiditis: a retrospective quantitative study of 112 cases

Since the first description by Wolfe et al of C-cell hyperplasia (CCH) in asymptomatic relatives of patients suffering from a medullary thyroid carcinoma (MTC), several investigators have described CCH associated with a chronic lymphocytic thyroiditis (CLT) not within the context of MTC or multiple endocrine neoplasia (MEN). We report the study of C-cell density in 112 cases of CLT on retrospective surgical material to determine the frequency of the association between CCH and CLT. The cases of CLT were compared with 19 normal thyroid glands obtained at necropsy. C cells, immunoreactive with a polyclonal anti-calcitonin (CT) antibody, were counted at high magnification (X400) and the number of low-power magnification (X100) microscopic fields (LPFs) containing at least 50 C cells per slide was assessed. Image analysis was performed to determine the C-cell density expressed in number of C cells/cm2. C-cell hyperplasia was defined by the following criteria: C-cell density > 40 cells/cm2 and the presence of at least three LPFs containing more than 50 C cells. Twenty percent of the cases of CLT showed a CCH thus defined, and four of them had an elevated serum CT level. Statistical analysis showed no clinical or biological correlation with the presence of CCH. However, the frequency of CCH was higher if a follicular cell carcinoma was associated with CLT. This study confirms a pathological association between CCH and CLT, provides new criteria for the definition of CCH on surgical pathology material, and reports four cases with an elevated serum CT level not within the context of MTC or MEN.

Immunohistochemistry of medullary thyroid carcinoma and C-cell hyperplasia by an affinity-purified anti-human calcitonin antiserum

BACKGROUND

The diagnosis of medullary thyroid carcinoma (MTC) depends on the calcitonin immunohistochemistry. Familial MTC is associated with C-cell hyperplasia (CCH), whereas sporadic MTC is not. A specific and sensitive calcitonin immunohistochemistry is necessary for the diagnosis of MTC and CCH.

METHODS

An affinity-purified anti-calcitonin antiserum (APxCT) was used for immunohistochemistry of the thyroids of 15 patients with MTC. The thyroids of five patients with familial MTC were studied in detail, with each gland sectioned in 48 areas.

RESULTS

Between three and ten independent MTC were found in each thyroid, and CCH was found in all five patients (24.2%, varying from 8.4-56.3% of the 48 areas from each thyroid). MTC and CCH were localized mainly in the middle third and in the central axis of the thyroid lobes. They often were found together in the same area (in a total of 21 areas for the five thyroids sectioned in 48 areas) but ten areas with MTC did not have CCH, and 37 areas with CCH did not have MTC. In ten thyroids partially studied, CCH was indicated in three patients thought to have sporadic MTC. In two thyroids, with follicular and papillary carcinoma, a higher density of C-cells was found around the tumors, but disease was not characterized as CCH.

CONCLUSIONS

APxCT antiserum increased the immunohistochemical specificity and sensitivity. The distinction of the familial from the sporadic MTC requires a careful and extensive search of CCH. C-cells in high density may be found around follicular cell carcinomas, being a potential source of diagnostic error.

Solid cell nests of the thyroid gland

The histogenesis and clinical significance of solid cell nests (SCN) of the thyroid are not fully understood. From August 1987 to December 1989 a total of 2544 patients with thyroid and parathyroid diseases underwent surgery at Ito Hospital, and SCN were revealed within the thyroid parenchyma in 21 (0.8%). Distribution of SCN was not limited to the upper one-third of the lateral lobe, and SCN were found even in the isthmus lobe. In 5 cases microcysts were also noted within SCN, and their content was thought to be acidic proteoglycan. Immunohistochemical study revealed that SCN were negative for thyroglobulin and calcitonin but positive for carcinoembryonic antigen. Thirteen of 21 cases showed positive immunostaining with cytokeratin. Scattered calcitonin-positive cells were noted around the SCN. It is suggested from these findings that SCN of the thyroid are closely related to certain cells of ultimobranchial body vestiges which may be not of neuroectodermal origin but of endodermal origin.

Solid cell nests of the thyroid

The ultimobranchial thyroid solid cell nests (SCN), irregular structures of about 1 mm in maximal diameter, are usually found in the middle third of the thyroid lateral lobes. SCN are basically composed of non-keratinizing epidermoid cells which lack intercellular bridges and are immunohistochemically positive for a panel of high and low molecular weight keratin proteins, as well as for carcinoembryonic antigen. In addition, SCN display isolated or grouped peripheral calcitonin-immunoreactive 'clear' (C) cells in up to 54 per cent of cases. The SCN central lumen, when present, is usually surrounded by mucinous cells; in addition, it may contain desquamated cells, cell debris, acid mucosubstances, characteristic PAS-positive granular material after diastase treatment, and colloid-like material. The so-called mixed follicles, structures lined by epidermoid cells of SCN and follicular epithelium, are often found as an additional component of the ultimobranchial remnants. The relationship of SCN to thyroid parenchymal cells and the probable implications of the thyroid 'ultimobranchial system' to tumour histogenesis are analysed. Pitfalls that may emerge with regard to SCN in practical pathological approaches are emphasized.

C-cell hyperplasia in thyroid tissue adjacent to follicular cell tumors

An immunohistochemical study was conducted on the number and distribution of C-cells in the nonneoplastic thyroid tissue adjacent to tumors of follicular cell origin. It consisted of 49 cases, of which 25 were papillary carcinomas, 22 were follicular adenomas, and 2 were follicular carcinomas. Twenty normal adult thyroids from the Broward's Medical Examiner's morgue served as controls. In 17 of the 49 cases (34.6%), there was a statistically significant increase in the number of C-cells in the normal-appearing thyroid tissue adjacent to follicular cell tumors, with at least 50 C-cells in one low power field, while only one of 20 normal thyroids had a similar number of cells. (P = .02; chi 2 = 5.05). In two tumor cases there were more than 100 C-cells in several low power fields with formation of small C-cell nodules similar to those described in the type II Multiple Endocrine Neoplasia Syndrome (MEN). It was concluded that the nonneoplastic thyroid tissue adjacent to 34.6% of tumors with follicular cell phenotypes contains significantly more C-cells than those present in normal adult thyroids. The possible pathogenesis and clinical significance of these findings are discussed.

Regulation of calcitonin gene transcription by vitamin D metabolites in vivo in the rat

Calcitonin is secreted by the C cells of the thyroid in response to a raised serum calcium, and acts on bone to lower serum calcium. The C cells have specific receptors for the dihydroxymetabolite of vitamin D3, 1,25(OH)2D3. Moreover, calcitonin stimulates the synthesis of 1,25(OH)2D3 in the kidney. Parathyroid hormone (PTH), the third calciotrophic hormone, is also trophic to the renal synthesis of 1,25(OH)2D3, and in turn 1,25(OH)2D3 inhibits PTH gene transcription and synthesis. We report here the marked inhibition of calcitonin gene transcription by the injection of physiologically relevant doses of 1,25(OH)2D3 to normal rats that did not raise serum calcium. Calcitonin mRNA levels after 100 pmol 1,25(OH)2D3 decreased to 6% of basal at 6 h and 4% at 48 h, and a dose response showed a marked effect even after 12.5 pmol 1,25(OH)2D3, with no appreciably greater effect with larger doses (up to 200 pmol). Control genes, actin, thyroglobulin (thyroid follicular cells), somatostatin (thyroid C-cells) were not affected by 1,25(OH)2D3. Gel blots showed that 1,25(OH)2D3 decreased calcitonin mRNA levels without any change in its size. In vitro nuclear transcription showed that 1,25(OH)2D3-treated (100 pmol) rats' calcitonin transcription was 10% of control, while thyroglobulin and actin were 100%. We propose that calcium is the major regulator of PTH and calcitonin secretion, while 1,25(OH)2D3 is an important regulator of PTH and calcitonin gene transcription. We believe this to be the first demonstration of an effect of 1,25(OH)2D3 on the C cells thereby establishing a new target organ and site of action of vitamin D. Calcitonin is trophic to 1,25(OH)2D3 synthesis, which in turn inhibits calcitonin synthesis, which are the components of a new endocrinological feedback loop.

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.