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Kavazis C, Romanidis K, Pitiakoudis M, Kesisoglou I, Laskou S, Sapalidis K. The role of prophylactic parathyroidectomy during thyroidectomy for MTC in patients with MEN2A syndrome. Folia Med (Plovdiv) 2023; 65:720-727. [PMID: 38351753 DOI: 10.3897/folmed.65.e86749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 08/08/2022] [Indexed: 02/16/2024] Open
Abstract
AIM To define the role of prophylactic parathyroidectomy in the surgical treatment of medullary thyroid carcinoma (MTC) in multiple endocrine neoplasia type IIa (MEN2A) syndrome through a literature review.
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Affiliation(s)
- Christos Kavazis
- General University Hospital of Alexandroupolis, Alexandroupolis, Greece
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2
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Majithia J, Mahajan A, Vaish R, Prakash G, Patwardhan S, Sarin R. Imaging Recommendations for Diagnosis, Staging, and Management of Hereditary Malignancies. Indian J Med Paediatr Oncol 2023. [DOI: 10.1055/s-0042-1760325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023] Open
Abstract
AbstractHereditary cancer syndromes, characterized by genetically distinct neoplasms developing in specific organs in more than one family members, predispose an individual to early onset of distinct site-specific tumors. Early age of onset, multiorgan involvement, multiple and bilateral tumors, advanced disease at presentation, and aggressive tumor histology are few characteristic features of hereditary cancer syndromes. A multidisciplinary approach to hereditary cancers has led to a paradigm shift in the field of preventive oncology and precision medicine. Imaging plays a pivotal role in the screening, testing, and follow-up of individuals and their first- and second-degree relatives with hereditary cancers. In fact, a radiologist is often the first to apprise the clinician about the possibility of an underlying hereditary cancer syndrome based on pathognomonic imaging findings. This article focuses on the imaging spectrum of few common hereditary cancer syndromes with specific mention of the imaging features of associated common and uncommon tumors in each syndrome. The screening and surveillance recommendations for each condition with specific management approaches, in contrast to sporadic cases, have also been described.
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Affiliation(s)
- Jinita Majithia
- Department of Radiodiagnosis, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Abhishek Mahajan
- Department of Radiology, The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - Richa Vaish
- Department of Head and Neck Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Gagan Prakash
- Department of Uro-Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Saket Patwardhan
- Department of Radiodiagnosis, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Rajiv Sarin
- Department of Radiation Oncology and In-Charge Cancer Genetics, Tata Memorial Hospital and Advanced Centre for Treatment Research and Education in Cancer (ACTREC), Mumbai, Maharashtra, India
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3
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Minisola S, Arnold A, Belaya Z, Brandi ML, Clarke BL, Hannan FM, Hofbauer LC, Insogna KL, Lacroix A, Liberman U, Palermo A, Pepe J, Rizzoli R, Wermers R, Thakker RV. Epidemiology, Pathophysiology, and Genetics of Primary Hyperparathyroidism. J Bone Miner Res 2022; 37:2315-2329. [PMID: 36245271 PMCID: PMC10092691 DOI: 10.1002/jbmr.4665] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 07/18/2022] [Accepted: 07/29/2022] [Indexed: 11/11/2022]
Abstract
In this narrative review, we present data gathered over four decades (1980-2020) on the epidemiology, pathophysiology and genetics of primary hyperparathyroidism (PHPT). PHPT is typically a disease of postmenopausal women, but its prevalence and incidence vary globally and depend on a number of factors, the most important being the availability to measure serum calcium and parathyroid hormone levels for screening. In the Western world, the change in presentation to asymptomatic PHPT is likely to occur, over time also, in Eastern regions. The selection of the population to be screened will, of course, affect the epidemiological data (ie, general practice as opposed to tertiary center). Parathyroid hormone has a pivotal role in regulating calcium homeostasis; small changes in extracellular Ca++ concentrations are detected by parathyroid cells, which express calcium-sensing receptors (CaSRs). Clonally dysregulated overgrowth of one or more parathyroid glands together with reduced expression of CaSRs is the most important pathophysiologic basis of PHPT. The spectrum of skeletal disease reflects different degrees of dysregulated bone remodeling. Intestinal calcium hyperabsorption together with increased bone resorption lead to increased filtered load of calcium that, in addition to other metabolic factors, predispose to the appearance of calcium-containing kidney stones. A genetic basis of PHPT can be identified in about 10% of all cases. These may occur as a part of multiple endocrine neoplasia syndromes (MEN1-MEN4), or the hyperparathyroidism jaw-tumor syndrome, or it may be caused by nonsyndromic isolated endocrinopathy, such as familial isolated PHPT and neonatal severe hyperparathyroidism. DNA testing may have value in: confirming the clinical diagnosis in a proband; eg, by distinguishing PHPT from familial hypocalciuric hypercalcemia (FHH). Mutation-specific carrier testing can be performed on a proband's relatives and identify where the proband is a mutation carrier, ruling out phenocopies that may confound the diagnosis; and potentially prevention via prenatal/preimplantation diagnosis. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Salvatore Minisola
- Department of Clinical, Internal, Anaesthesiologic and Cardiovascular Sciences, 'Sapienza', Rome University, Rome, Italy
| | - Andrew Arnold
- Center for Molecular Oncology and Division of Endocrinology & Metabolism, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Zhanna Belaya
- Department of Neuroendocrinology and Bone Disease, The National Medical Research Centre for Endocrinology, Moscow, Russia
| | - Maria Luisa Brandi
- F.I.R.M.O. Italian Foundation for the Research on Bone Diseases, Florence, Italy
| | - Bart L Clarke
- Mayo Clinic Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Fadil M Hannan
- Academic Endocrine Unit, Radcliffe Department of Medicine, University of Oxford, Oxford Centre for Diabetes, Endocrinology and Metabolism (OCDEM), Churchill Hospital, Oxford, UK.,Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK
| | - Lorenz C Hofbauer
- Division of Endocrinology, Diabetes, and Bone Diseases & Center for Healthy Aging, Technische Universität Dresden, Dresden, Germany
| | - Karl L Insogna
- Yale Bone Center Yale School of Medicine, Yale University, New Haven, CT, USA
| | - André Lacroix
- Division of Endocrinology, Department of Medicine and Research Center, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Canada
| | - Uri Liberman
- Department of Physiology and Pharmacology, Tel Aviv University School of Medicine, Tel Aviv, Israel
| | - Andrea Palermo
- Unit of Metabolic Bone and Thyroid Disorders, Fondazione Policlinico Universitario Campus Bio-Medico and Unit of Endocrinology and Diabetes, Campus Bio-Medico University, Rome, Italy
| | - Jessica Pepe
- Department of Clinical, Internal, Anaesthesiologic and Cardiovascular Sciences, 'Sapienza', Rome University, Rome, Italy
| | - René Rizzoli
- Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Robert Wermers
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition and Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Rajesh V Thakker
- Academic Endocrine Unit, Radcliffe Department of Medicine, University of Oxford, Oxford Centre for Diabetes, Endocrinology and Metabolism (OCDEM), Churchill Hospital, Oxford, UK.,Oxford National Institute for Health Research (NIHR) Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
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4
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Kittah NE, Gruber LM, Bancos I, Hamidi O, Tamhane S, Iñiguez-Ariza N, Babovic-Vuksanovic D, Thompson GB, Lteif A, Young WF, Erickson D. Bilateral pheochromocytoma: Clinical characteristics, treatment and longitudinal follow-up. Clin Endocrinol (Oxf) 2020; 93:288-295. [PMID: 32410303 DOI: 10.1111/cen.14222] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 04/24/2020] [Accepted: 05/08/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Comprehensive data about patients with bilateral pheochromocytoma are limited. We aimed to describe the clinical presentation, genetic analysis, treatment and outcomes of patients with bilateral pheochromocytoma. DESIGN A retrospective study at a tertiary care centre. PATIENTS All patients with bilateral pheochromocytoma evaluated at Mayo Clinic in Rochester, Minnesota between January 1951 and December 2015. MEASUREMENTS Tumour size, genetic testing, plasma/urine metanephrines and catecholamines. RESULTS A total of 94 patients (51% women) were diagnosed with bilateral pheochromocytoma at a median age at first presentation of 31 years (range, 4-70). Bilateral disease was noted in 8.0% of pheochromocytoma patient overall and 37.5% of patients 18 years of younger. Most patients presented with synchronous tumours (80%). Median time to metachronous tumours was 4.5 years (range, 1-38). Genetic disease was identified in 75 (80%) patients, including MEN 2A (42.6%), VHL (19.1%), MEN 2B (9.6%) and NF1 (8.5%). Excess catecholamines were present in 97% of patients. Patients with synchronous pheochromocytoma commonly underwent simultaneous bilateral adrenalectomy (99%), and 18 (24%) had cortical-sparing surgery. Multicentric tumours were reported in 23 of 77 (30%) patients with available data. Recurrent disease was found in 9.6% of patients, and 8.5% developed metastatic disease. Median follow-up was 8.5 years. At the study conclusion, 4 patients had died due to pheochromocytoma or adrenalectomy. CONCLUSIONS Bilateral pheochromocytoma occurred in 7.0% of adults with pheochromocytoma and 37.5% of paediatric patients. Genetic disease was identified in 80% of patients, predominantly MEN2A. Multicentric tumours were common, but most were still cured following adrenalectomy.
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Affiliation(s)
- Nana Esi Kittah
- Division of Endocrinology, Diabetes, and Nutrition, Mayo Clinic, Rochester, MN, USA
- Health Care Partners of Nevada, Endocrinology, Las Vegas, NV, USA
| | - Lucinda M Gruber
- Division of Endocrinology, Diabetes, and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Irina Bancos
- Division of Endocrinology, Diabetes, and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Oksana Hamidi
- Division of Endocrinology, Diabetes, and Nutrition, Mayo Clinic, Rochester, MN, USA
- Division of Endocrinology and Metabolism, UT Southwestern Medical Center, Dallas, TX, USA
| | | | - Nicole Iñiguez-Ariza
- Division of Endocrinology, Diabetes, and Nutrition, Mayo Clinic, Rochester, MN, USA
- Department of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | | | - Aida Lteif
- Division of Pediatric Endocrinology and Metabolism, Mayo Clinic, Rochester, MN, USA
| | - William F Young
- Division of Endocrinology, Diabetes, and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Dana Erickson
- Division of Endocrinology, Diabetes, and Nutrition, Mayo Clinic, Rochester, MN, USA
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Abstract
OBJECTIVE. Multiple endocrine neoplasia (MEN) syndromes are autosomal-dominant genetic disorders that predispose two or more organs of the endocrine system to tumor development. Although the diagnosis relies on clinical and serologic findings, imaging provides critical information for surgical management with the ultimate goal of complete tumor resection. CONCLUSION. This article reviews abdominal neoplasms associated with the various subtypes of MEN syndromes, with a focus on clinical presentation and characteristic imaging features.
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Machens A, Dralle H. Long-term outcome after DNA-based prophylactic neck surgery in children at risk of hereditary medullary thyroid cancer. Best Pract Res Clin Endocrinol Metab 2019; 33:101274. [PMID: 31043326 DOI: 10.1016/j.beem.2019.04.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Advances in sequencing technology, providing unprecedented insights into cancer progression, have shifted the treatment paradigm towards precision medicine for hereditary medullary thyroid cancer (MTC), away from the 'one-size-fits-all' approach predicated on genetic risk alone. The DNA-based/biochemical concept, factoring serum calcitonin into the benefit-risk equation, optimizes biochemical cure while minimizing extent of prophylactic surgery and operative morbidity in children at risk. The transformative effect that has taking effect on medical practice has been impressive: Increasingly earlier molecular diagnosis and more limited prophylactic neck operations yielded excellent clinical outcomes at expert facilities 7-16 years postoperatively: biochemical cure rates approximating 100%; absence of residual structural disease or recurrence; and rarely any permanent operative morbidity. These excellent results, contingent on proper health care funding and pediatric surgical specialization, make a case for early prophylactic thyroidectomy in experienced hands once calcitonin serum levels exceed the upper normal limit of the assay in young gene carriers.
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Affiliation(s)
- Andreas Machens
- Medical Faculty, Department of Visceral, Vascular and Endocrine Surgery, Martin Luther University Halle-Wittenberg, Ernst-Grube-Str. 40, D-06097 Halle (Saale), Germany.
| | - Henning Dralle
- Medical Faculty, Department of Visceral, Vascular and Endocrine Surgery, Martin Luther University Halle-Wittenberg, Ernst-Grube-Str. 40, D-06097 Halle (Saale), Germany; Department of General, Visceral and Transplantation Surgery, Section of Endocrine Surgery, University of Duisburg-Essen, D-45122 Essen, Germany
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Sarkadi B, Baghy K, Sápi Z, Nyirő G, Likó I, Patócs A. Germline BRCA1 Mutation Detected in a Multiple Endocrine Neoplasia Type 2 Case With RET Codon 634 Mutation. Front Genet 2019; 10:544. [PMID: 31263477 PMCID: PMC6584812 DOI: 10.3389/fgene.2019.00544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 05/22/2019] [Indexed: 11/26/2022] Open
Abstract
Coincidences of more than one pathogenic mutation in high and/or moderate risk-associated cancer genes have been rarely reported, and the implication for disease progression has been debated. We present a case harboring two autosomal dominant inherited mutations potentially aggravating the phenotype. Case report: A 16-year-old female was referred to the Endocrine Unit due to two palpable thyroid nodules and hair loss. Two hypoechoic, inhomogeneous masses with microcalcification in the thyroid gland were confirmed as medullary thyroid carcinoma. Genetic testing revealed a pathogenic heterozygous RET mutation associated with multiple endocrine neoplasia type 2 (MEN2). Furthermore, genetic screening identified the same mutation in the proband’s clinically negative brother as well as in his two sons. The proband’s mother and maternal aunt died of breast cancer. No samples were available from the deceased. The proband underwent further genetic counseling and BRCA1/2 testing. A novel, frameshift heterozygous BRCA1 mutation (BRCA1 p.Ile90Serfs, NC_000017.10:g.41256905_41256917) was identified in the proband, but it was absent in the brother and father, indicative of maternal inheritance. Breast or ovarian cancer was neither detected in our case at initial presentation nor during the 6-year follow-up. Conclusion: Coincidence of two monogenic autosomal dominant tumor syndromes is extremely rare, but it represents a significant therapeutic and cancer surveillance challenge. Due to the wider use of next generation sequencing in clinical practice, similar situations may occur more frequently.
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Affiliation(s)
- Balázs Sarkadi
- HAS-SE "Lendulet" Hereditary Endocrine Tumors Research Group, Hungarian Academy of Sciences, Semmelweis University, Budapest, Hungary.,2nd Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Kornélia Baghy
- National Bionics Program, Budapest, Hungary.,1st Department of Pathology and Experimental Cancer Research, Semmelweis University, Budapest, Hungary
| | - Zoltán Sápi
- 1st Department of Pathology and Experimental Cancer Research, Semmelweis University, Budapest, Hungary
| | - Gábor Nyirő
- National Bionics Program, Budapest, Hungary.,HAS-SE Molecular Medicine Research Group, Hungarian Academy of Sciences, Semmelweis University, Budapest, Hungary
| | - István Likó
- HAS-SE "Lendulet" Hereditary Endocrine Tumors Research Group, Hungarian Academy of Sciences, Semmelweis University, Budapest, Hungary.,National Bionics Program, Budapest, Hungary
| | - Attila Patócs
- HAS-SE "Lendulet" Hereditary Endocrine Tumors Research Group, Hungarian Academy of Sciences, Semmelweis University, Budapest, Hungary.,Department of Laboratory Medicine, Semmelweis University, Budapest, Hungary
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8
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Parkhurst E, Calonico E, Abboy S. Utilization of Genetic Testing for RET Mutations in Patients with Medullary Thyroid Carcinoma: a Single-Center Experience. J Genet Couns 2018; 27:1411-1416. [DOI: 10.1007/s10897-018-0273-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 06/14/2018] [Indexed: 12/18/2022]
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Rajabi S, Hedayati M. Medullary Thyroid Cancer: Clinical Characteristics and New Insights into Therapeutic Strategies Targeting Tyrosine Kinases. Mol Diagn Ther 2018; 21:607-620. [PMID: 28698976 DOI: 10.1007/s40291-017-0289-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Medullary thyroid carcinoma (MTC) is a hyperplasia of thyroid C-cells, accounting for 5-10% of all thyroid cancers. MTCs may appear as sporadic or hereditary forms, and several molecules and signaling pathways have been found to function defectively in MTC cells. Tyrosine kinases are the most well-studied molecules that have abnormal function in these tumor cells. Due to their limited response, chemotherapeutic agents and radiation therapy are not effective in treating patients with advanced metastatic MTC. In the past decade, significant attention has been given to the utilization of multikinase inhibitors as targeted therapeutic agents for treating MTC patients, with the most promising results arising from the study of tyrosine kinase inhibitors, which generally bind to the ATP binding sites of these kinases. Two drugs-vandetanib and cabozantinib-are approved for the treatment of aggressive advanced MTC; however, the potential for toxicities and adverse effects of these agents on patient quality of life need to be considered against any therapeutic gain. According to recent data, it appears that inhibition of only one receptor or molecule in a pathway is not as effective as simultaneous inhibition of different pathways, indicating the need to use combination therapy. The main purpose of this review is to describe the clinical characteristics, molecular mechanisms, and current molecular and targeted therapeutic strategies active in clinical trials for advanced MTC treatment.
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Affiliation(s)
- Sadegh Rajabi
- Department of Clinical Biochemistry, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mehdi Hedayati
- Cellular and Molecular Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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10
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Scopsi L, Castellani MR, Gullo M, Cusumano F, Camerini E, Pasini B, Orefice S. Malignant Pheochromocytoma in Multiple Endocrine Neoplasia Type 2B Syndrome. Case Report and Review of the Literature. TUMORI JOURNAL 2018; 82:480-4. [PMID: 9063528 DOI: 10.1177/030089169608200514] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A malignant behavior (i.e., distant metastatic spread) has been recorded in 3-4% of pheochromocytomas occurring in the context of multiple endocrine neoplasia type 2A syndrome, but has never been documented in patients with the type 2B form. In this report we describe a case of malignant pheochromocytoma arising in the latter syndrome setting. The patient, a white young male, had the full-blown syndrome, including multicentric, bilateral medullary thyroid carcinoma metastatic to regional lymph nodes, mucosal neuromas, digestive ganglioneuromatosis, marfanoid habitus, and bumpy lips. Three and a half years after surgical resection of an apparently benign adrenal pheochromocytoma he developed widespread osseous metastases. The presence of hypertensive crises and high urinary catecholamine excretion rates, coupled to moderate hypercalcitoninemia, normal circulating carcinoembryonic antigen levels, negative whole-body 99mTc-(V) dimercaptosuccinic acid scan, and absence of neck or mediastinal disease by magnetic resonance imaging, proved that the metastases were from his previous adrenal and not thyroid tumor. Furthermore, since the bone metastases strongly accumulated 131I-metaiodobenzylguanidine, several courses of the radiocompound were given, which resulted in an objective, though partial, tumor regression.
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Affiliation(s)
- L Scopsi
- Endocrinology Unit, Istituto Nazionale Tumori, Milan, Italy.
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Machens A, Dralle H. Advances in risk-oriented surgery for multiple endocrine neoplasia type 2. Endocr Relat Cancer 2018; 25:T41-T52. [PMID: 28883084 DOI: 10.1530/erc-17-0202] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Accepted: 09/07/2017] [Indexed: 12/20/2022]
Abstract
Genetic association studies hinge on definite clinical case definitions of the disease of interest. This is why more penetrant mutations were overrepresented in early multiple endocrine neoplasia type 2 (MEN2) studies, whereas less penetrant mutations went underrepresented. Enrichment of genetic association studies with advanced disease may produce a flawed understanding of disease evolution, precipitating far-reaching surgical strategies like bilateral total adrenalectomy and 4-gland parathyroidectomy in MEN2. The insight into the natural course of the disease gleaned over the past 25 years caused a paradigm shift in MEN2: from the removal of target organs at the expense of greater operative morbidity to close biochemical surveillance and targeted resection of adrenal tumors and hyperplastic parathyroid glands. The lead time provided by early identification of asymptomatic MEN2 carriers under biochemical surveillance delimits a 'window of opportunity', within which (i) pre-emptive total thyroidectomy alone is adequate, circumventing morbidity attendant to central node dissection; (ii) subtotal 'tissue-sparing' adrenalectomy is sufficient, trading the risk of steroid dependency for the risk of a second pheochromocytoma in the adrenal remnant and (iii) parathyroidectomy is limited to enlarged glands, trading the risk of postoperative hypoparathyroidism for the risk of leaving behind hyperactive parathyroid glands. Future research should delineate further the mutation-specific, age-dependent penetrance of pheochromocytoma and primary hyperparathyroidism to refine the risk-oriented approach to MEN2. The sweeping changes in the management of MEN2 since the new millenium hold the hope that death and major morbidity from this uncommon disease can be eliminated in our lifetime.
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Affiliation(s)
- Andreas Machens
- Department of GeneralVisceral and Vascular Surgery, Martin Luther University Halle-Wittenberg, Halle, Saale, Germany
| | - Henning Dralle
- Department of GeneralVisceral and Transplantation Surgery, Section of Endocrine Surgery, University of Duisburg-Essen, Essen, Germany
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Machens A, Elwerr M, Lorenz K, Weber F, Dralle H. Long-term outcome of prophylactic thyroidectomy in children carrying RET germline mutations. Br J Surg 2018; 105:e150-e157. [DOI: 10.1002/bjs.10746] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 09/16/2017] [Accepted: 10/03/2017] [Indexed: 01/10/2023]
Abstract
Abstract
Background
A comprehensive assessment has not been undertaken of long-term outcomes in children carrying germline RET mutations and undergoing prophylactic thyroidectomy with the aim of preventing medullary thyroid cancer (MTC).
Methods
A retrospective outcome study (1994–2017) of prophylactic thyroidectomy in children, with and without central node dissection, was performed at a tertiary surgical centre.
Results
Some 167 children underwent prophylactic thyroidectomy, 109 without and 58 with concomitant central node dissection. In the highest-risk mutational category, MTC was found in five of six children (83 per cent) aged 3 years or less. In the high-risk category, MTC was present in six of 20 children (30 per cent) aged 3 years or less, 16 of 36 (44 per cent) aged 4–6 years, and 11 of 16 (69 per cent) aged 7–12 years (P = 0·081). In the moderate-risk category, MTC was seen in one of nine children (11 per cent) aged 3 years or less, one of 26 (4 per cent) aged 4–6 years, three of 26 (12 per cent) aged 7–12 years, and seven of 16 (44 per cent) aged 13–18 years (P = 0·006). Postoperative hypoparathyroidism was more frequent in older children (32 per cent in the oldest age group versus 3 per cent in the youngest; P = 0·002), whether or not central node dissection was carried out. Three children developed recurrent laryngeal nerve palsy; all had undergone central node dissection (P = 0·040). All complications resolved within 6 months. Postoperative normalization of calcitonin serum levels was achieved in 114 (99·1 per cent) of 115 children with raised preoperative values. No residual structural disease or recurrence was observed.
Conclusion
Early prophylactic thyroidectomy is a viable surgical concept in experienced hands, sparing older children the postoperative morbidity associated with delayed neck surgery.
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Affiliation(s)
- A Machens
- Department of General, Visceral and Vascular Surgery, Medical Faculty, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - M Elwerr
- Department of General, Visceral and Vascular Surgery, Medical Faculty, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - K Lorenz
- Department of General, Visceral and Vascular Surgery, Medical Faculty, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - F Weber
- Department of General, Visceral and Transplantation Surgery, Section of Endocrine Surgery, University of Duisburg-Essen, Essen, Germany
| | - H Dralle
- Department of General, Visceral and Vascular Surgery, Medical Faculty, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
- Department of General, Visceral and Transplantation Surgery, Section of Endocrine Surgery, University of Duisburg-Essen, Essen, Germany
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13
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Saltiki K, Anagnostou E, Simeakis G, Kouki S, Angelopoulou A, Sarika L, Papathoma A, Alevizaki M. Familial MTC with RET exon 8 Gly533Cys mutation: origin and prevalence of second malignancy. Endocr Connect 2017; 6:676-684. [PMID: 28951487 PMCID: PMC5655672 DOI: 10.1530/ec-17-0147] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 09/26/2017] [Indexed: 01/04/2023]
Abstract
INTRODUCTION High prevalence of RET p.Gly533Cys (c.1597G > T) has been found in familial MTC in Greece (exon 8 fMTC). We studied their origin and compared clinical characteristics with non-exon 8 fMTC. METHODS 102 fMTC (FMTC and MEN2A) patients (31.4% males) were followed for 2.9-37 years (median 6 years). Fifty-one carried the RET exon 8 mutation; the remaining were non-exon 8 fMTC (exons 10, 11, 13, 14). Pre-, post-operative calcitonin, disease extent at diagnosis and follow-up and families' place of origin were recorded. RESULTS Exon 8 fMTC were older (42.3 ± 13.3 vs 30.8 ± 17.8 years, P < 0.001), including index cases (P = 0.016). In index cases, the stage at diagnosis was more favorable in exon 8 fMTC compared to non-exon 8 fMTC (stage I and II: 65% vs 23.8%, stage III: 25% vs 57.1%, stage IV: 10% vs 19%, P = 0.025). More favorable outcome was noted in exon 8 fMTCs (remission: 72.5% vs 45.8%, stable disease: 27.5% vs 41.7%, progression: 0.0% vs 12.5%, P = 0.001). Exon 8 fMTC patients carried more frequently a second malignancy (25.5% vs 6.3%, P = 0.009); 69% of these were PTCs. Exon 8 fMTC patients were significantly older at diagnosis compared to non-exon 8 moderate-risk RET carriers and presented more favorable clinical outcome (remission: 72.5% vs 50%, stable disease: 27.5% vs 41.7%, progression: 0.0% vs 8.3%, P = 0.021). This difference remained when only index cases were analyzed. 'Hot spots' in the origin of exon 8 fMTCs families were recognized. No phenotype or outcome differences were found between the exon 8 families from the various regions. CONCLUSIONS In exon 8 fMTCs' older age, favorable disease stage at diagnosis and favorable outcome suggest slow disease progression compared to non-exon 8 fMTC. Compared with moderate-risk RET mutation carriers, exon 8 fMTC patients have a more favorable clinical outcome. The higher prevalence of second malignancies, especially PTC, not previously reported, merits further investigation. Increased awareness for inherited disease is required for patients with apparently sporadic MTC originating from recognized 'hot spots', as the age at presentation is usually delayed.
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Affiliation(s)
- Katerina Saltiki
- Endocrine UnitDepartment of Medical Therapeutics, National and Kapodistrian University of Athens, Alexandra Hospital, Athens, Greece
| | - Elli Anagnostou
- Endocrine UnitDepartment of Medical Therapeutics, National and Kapodistrian University of Athens, Alexandra Hospital, Athens, Greece
| | - George Simeakis
- Endocrine UnitDepartment of Medical Therapeutics, National and Kapodistrian University of Athens, Alexandra Hospital, Athens, Greece
| | - Sofia Kouki
- Endocrine UnitDepartment of Medical Therapeutics, National and Kapodistrian University of Athens, Alexandra Hospital, Athens, Greece
| | - Anastasia Angelopoulou
- Endocrine UnitDepartment of Medical Therapeutics, National and Kapodistrian University of Athens, Alexandra Hospital, Athens, Greece
| | - Leda Sarika
- Endocrine UnitDepartment of Medical Therapeutics, National and Kapodistrian University of Athens, Alexandra Hospital, Athens, Greece
| | - Alexandra Papathoma
- Endocrine UnitDepartment of Medical Therapeutics, National and Kapodistrian University of Athens, Alexandra Hospital, Athens, Greece
| | - Maria Alevizaki
- Endocrine UnitDepartment of Medical Therapeutics, National and Kapodistrian University of Athens, Alexandra Hospital, Athens, Greece
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14
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Angelousi A, Settas N, Faucz FR, Lyssikatos C, Quezado M, Nasiri-Ansari N, Stratakis CA, Kassi E. Medullary thyroid cancer, leukemia, mesothelioma and meningioma associated with germline APC and RASAL1 variants: a new syndrome? Hormones (Athens) 2017. [PMID: 29518763 PMCID: PMC6341468 DOI: 10.14310/horm.2002.1763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Medullary thyroid carcinoma (MTC) is a neuroendocrine tumor hereditary in 35% of cases. The most common syndromic form is in the context of the multiple endocrine neoplasia type 2 (MEN 2) syndromes in association with other tumors and due to germline RET mutations. We describe a 57-year-old female patient diagnosed with sporadic MTC. The patient had a history of other neoplasias, such as acute myeloid leukemia, for which she had received chemotherapy, and two other solid tumors, peritoneal mesothelioma and meningioma. Genetic analyses were carried out including whole exome and Sanger sequencing (WES and SS) and loss-of-heterozygosity (LOH) testing for the respective loci. Immunohistochemistry (IHC) was used for the detection of proteins of interest. WES showed two germline variants in the APC and RASAL1 genes confirmed by SS. In MTC tissue only there was a RETvariant identified by SS; germline studies did not show any RETsequence changes. The pattern of tumors in this patient is unusual for either one of the APC- orRASAL1-associated neoplasms and her non-MEN 2-associated MTC contained a RET variant like other sporadic MTCs. As in other patients with more than one genetic variant predisposing to tumors, it is possible that this case represents a unique association.
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Affiliation(s)
- Anna Angelousi
- 1st Department of Internal Medicine, Laiko Hospital, Medical School, National and Kapodistrian University of Athens, 75 Mikras Asias Str., Goudi, 11527, Athens, Greece
- Section on Endocrinology & Genetics, Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD), National Insitutes of Health (NIH), Bethesda, USA
| | - Nikolaos Settas
- Section on Endocrinology & Genetics, Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD), National Insitutes of Health (NIH), Bethesda, USA
| | - Fabio R Faucz
- Section on Endocrinology & Genetics, Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD), National Insitutes of Health (NIH), Bethesda, USA
| | - Charalampos Lyssikatos
- Section on Endocrinology & Genetics, Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD), National Insitutes of Health (NIH), Bethesda, USA
| | - Martha Quezado
- Laboratory of Pathology, National Cancer Institute (NCI), NIH, Bethesda, USA
| | - Narjes Nasiri-Ansari
- Department of Biological Chemistry, National and Kapodistrian University of Athens, Athens, Greece
| | - Constantine A Stratakis
- Section on Endocrinology & Genetics, Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD), National Insitutes of Health (NIH), Bethesda, USA
| | - Eva Kassi
- 1st Department of Internal Medicine, Laiko Hospital, Medical School, National and Kapodistrian University of Athens, 75 Mikras Asias Str., Goudi, 11527, Athens, Greece.
- Department of Biological Chemistry, National and Kapodistrian University of Athens, Athens, Greece.
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15
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Opsahl EM, Brauckhoff M, Schlichting E, Helset K, Svartberg J, Brauckhoff K, Mæhle L, Engebretsen LF, Sigstad E, Grøholt KK, Akslen LA, Jørgensen LH, Varhaug JE, Bjøro T. A Nationwide Study of Multiple Endocrine Neoplasia Type 2A in Norway: Predictive and Prognostic Factors for the Clinical Course of Medullary Thyroid Carcinoma. Thyroid 2016; 26:1225-38. [PMID: 27400880 DOI: 10.1089/thy.2015.0673] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Multiple endocrine neoplasia type 2A (MEN 2A) is an autosomal dominant syndrome caused by activating germline mutations in the RET (REarranged during Transfection) proto-oncogene. MEN 2A has a strong (>95%) and age-dependent (5-25 years) clinical penetrance of medullary thyroid carcinoma (MTC). Several major studies have analyzed the predictive and prognostic factors for MEN 2A to find indicators that predict the optimal timing of prophylactic thyroidectomy. The aims of this study were to describe all known RET positive MEN 2A patients diagnosed in Norway and to evaluate the clinical course of MTC, as well as its predictive and prognostic factors. METHODS This nationwide retrospective cohort study included data for 65 (14 index and 51 screening patients) out of a total of 67 MEN 2A patients with the RET gene mutation who were diagnosed in Norway since 1974. Data were collected by reviewing patient files. The variables analyzed were genotype, phenotype, preoperative basal calcitonin, age at thyroid surgery, central lymph node dissection and nodal status at primary surgery, number of surgical procedures, and biochemical cure. Of the 65 patients, 60 had undergone thyroid surgery. The median follow-up period was 9.9 years. The patients were divided into pre-RET-and RET-era, which included patients who had thyroid surgery before January 1, 1994, and after, respectively. RESULTS In index and screening patients, MTC was found, respectively, in 100% and 45% of cases, central lymph node dissection at primary surgery was done for 64% and 52% of patients, and the median total number of surgical procedures was two (range 1-6) and one (range 1-4). At primary surgery, all patients (n = 13) with lymph node metastases had preoperative basal calcitonin levels ≥68 pg/mL, and all patients (n = 17) without central lymph node dissection and preoperative basal calcitonin <40 pg/mL were biochemically cured. Multivariate analysis showed that preoperative basal calcitonin was a significant predictive factor for MTC superior to age at thyroid surgery when analyzing the entire period (p = 0.009) and the RET-era separately (p = 0.021). Prognostic factors for biochemical cure were preoperative basal calcitonin, central lymph node dissection, and nodal status at primary surgery (p = 0.037, p = 0.002, and p = 0.005) when analyzing the entire period, but only nodal status at primary surgery when the RET-era was considered separately (p = 0.006). CONCLUSIONS Preoperative basal calcitonin alone can serve as an indicator for optimal timing and the extent of thyroid surgery for MEN 2A patients that could be considered safe. The results are consistent with previously reported data.
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Affiliation(s)
- Else Marie Opsahl
- 1 Department of Oncology, Section for Breast and Endocrine Surgery, Oslo University Hospital , Oslo, Norway
- 2 Institute of Clinical Medicine, University of Oslo , Oslo, Norway
| | - Michael Brauckhoff
- 3 Department of Breast and Endocrine Surgery, Haukeland University Hospital , Bergen, Norway
- 4 Department of Clinical Science, University of Bergen , Bergen, Norway
| | - Ellen Schlichting
- 1 Department of Oncology, Section for Breast and Endocrine Surgery, Oslo University Hospital , Oslo, Norway
| | - Kristin Helset
- 5 Department of Breast and Endocrine Surgery, St. Olavs University Hospital , Trondheim, Norway
| | - Johan Svartberg
- 6 Division of Internal Medicine, University Hospital of North Norway , Tromsø, Norway
- 7 Institute of Clinical Medicine, UIT, The Arctic University of Norway , Tromsø, Norway
| | - Katrin Brauckhoff
- 3 Department of Breast and Endocrine Surgery, Haukeland University Hospital , Bergen, Norway
| | - Lovise Mæhle
- 8 Department of Medical Genetics, Oslo University Hospital , Oslo, Norway
| | | | - Eva Sigstad
- 10 Department of Pathology, Oslo University Hospital , Oslo, Norway
| | | | - Lars Andreas Akslen
- 11 Centre for Cancer Biomarkers CCBIO, Department of Clinical Medicine, Section for Pathology, University of Bergen , Bergen, Norway
- 12 Department of Pathology, Haukeland University Hospital , Bergen, Norway
| | | | - Jan Erik Varhaug
- 3 Department of Breast and Endocrine Surgery, Haukeland University Hospital , Bergen, Norway
- 4 Department of Clinical Science, University of Bergen , Bergen, Norway
| | - Trine Bjøro
- 2 Institute of Clinical Medicine, University of Oslo , Oslo, Norway
- 14 Department of Medical Biochemistry, Oslo University Hospital , Oslo, Norway
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16
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Aydoğan Bİ, Yüksel B, Tuna MM, Navdar Başaran M, Akkurt Kocaeli A, Ertörer ME, Aydın K, Güldiken S, Şimşek Y, Cihan Karaca Z, Yılmaz M, Aktürk M, Anaforoğlu İ, Kebapçı N, Duran C, Taşlıpınar A, Kulaksızoğlu M, Gürsoy A, Dağdelen S, Erdoğan MF. Distribution of RET Mutations and Evaluation of Treatment Approaches in Hereditary Medullary Thyroid Carcinoma in Turkey. J Clin Res Pediatr Endocrinol 2016; 8:13-20. [PMID: 26758973 PMCID: PMC4805043 DOI: 10.4274/jcrpe.2219] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE This retrospective multicenter study, centrally conducted and supported by the Society of Endocrinology and Metabolism of Turkey, aimed to evaluate the impact of free RET proto-oncogene testing in medullary thyroid carcinoma (MTC) patients. Surgical timing, adequacy of the treatment, and frequency of prophylactic thyroidectomy (PTx) in mutation carriers were also assessed. METHODS Genetic testing for MTC and pheochromocytoma was conducted between July 2008 and January 2012 in 512 patients. Application forms and RET mutation analyses of these patients whose blood samples were sent from various centers around Turkey were assessed retrospectively. An evaluation form was sent to the physicians of the eligible 319 patients who had confirmed sporadic MTC, familial MTC (FMTC), multiple endocrine neoplasia type 2 (MEN2), or who were mutation carriers. Physicians were asked to give information about the surgical history, latest calcitonin levels, morbidity, mortality, genetic screening, and PTx among family members. Twenty-five centers responded by filling in the forms of 192 patients. RESULTS Among the 319 patients, RET mutation was detected in 71 (22.3%). Cys634Arg mutation was the most prevalent mutation (43.7%), followed by Val804Met in 18 patients (25.4%), and Cys634Tyr in 6 patients (8.5%). Among 192 MTC patients, the diagnosis was sporadic MTC in 146 (76.4%), FMTC in 14 (7.3%), MEN2A in 15 patients (7.9%), and MEN2B in one patient. The number of mutation carriers among 154 apparently sporadic MTC patients was 8 (5.2%). Ten patients were submitted to PTx out of twenty-four mutation carriers at a mean age of 35±19 years. CONCLUSION Turkish people have a similar RET proto-oncogene mutation distribution when compared to other Mediterranean countries. Despite free RET gene testing, the number of the PTx in Turkey is limited and relatively late in the life span of the carriers. This is mainly due to patient and family incompliance and incomplete family counselling.
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Affiliation(s)
- Berna İmge Aydoğan
- Ankara University Faculty of Medicine, Department of Endocrinology and Metabolism, Ankara, Turkey, Phone: +90 312 309 45 05 E-mail:
| | - Bağdagül Yüksel
- Ankara University Faculty of Medicine, Department of Endocrinology and Metabolism, Ankara, Turkey
| | - Mazhar Müslüm Tuna
- Ankara Numune Training and Research Hospital, Clinic of Endocrinology and Metabolism, Ankara, Turkey
| | - Mehtap Navdar Başaran
- Ankara Numune Training and Research Hospital, Clinic of Endocrinology and Metabolism, Ankara, Turkey
| | - Ayşen Akkurt Kocaeli
- Uludağ University Faculty of Medicine, Department of Endocrinology and Metabolism, Bursa, Turkey
| | - Melek Eda Ertörer
- Başkent University Faculty of Medicine, Department of Endocrinology and Metabolism, Adana, Turkey
| | - Kadriye Aydın
- Hacettepe University Faculty of Medicine, Department of Endocrinology and Metabolism, Ankara, Turkey
| | - Sibel Güldiken
- Trakya University Faculty of Medicine, Department of Endocrinology and Metabolism, Edirne, Turkey
| | - Yasin Şimşek
- Erciyes University Faculty of Medicine, Department of Endocrinology and Metabolism, Kayseri, Turkey
| | - Züleyha Cihan Karaca
- Erciyes University Faculty of Medicine, Department of Endocrinology and Metabolism, Kayseri, Turkey
| | - Merve Yılmaz
- Dokuz Eylül University Faculty of Medicine, Department of Endocrinology and Metabolism, İzmir, Turkey
| | - Müjde Aktürk
- Gazi University Faculty of Medicine, Department of Endocrinology and Metabolism, Ankara, Turkey
| | - İnan Anaforoğlu
- Trabzon Numune Training and Research Hospital, Clinic of Endocrinology and Metabolism, Trabzon, Turkey
| | - Nur Kebapçı
- Osmangazi University Faculty of Medicine, Department of Endocrinology and Metabolism, Eskişehir, Turkey
| | - Cevdet Duran
- Konya Training and Research Hospital, Clinic of Endocrinology and Metabolism, Konya, Turkey
| | - Abdullah Taşlıpınar
- Gülhane Military Medical Academy, Department of Endocrinology and Metabolism, Ankara, Turkey
| | - Mustafa Kulaksızoğlu
- Necmettin Erbakan University Faculty of Medicine, Department of Endocrinology and Metabolism, Konya, Turkey
| | - Alptekin Gürsoy
- Güven Hospital, Clinic of Endocrinology and Metabolism, Ankara, Turkey
| | - Selçuk Dağdelen
- Hacettepe University Faculty of Medicine, Department of Endocrinology and Metabolism, Ankara, Turkey
| | - Murat Faik Erdoğan
- Ankara University Faculty of Medicine, Department of Endocrinology and Metabolism, Ankara, Turkey
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17
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Brandi ML, Tonelli F. Genetic Syndromes Associated with Primary Hyperparathyroidism. Updates Surg 2016. [DOI: 10.1007/978-88-470-5758-6_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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18
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Mavromati M, Amsallem M, Jublanc C, Bruckert E, Leenhardt L, Girerd X. Questioning the pathogenic role of the pTyr791Phe mutation of the RET proto-oncogene: Insight from a case report. ANNALES D'ENDOCRINOLOGIE 2015; 76:690-694. [PMID: 26639185 DOI: 10.1016/j.ando.2015.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
UNLABELLED The pTyr791Phe mutation of the RET proto-oncogene is associated with a low penetrance of medullar thyroid carcinoma (MTC). Thus, there is a lack in guidelines on management of these patients presenting without a thyroid disease. CLINICAL CASE A 27-year-old woman presented with a history of severe hypertension, paroxysmal tachycardia, diaphoresis and headaches. Twenty-four-hour urinary norepinephrine and normetanephrine levels were exclusively up to 20 times the normal limit. CT-scan and MRI found a 35-mm diameter right adrenal tumor, highly intense in T2- and hypo-intense in T1-weighted image, enhanced after gadolinium injection. After alpha-adrenergic blocker treatment, a surgical resection of the tumor was performed; this latter proved to be a pheochromocytoma. Genetic screening only revealed a germline pTyr791Phe mutation of the RET proto-oncogene. However, the patient showed no evidence of MEN2: basal calcitonin was normal and calcium infusion test was negative. Thyroid ultrasound revealed a TIRADS 3 nodule with benign cytology. Total thyroidectomy was suggested but withheld due to the patient's refusal and a close follow-up was decided. CONCLUSION This rare case of pTyr791Phe mutation-related pheochromocytoma without evidence of MTC questions the indication for prophylactic thyroidectomy in mutation carriers, as recent data challenges its pathogenicity.
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Affiliation(s)
- Maria Mavromati
- Department of Endocrinology and Metabolic Diseases, La Pitié-Salpêtrière Hospital, boulevard de l'Hôpital, 75013 Paris, France; Department of Endocrinology and Diabetes, University Hospital of Geneva, Geneva, Switzerland
| | - Myriam Amsallem
- Department of Endocrinology and Metabolic Diseases, La Pitié-Salpêtrière Hospital, boulevard de l'Hôpital, 75013 Paris, France.
| | - Christel Jublanc
- Department of Endocrinology and Metabolic Diseases, La Pitié-Salpêtrière Hospital, boulevard de l'Hôpital, 75013 Paris, France
| | - Eric Bruckert
- Department of Endocrinology and Metabolic Diseases, La Pitié-Salpêtrière Hospital, boulevard de l'Hôpital, 75013 Paris, France
| | - Laurence Leenhardt
- Department of Nuclear Medicine, La Pitié-Salpêtrière Hospital, boulevard de l'Hôpital, 75013 Paris, France
| | - Xavier Girerd
- Department of Endocrinology and Metabolic Diseases, La Pitié-Salpêtrière Hospital, boulevard de l'Hôpital, 75013 Paris, France
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19
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Giri D, McKay V, Weber A, Blair JC. Multiple endocrine neoplasia syndromes 1 and 2: manifestations and management in childhood and adolescence. Arch Dis Child 2015; 100:994-9. [PMID: 25854874 DOI: 10.1136/archdischild-2014-307028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 03/11/2015] [Indexed: 11/03/2022]
Abstract
The identification of the genetic causes of the multiple endocrine neoplasia (MEN) syndromes 1 and 2, and associated genotype-phenotype relationships, has revolutionised the clinical care of affected patients. A genetic diagnosis can be made during infancy and careful clinical surveillance, coupled with early intervention, has the potential to improve both morbidity and mortality. These developments have seen the management of patients with MEN move into the arena of paediatric medicine. In this review article, we consider the genetic causes of MEN together with the clinical manifestations and management of these syndromes.
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Affiliation(s)
- D Giri
- Department of Endocrinology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - V McKay
- Department of Medical Genetics, Liverpool Women's Hospital, Liverpool, UK
| | - A Weber
- Department of Medical Genetics, Liverpool Women's Hospital, Liverpool, UK
| | - J C Blair
- Department of Endocrinology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
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20
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Affiliation(s)
- Elizabeth G Grubbs
- Departments of Surgical Oncology (E.G.G.) and Endocrine Neoplasia and Hormonal Disorders (R.F.G.), University of Texas MD Anderson Cancer Center, Houston, Texas 77030
| | - Robert F Gagel
- Departments of Surgical Oncology (E.G.G.) and Endocrine Neoplasia and Hormonal Disorders (R.F.G.), University of Texas MD Anderson Cancer Center, Houston, Texas 77030
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21
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Abstract
Adrenal incidentalomas are adrenal masses discovered incidental to imaging studies performed for reasons unrelated to adrenal pathology. Although most adrenal incidentalomas are non-functioning benign adenomas, their increasing prevalence presents diagnostic and therapeutic challenges. The assessment of adrenal incidentalomas is aimed at deciding whether or not the tumour should be surgically removed. Adrenalectomy is indicated for phaeochromocytoma, other symptomatic hormone-secreting tumours and those with a high risk of malignancy. Biochemical screening for tumour hypersecretion is mandatory in all adrenal incidentalomas, since hormone secreting tumours may be clinically silent. The diagnosis of phaeochromocytoma is of paramount importance because of its life-threatening complications. Non-functioning adrenal incidentalomas need assessment for risk of malignancy, and this is based on the size of the tumour and its imaging characteristics. An observational policy with periodic radiological and biochemical reassessment is pursued in patients with non-functioning incidentalomas with low malignancy risk. The duration and frequency of reassessment remains unclear, as the natural history of adrenal incidentalomas has yet to be clearly defined, and there is a lack of controlled studies comparing surgical intervention with observation. However, the possibility of acquiring autonomous hypersecretion or conversion to malignancy in an incidentaloma diagnosed to be a benign non-functioning lesion is very low, and most patients may be safely discharged after an initial follow-up period of 2 years.
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Affiliation(s)
- P K Singh
- Endocrinology and Diabetes, University Hospitals of North Staffordshire, Stoke on Trent, UK
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22
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Dionigi G, Bianchi V, Rovera F, Boni L, Piantanida E, Tanda ML, Dionigi R, Bartalena L. Medullary thyroid carcinoma: surgical treatment advances. Expert Rev Anticancer Ther 2014; 7:877-85. [PMID: 17555398 DOI: 10.1586/14737140.7.6.877] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Since medullary thyroid cancer (MTC) was first recognized as a distinct tumor in 1959, it became clear that MTC is more difficult to cure than papillary thyroid cancer and has higher rates of recurrence and mortality. MTC represents 5-8% of thyroid cancers. It derives from parafollicular cells of the ultimobranchial body derived from the neural crest. MTC secretes calcitonin and other hormonal peptides and is considered part of the amine precursor uptake and decarboxilation system. MTC may occur either as a hereditary or nonhereditary entity. Hereditary MTC can occur either alone as the familial MTC or as the thyroid manifestation of multiple endocrine neoplasia (MEN) type 2 syndromes (MEN 2A MEN 2B). Activating point mutations of the RET proto-oncogene have demonstrated to be causative of the familial form of medullary thyroid cancer, both isolated familial MTC and associated with MEN 2A and 2B. In the last 10 years, major improvements and new technologies have been proposed and applied in thyroid surgery; among these are molecular diagnosis with genetic screening and mini-invasive video-assisted thyroidectomy. The history of thyroid surgery starts with Billroth, Kocher and Halsted, who developed the technique for thyroidectomy between 1873 and 1910. Prophylactic surgery for patients carrying a positive RET proto-oncogene has proven to be highly effective in curing those likely to experience the development of MTC. Video-assisted procedures with central compartment dissection have proved feasible for patients carrying a positive RET proto-oncogene. This paper reviews relevant medical literature published in the English language on surgery of MTC in well-controlled trials. We discuss the particular ethical and legal issues that thyroid prophylactic surgery raises. Searches were last updated in February 2007.
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Affiliation(s)
- Gianlorenzo Dionigi
- Department of Surgical Sciences, University of Insubria, Azienda Ospedaliero-Universitario, Fondazione Macchi 57, Varese, Italy.
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23
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Alevizaki M, Kyratzoglou E, Bamias A, Tzanela M, Dimopoulos MA, Saltiki K. Metachronous appearance of second malignancies in medullary thyroid carcinoma (MTC) patients: a diagnostic challenge and brief review of the literature. Endocrine 2013; 44:610-5. [PMID: 23608930 DOI: 10.1007/s12020-013-9961-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Accepted: 04/10/2013] [Indexed: 02/07/2023]
Abstract
Medullary thyroid carcinoma (MTC) is a rare tumour which frequently occurs in the context of the multiple endocrine neoplasia syndromes, where it coexists with other usually benign tumours. The clinical picture varies and distant metastases are frequently present at diagnosis. Calcitonin levels are elevated in the presence of metastatic disease. Two MTC cases are presented, which had elevated postoperative calcitonin levels. Imaging revealed lung lesions which were originally attributed to metastatic disease from the MTC. However, at follow-up, these cases presented unusual features. The rapid increase in the lung lesions and the development of hypercalcaemia in the first patient suggested a second unrelated tumour. Biopsy of the lung lesion was compatible with lung adenocarcinoma. In the second patient, the appearance of a liver mass, although calcitonin levels remained stable, led to biopsy of the lesion: this was negative for calcitonin and compatible with metastatic lung adenocarcinoma. These MTC cases show that further malignancies may coexist with MTC and may obscure the clinical picture and influence the therapeutic decisions, especially in the case of metastatic disease. Features such as unusual imaging characteristics and the development of hypercalcemia, never encountered in MTC outside the MEN2 syndromes, as well as 'disproportionately' low calcitonin levels, incompatible with extensive metastatic disease, were the factors that led to further work-up. Both the cases subsequently proved to carry an unsuspected second malignancy. It is crucial to discriminate the metastatic lesion attributed to MTC from another coexisting primary malignancy, because different therapeutic strategies are needed for each setting.
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Affiliation(s)
- Maria Alevizaki
- Endocrine Unit, Department of Medical Therapeutics, Alexandra Hospital, Athens University School of Medicine, 80, Vas Sofias ave, 11528, Athens, Greece
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Cui Q, Wang W, Fu Z, Shao X, Zhang Z, Zhang M, Ju X, Wang K, Chen J, Zhou H. Integrated DNA-based/biochemical screening for early diagnosis of multiple endocrine neoplasia type 2A (MEN2A). J Biomed Res 2013; 27:145-50. [PMID: 23554805 PMCID: PMC3602872 DOI: 10.7555/jbr.27.20120121] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2012] [Revised: 11/06/2012] [Accepted: 11/16/2012] [Indexed: 12/16/2022] Open
Abstract
Multiple endocrine neoplasia type 2A (MEN2A), a subtype of MEN2, is characterized by medullary thyroid cancer, pheochromocytoma, and primary hyperparathyroidism. A Han Chinese pedigree with MEN2A was investigated following confirmation of the proband's diagnosis by pathological findings and DNA/biochemical screening. DNA samples from 4 other family members were collected and exon 5, 8, 10, 11, 13, 16 and 18 of the RET proto-oncogene were sequenced and then analyzed. A missense mutation of TGG (Trp) to TGC (Cys) at codon 634 (the classic MEN2A mutation) in exon 11 of the RET gene was detected in 3 family members, including the proband. Sequencing data were compared with the human gene mutation database. Elevated serum calcitonin level was detected initially; medullary thyroid carcinoma was revealed in the 3 cases and adrenal pheochromocytoma was also found in the proband. Elective operations were successfully performed on the adrenal and thyroid glands because of pheochromocytoma and medullary thyroid carcinoma. Our case study confirms that integrated DNA-based/biochemical screening is crucial for early diagnosis of MEN2A and is helpful in the screening of their relatives. In addition, DNA-based screening may occasionally uncover a previously unknown RET sequence.
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Affiliation(s)
- Qin Cui
- Department of Geriatrics, Department of Cadres, Tong Ling People's Hospital, Tongling, Anhui 244000, China
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Grubbs EG, Rich TA, Ng C, Bhosale PR, Jimenez C, Evans DB, Lee JE, Perrier ND. Long-term outcomes of surgical treatment for hereditary pheochromocytoma. J Am Coll Surg 2013; 216:280-9. [PMID: 23317575 DOI: 10.1016/j.jamcollsurg.2012.10.012] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Revised: 10/05/2012] [Accepted: 10/15/2012] [Indexed: 02/03/2023]
Abstract
BACKGROUND The ideal surgical management of hereditary pheochromocytomas includes planning for a potential metachronous bilateral presentation and the possibility of lifelong steroid dependence if bilateral adrenalectomy is needed. An intact and viable cortical remnant after bilateral pheochromocytoma resection can eliminate the necessity for steroid dependency, but can increase the risk of pheochromocytoma recurrence. STUDY DESIGN We retrospectively reviewed outcomes of all patients with a diagnosis of hereditary pheochromocytomas treated at our tertiary cancer institution from 1962-2011, with subset analysis of patients undergoing a cortical-sparing procedure in the setting of bilateral adrenalectomy. RESULTS Of the ninety-six patients who underwent adrenalectomy for hereditary pheochromocytomas, 47 presented with bilateral disease. In 15 of the 49 patients (30%) who originally underwent unilateral adrenalectomy, pheochromocytoma developed in the contralateral gland at a median of 8.2 years (range 1 to 20 years) after the initial diagnosis. There were 4 recurrences in 55 cortical-sparing remnants (7%) and 3 recurrences in the adrenal bed after 101 intended total adrenal resections (3%) (p = 0.24). Total bilateral adrenalectomy was performed in 25 patients and acute adrenal insufficiency developed in 5 (20%) of those patients. An intended cortical-sparing adrenalectomy was performed in 39 patients and acute adrenal insufficiency developed in 1 (3%). Of these patients with adequate follow-up, 21 of 27 (78%) were steroid independent at 3-year follow-up. Sex, median age, adrenal vein preservation, metachronous adrenal resection, and bilateral cortical-sparing procedures did not predict steroid independence at 3 years. CONCLUSIONS Cortical-sparing adrenalectomy avoids long-term corticosteroid dependence in the majority of patients with hereditary pheochromocytoma with minimal risk of acute adrenal insufficiency. Recurrence occurs in approximately 7% of adrenal remnants.
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Affiliation(s)
- Elizabeth G Grubbs
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX 77030-4008, USA.
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Abstract
Incremental advances in medical technology, such as the development of sensitive hormonal assays for routine clinical care, are the drivers of medical progress. This principle is exemplified by the creation of the concept of multiple endocrine neoplasia type 2, encompassing medullary thyroid cancer, pheochromocytoma, and primary hyperparathyroidism, which did not emerge before the early 1960s. This review sets out to highlight key achievements, such as joint biochemical and DNA-based screening of individuals at risk of developing multiple endocrine neoplasia type 2, before casting a spotlight on current challenges which include: (i) ill-defined upper limits of calcitonin assays for infants and young children, rendering it difficult to implement the biochemical part of the integrated DNA-based/biochemical concept; (ii) our increasingly mobile society in which different service providers are caring for one individual at various stages in the disease process. With familial relationships disintegrating as a result of geographic dispersion, information about the history of the origin family may become sketchy or just unavailable. This is when DNA-based gene tests come into play, confirming or excluding an individual's genetic predisposition to multiple endocrine neoplasia type 2 even before there is any biochemical or clinical evidence of the disease. However, the unrivaled molecular genetic progress in multiple endocrine neoplasia type 2 does not come without a price. Screening may uncover unknown gene sequence variants representing either harmless polymorphisms or pathogenic mutations. In this setting, functional characterization of mutant cells in vitro may generate helpful ancillary evidence with regard to the pathogenicity of gene variants in comparison with established mutations.
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Affiliation(s)
- Andreas Machens
- Department of General, Visceral and Vascular Surgery, Martin-Luther-University Halle-Wittenberg, Halle, Germany.
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Neocleous V, Skordis N, Portides G, Efstathiou E, Costi C, Ioannou N, Pantzaris M, Anastasiadou V, Deltas C, Phylactou LA. RET proto-oncogene mutations are restricted to codon 618 in Cypriot families with multiple endocrine neoplasia 2. J Endocrinol Invest 2011; 34:764-9. [PMID: 21422799 DOI: 10.3275/7605] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND RET germline mutations predispose to the development of inherited cancer syndrome multiple endocrine neoplasia type 2 (MEN2). Several variants of the RET proto-oncogene including G691S and S904S have been suggested to act as genetic modifiers at the age of onset ofMEN2. AIM The aim of this study is to characterize clinically and molecularly 7 Cypriot patients with familial medullary thyroid carcinoma (FMTC) and 1 with MEN2A and also to determine the allelic frequencies of the RET variants G691S and S904S. SUBJECTS AND METHODS Seven probands from FMTC families and 1 from MEN2A were screened for the presence of RET mutations and the G691S and S904S variants. Additionally, 226 healthy Cypriots, who served as controls were analysed in an attempt to compare the frequencies of G691S and S904S RET variants to those observed in the 8 patients. RESULTS The clinical diagnosis of the probands was based on clinical presentation and supported with biochemical findings. The germline C618R mutation of exon 10 was identified in all 8 probands and in 15 relatives from 7 different families. No significant difference in the G691S/S904S variants allele frequencies between patients (4/16 or 25%) and controls (124/452 or 27.4%) was found. CONCLUSIONS Mutational screening of the RET gene identified a common mutation (C618R) in all 8 (7 FMTC and 1 MEN2A) unrelated Cypriot patients which may be explained by a founder effect. Additionally, no association of the G691S/S904S variants was linked with the disease.
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Affiliation(s)
- V Neocleous
- Department of Molecular Genetics, Function and Therapy, Cyprus Institute of Neurology and Genetics, P.O. Box 23462, 1683 Nicosia, Cyprus
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Radiologic Appearance of Hereditary Adrenal and Extraadrenal Paraganglioma. AJR Am J Roentgenol 2011; 197:W687-95. [DOI: 10.2214/ajr.10.5419] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Waguespack SG, Rich TA, Perrier ND, Jimenez C, Cote GJ. Management of medullary thyroid carcinoma and MEN2 syndromes in childhood. Nat Rev Endocrinol 2011; 7:596-607. [PMID: 21862994 DOI: 10.1038/nrendo.2011.139] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Medullary thyroid carcinoma (MTC) and the multiple endocrine neoplasia (MEN) type 2 syndromes are rare but important endocrine diseases that are increasingly managed by pediatric providers. MTC is generally associated with a favorable prognosis when diagnosed during childhood, where it frequently occurs secondary to activating mutations in the RET proto-oncogene and arises from pre-existing C-cell hyperplasia. MEN2A accounts for 90-95% of childhood MTC cases and is most commonly due to mutations in codon 634 of RET. MEN2B is associated with the most aggressive clinical presentation of MTC and is almost always due to the Met918Thr mutation of RET. Surgery is the primary treatment and only chance of cure, although the advent of targeted therapies seems to be improving progression-free survival in advanced cases. Since the discovery of the role of RET in MEN2A, considerable advances in the management of this syndrome have occurred, and most of the children with MEN2A who have undergone early thyroidectomy will now lead full, productive lives. Strong genotype-phenotype correlations have facilitated the development of guidelines for interventions. Contemporary approaches for deciding the appropriate age at which surgery should take place incorporate data from ultrasonography and calcitonin measurements in addition to the results of genotyping. To optimize care and to facilitate ongoing research, children with MTC and the MEN2 syndromes are optimally treated at tertiary centers with multidisciplinary expertise.
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Affiliation(s)
- Steven G Waguespack
- The Department of Endocrine Neoplasia and Hormonal Disorders, PO Box 301402, Unit 1461, Houston, TX 77230-1402, USA.
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Mukherjee S, Zakalik D. RET codon 804 mutations in multiple endocrine neoplasia 2: genotype-phenotype correlations and implications in clinical management. Clin Genet 2010; 79:1-16. [DOI: 10.1111/j.1399-0004.2010.01453.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Jatoi I, Benson JR, Liau SS, Chen Y, Cisco RM, Norton JA, Moley JF, Khalifeh KW, Choti MA. The role of surgery in cancer prevention. Curr Probl Surg 2010; 47:750-830. [PMID: 20816140 DOI: 10.1067/j.cpsurg.2010.06.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Ismail Jatoi
- Division of Surgical Oncology, University of Texas Health Sciences Center, San Antonio, Texas, USA
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Abstract
Medullary thyroid cancer (MTC), accounts for approximately 5% to 10% of all thyroid cancers. Significant advances in the understanding of the biology and clinical outcomes of MTC have been made over the last decade, culminating most recently in the publication of treatment guidelines by the American Thyroid Association that follow an evidence-based approach that is summarized in this presentation. Prognosis, genetic testing, surgical technique, and re-operation are also discussed.
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Affiliation(s)
- Alan P B Dackiw
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
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Traugott AL, Moley JF. Multiple endocrine neoplasia type 2: clinical manifestations and management. Cancer Treat Res 2010; 153:321-37. [PMID: 19957233 DOI: 10.1007/978-1-4419-0857-5_18] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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van Duinen N, Steenvoorden D, Bonsing BA, Vuyk J, Vriends AHJT, Jansen JC, Romijn JA, Corssmit EPM. Pheochromocytomas detected by biochemical screening in predisposed subjects are associated with lower prevalence of clinical and biochemical manifestations and smaller tumors than pheochromocytomas detected by signs and symptoms. Eur J Endocrinol 2010; 163:121-7. [PMID: 20435616 DOI: 10.1530/eje-10-0114] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
CONTEXT Sporadic pheochromocytomas are detected by clinical signs and symptoms, whereas pheochromocytomas in patients with a known hereditary predisposition for these tumors are detected by repetitive screening for catecholamine excess. OBJECTIVE To document the clinical, biochemical, and pathological differences between patients with sporadic pheochromocytomas, detected by signs and symptoms and patients with pheochromocytomas, detected by biochemical screening in established hereditary syndromes. DESIGN Retrospective follow-up study. PATIENTS AND METHODS We included 60 consecutive patients diagnosed with pheochromocytoma (pheochromocytomas detected by signs and symptoms: n=28 and pheochromocytomas detected by screening: n=32) in our center. RESULTS Patients with pheochromocytomas detected by screening presented with less complaints of diaphoresis (P<0.01), palpitations (P=0.01), paleness (P=0.01), nausea (P<0.01), and vomiting (P=0.01) compared with patients with symptomatic pheochromocytomas. Patients with pheochromocytomas detected by screening tended to be younger at the time of diagnosis (41+/-2 vs 47+/-3 years, P=0.07). In addition, patients with pheochromocytomas detected by screening had significantly lower rates of 24-h urinary catecholamine excretion, and considerably smaller tumors (3.7+/-0.5 vs 7.3+/-0.7 cm, P<0.01). CONCLUSIONS Pheochromocytomas detected by screening of patients with a hereditary predisposition have a much lower prevalence of signs and symptoms, lower catecholamine excess, and smaller tumors, compared with sporadic pheochromocytomas, detected by signs and symptoms. These data support the benefits of screening for pheochromocytomas in patients with hereditary syndromes predisposing for these tumors.
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Affiliation(s)
- N van Duinen
- Department of Endocrinology and Metabolic Diseases, Center of Human and Clinical Genetics, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands.
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Schreinemakers JMJ, Vriens MR, Valk GD, de Groot JWB, Plukker JT, Bax KMA, Hamming JF, van der Luijt RB, Aronson DC, Borel Rinkes IHM. Factors predicting outcome of total thyroidectomy in young patients with multiple endocrine neoplasia type 2: a nationwide long-term follow-up study. World J Surg 2010; 34:852-60. [PMID: 20063095 PMCID: PMC2832884 DOI: 10.1007/s00268-009-0370-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Background Multiple endocrine neoplasia type 2 (MEN 2) is caused by a RET mutation in chromosome 10. All MEN 2 patients develop medullary thyroid carcinoma (MTC). The age-related risk of MTC is associated with the type of RET mutation. Our aim was to identify prognostic factors associated with recurrent MTC in MEN 2 patients. Methods In a nationwide case–control study, all patients who underwent total thyroidectomy in the Netherlands under the age of 20 years were classified into standard (1), high (2), or very high risk (3) for MTC based on RET-mutation type. Disease-free patients were compared with those with recurrent disease. Results A total of 93 patients were included in the study. Sixty-six percent had MTC on histology, the youngest being 1 year old. Codon 634 was most affected. Sixteen (18%) patients had persistent or recurrent disease, one of whom died. Significantly associated determinants of outcome in univariate analysis were higher age at surgery, no age-appropriate prophylactic surgery according to risk level, elevated preoperative calcitonin levels, affected codon, and the presence of lymph node metastases at surgery. On multivariate analysis only age of surgery was the single independent factor associated with persistent disease. Conclusions Prophylactic thyroidectomy beyond the recommended age is associated with persistent/recurrent disease. In addition, codon 634 mutation is associated with a high risk of recurrence requiring early surgery for all these patients.
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Affiliation(s)
- Jennifer M J Schreinemakers
- Department of Surgery, University Medical Center Utrecht, Hpnr. G04.228, Heidelberglaan 100, 3584CX Utrecht, The Netherlands
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Toledo RA, Wagner SM, Coutinho FL, Lourenço DM, Azevedo JA, Longuini VC, Reis MTA, Siqueira SAC, Lucon AM, Tavares MR, Fragoso MCBV, Pereira AA, Dahia PLM, Mulligan LM, Toledo SPA. High penetrance of pheochromocytoma associated with the novel C634Y/Y791F double germline mutation in the RET protooncogene. J Clin Endocrinol Metab 2010; 95:1318-27. [PMID: 20080836 DOI: 10.1210/jc.2009-1355] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Previous studies have shown that double RET mutations may be associated with unusual multiple endocrine neoplasia type 2 (MEN 2) phenotypes. OBJECTIVE Our objective was to report the clinical features of patients harboring a previously unreported double mutation of the RET gene and to characterize this mutation in vitro. PATIENTS Sixteen patients from four unrelated families and harboring the C634Y/Y791F double RET germline mutation were included in the study. RESULTS Large pheochromocytomas measuring 6.0-14 cm and weighing up to 640 g were identified in the four index cases. Three of the four tumors were bilateral. High penetrance of pheochromocytoma was also seen in the C634Y/Y791F-mutation-positive relatives (seven of nine, 77.7%). Of these, two cases had bilateral tumors, one presented with multifocal tumors, two cases had large tumors (>5 cm), and one case, which was diagnosed with a large (5.5 x 4.5 x 4.0 cm) pheochromocytoma, reported early onset of symptoms of the disease (14 yr old). The overall penetrance of pheochromocytoma was 84.6% (11 of 13). Development of medullary thyroid carcinoma in our patients seemed similar to that observed in patients with codon 634 mutations. Haplotype analysis demonstrated that the mutation did not arise from a common ancestor. In vitro studies showed the double C634Y/Y791F RET receptor was significantly more phosphorylated than either activated wild-type receptor or single C634Y and Y791F RET mutants. CONCLUSIONS Our data suggest that the natural history of the novel C634Y/Y791F double mutation carries a codon 634-like pattern of medullary thyroid carcinoma development, is associated with increased susceptibility to unusually large bilateral pheochromocytomas, and is likely more biologically active than each individual mutation.
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Affiliation(s)
- Rodrigo A Toledo
- Faculdade de Medicina da Universidade de São Paulo, Avenida Dr. Arnaldo, 455, 5 degrees andar, Cerqueira César, 012406-903, São Paulo, Brazil.
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Quesada Charneco M. [Primary hyperparathyroidism in special situations: multiple endocrine neoplasia syndromes and parathyroid cancer]. ENDOCRINOLOGIA Y NUTRICION : ORGANO DE LA SOCIEDAD ESPANOLA DE ENDOCRINOLOGIA Y NUTRICION 2009; 56 Suppl 1:35-40. [PMID: 19627759 DOI: 10.1016/s1575-0922(09)70854-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Primary hyperparathyroidism (PHP) is a known endocrine disorder. Many years ago, the most frequent forms of clinical presentation were symptomatic renal or skeletal disease with moderate or severe hypercalcemia; however, currently, most patients have few symptoms and mild hypercalcemia. The last NIH Workshop on Asymptomatic PHP developed criteria for the management of this disease. Multiple endocrine neoplasia (MEN) types 1 and 2 are two genetic syndromes caused by different types of molecular abnormalities. PHP is the most common manifestation of MEN-1 and is the last feature to appear in MEN 2A. Parathyroid carcinoma (PC) is a rare neoplasm and an uncommon cause of parathyroid hormone (PTH)-dependent hypercalcemia. In this report, the treatment of PHP in MEN syndrome and PC are reviewed. Special attention is paid to a new class of drugs called "calcimimetics", which are powerful compounds that may be highly useful in the treatment of both conditions.
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Tonelli F, Marcucci T, Giudici F, Falchetti A, Brandi ML. Surgical approach in hereditary hyperparathyroidism. Endocr J 2009; 56:827-41. [PMID: 19797826 DOI: 10.1507/endocrj.k09e-204] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Francesco Tonelli
- Surgical Unit, Department of Clinical Physiopathology, and Regional Center for Hereditary Endocrine Tumors, University of Florence, Florence, Italy
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Rossi GP, Seccia TM, Pessina AC. Clinical Use of Laboratory Tests for the Identification of Secondary Forms of Arterial Hypertension. Crit Rev Clin Lab Sci 2008; 44:1-85. [PMID: 17175520 DOI: 10.1080/10408360600931831] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The prevalence of secondary hypertension can be underestimated if appropriate tests are not performed. The importance of selecting patients with a high pre-test probability of secondary forms of hypertension is first discussed. The laboratory tests currently used for seeking a cause of hypertension are critically reviewed, with emphasis on their operative features and limitations. Strategies to identify primary aldosteronism, the most frequent form of secondary hypertension, and to determine its unilateral or bilateral causes are described. Treatment entails adrenalectomy in unilateral forms, and mineralocorticoid receptor blockade in bilateral forms. Renovascular hypertension is also a common, curable form of hypertension, that should be identified as early as possible to avoid the onset of cardiovascular target organ damage. The tests for its confirmation or exclusion are discussed. The various tests available for the diagnosis of pheochromocytoma, which is much rarer than the above but extremely important to identify, are also described, with emphasis on recent developments in genetic testing. Finally, the tests for diagnosing some rarer monogenic forms and other renal and endocrine causes of arterial hypertension are explored.
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Affiliation(s)
- Gian Paolo Rossi
- Department of Clinical and Experimental Medicine, University of Padova, Padova, Italy.
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Lewis CE, Yeh MW. Inherited endocrinopathies: an update. Mol Genet Metab 2008; 94:271-82. [PMID: 18434223 DOI: 10.1016/j.ymgme.2008.03.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2007] [Revised: 03/10/2008] [Accepted: 03/10/2008] [Indexed: 12/15/2022]
Abstract
Inherited endocrinopathies, including multiple endocrine neoplasia type 1 (MEN-1), multiple endocrine neoplasia type 2 syndromes (MEN-2A, MEN-2B, familial medullary thyroid carcinoma), and inherited syndromes with pheochromocytoma (von Hippel-Lindau disease, neurofibromatosis type 1, others), comprise a heterogeneous group of cancer susceptibility syndromes that affect one or more components of the endocrine system. During the past several years, novel findings regarding genotype-phenotype correlation have highlighted the importance of establishing a genetic diagnosis in the treatment of these diseases. Here, we present a case-based review of recent advances in the genetics, diagnosis and management of inherited endocrinopathies.
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Affiliation(s)
- Catherine E Lewis
- Department of General Surgery, David Geffen School of Medicine, University of California, 10833 Le Conte Avenue, Los Angeles, CA 90095-6904, USA
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Abstract
Medullary thyroid carcinoma (MTC) is responsible for 13.4% of the total deaths attributable to thyroid cancer in human beings and research on MTC over the last 40 years has identified the RET proto-oncogene as a very relevant component of development of both sporadic and hereditary MTC. An activating germline RET proto-oncogene mutation responsible for a multiple endocrine neoplasia syndrome type 2 (MEN2) or a familial hereditary MTC syndrome is carried by 25% to 35% of patients with MTC. The recognition of RET proto-oncogene mutations by genetic sequencing has allowed us to differentiate hereditary from sporadic MTC, so that it is now possible to identify and treat children at risk for this disease before development of metastasis. Thanks to this discovery, we can now establish the association of MTC with other tumors in the context of MEN2 syndrome; determine adequate follow-up, prognosis, and treatment for patients with hereditary disease; and use this information to develop new therapies against both sporadic and hereditary MTCs.
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Affiliation(s)
- Camilo Jiménez
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Unit 435, 1515 Holcombe Boulevard, Houston, TX 77030-4009, USA
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Philip M, Guerrero MA, Evans DB, Hunter GJ, Edeiken-Monroe BS, Vu T, Perrier ND. Efficacy of 4D-CT preoperative localization in 2 patients with MEN 2A. JOURNAL OF SURGICAL EDUCATION 2008; 65:182-185. [PMID: 18571130 DOI: 10.1016/j.jsurg.2008.02.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2007] [Revised: 12/21/2007] [Accepted: 02/20/2008] [Indexed: 05/26/2023]
Abstract
Multiple endocrine neoplasia type 2A (MEN2A) is an autosomal dominant syndrome that is associated with hyperparathyroidism in 20% to 30% of adult gene carriers. The appropriate surgical management of these patients remains in question. Approaches to this disease range from selective gland resection to a subtotal parathyroidectomy with or without autotransplantation. Despite surgical intervention, disease recurrence is problematic. Surgical management of patients found to have recurrence relies on localizing the anatomic location of the hyperfunctional gland(s). The primary imaging modality for localization of hyperfunctioning parathyroid glands is technetium 99m sestamibi single photon emission computed tomography (SPECT). Although sestamibi imaging has a sensitivity of 60% to 90%, specific anatomic detail is not always present by this imaging modality. Four-dimensional computed tomography (4D-CT) scans allow localization of ectopic parathyroid glands and autotransplanted parathyroid tissue, and they provide the anatomic detail necessary for decisions about appropriate surgical management. Another benefit of the 4D-CT scan is that enhancement characteristics, which are determined by contrast opacification of the hyperfunctional parathyroid tissue over 4 phases of the scan, correlate with metabolic activity. We recommend the use of 4D-CT scanning because of its capacity to identify hyperfunctional parathyroid glands and to provide anatomic information important in preoperative planning.
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Affiliation(s)
- Maria Philip
- Department of Endocrine Surgery and Surgical Ontology, M.D. Anderson Cancer Center, University of Texas Medical School, Houston, TX 77230, USA
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Machens A, Dralle H. Genotype-phenotype based surgical concept of hereditary medullary thyroid carcinoma. World J Surg 2007; 31:957-68. [PMID: 17453286 DOI: 10.1007/s00268-006-0769-y] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Since DNA tests have enabled reliable identification of asymptomatic RET (rearranged during transfection) gene carriers, myriads of publications have appeared on genotype-phenotype relationships. A comprehensive appraisal of this body of evidence using evidence-based methodology is pending. METHODS This study was based on systematic evaluation of the literature using evidence-based criteria. RESULTS (1) There is a distinct age-related progression of hereditary medullary thyroid carcinoma (MTC) in carriers of RET mutations (grade C). (2) Among the high-risk RET mutations, those in codon 634 cause higher penetrance rates of the multiple endocrine neoplasia 2A phenotype (MTC, pheochromocytoma, and parathyroid hyperplasia/adenoma) than mutations in codons 609, 611, 618, and 620, irrespective of the amino acid substituting for cysteine (grade C). (3) DNA-based screening is superior to calcitonin-based screening in asymptomatic RET carriers (grade C). (4) Using a worst-case scenario, i.e., considering the earliest finding of MTC in asymptomatic RET carriers, pre-emptive thyroidectomy should be performed before that time (grade C) to be truly prophylactic. Specifically, for carriers of highest-risk mutations (codon 918): within the first year of life; for carriers of high-risk mutations (codon 609, 611, 618, 620, 630, and 634): before the age of 5 years; and for carriers of least-high risk mutations (codon 768, 790, 791, 804, and 891): before the age of 5-10 years. Strict adherence to these grade C recommendations can result in undertreatment of the former (codon 634) and overtreatment of the latter. CONCLUSIONS These genotype-phenotype correlations provide a solid foundation on which to base surgical concepts, leaving little room for randomized controlled clinical trials.
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Affiliation(s)
- Andreas Machens
- Department of General, Visceral and Vascular Surgery, Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Str. 40, D-06097, Halle/Saale, Germany.
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46
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Clinical and Genetic Experience in Turkish Multiple Endocrine Neoplasia Type 2 Families. ACTA ACUST UNITED AC 2007. [DOI: 10.1097/ten.0b013e31815151b5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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47
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Abstract
In 1996, the authors were asked to review the subject of thyroid cancer in children. Over the subsequent decade, much has been learned about the treatment and outcome of these uncommon tumors. We now recognize quantitative and perhaps qualitative differences in genetic mutations and growth factor expression patterns in childhood thyroid cancers compared with those of adults. We also know that thyroid cancers induce a robust immune response in children that might contribute to their longevity. Patients under 10 years of age probably represent a unique subset of children at particularly high risk for persistent or recurrent disease; the management of these patients is under evaluation. We remain limited in our knowledge of how to stratify children into low- and high-risk categories for appropriate long-term follow-up and in our knowledge of how to treat children who have detectable serum thyroglobulin but negative imaging studies. In this article, the authors update our understanding of thyroid cancers in children with special emphasis on how these data relate to the current guidelines for management of thyroid cancer developed by the American Thyroid Association Taskforce. The limited data regarding management of children who have detectable serum thyroglobulin but negative whole-body scans are also reviewed.
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Affiliation(s)
- Catherine Dinauer
- Department of Pediatrics, Yale School of Medicine, P.O. Box 208081, 464 Congress Avenue, New Haven, CT 06520-8081, USA
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48
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Mittendorf EA, Evans DB, Lee JE, Perrier ND. Pheochromocytoma: advances in genetics, diagnosis, localization, and treatment. Hematol Oncol Clin North Am 2007; 21:509-25; ix. [PMID: 17548037 DOI: 10.1016/j.hoc.2007.04.012] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Pheochromocytomas are rare, catecholamine-secreting tumors arising most frequently in the chromaffin cells of the adrenal glands. Recent studies have suggested that genetic mutations are more frequent than previously appreciated in patients with these lesions. Advances continue to be made not only in the genetic evaluation of these patients but also in the biochemical confirmation and tumor localization. Surgery remains the definitive treatment, and advances in laparoscopic techniques as well as cortical-sparing procedures have reduced the morbidity associated with tumor resection.
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Affiliation(s)
- Elizabeth A Mittendorf
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Unit 444, Houston, TX 77030, USA
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49
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Abstract
Medullary thyroid carcinoma is a neuroendocrine tumor derived from the C cells of the thyroid gland and accounts for approximately 5% of all thyroid carcinomas. Approximately 30% of the cases are associated with an autosomal dominant syndrome called multiple endocrine neoplasia type 2, and the identification of these individuals is important because affected family members may benefit from an early diagnosis. The treatment of this disease is predominantly surgical, and the impact of radiotherapy and chemotherapy is limited. The identification of the associated molecular events has lead to the development of specific molecular targeted agents that may change the way this disease is treated in the near future.
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Affiliation(s)
- Ana O Hoff
- Centro de Oncologia, Hospital Sírio Libanês, Sao Paulo, Brazil.
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50
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Pacak K, Eisenhofer G, Ahlman H, Bornstein SR, Gimenez-Roqueplo AP, Grossman AB, Kimura N, Mannelli M, McNicol AM, Tischler AS. Pheochromocytoma: recommendations for clinical practice from the First International Symposium. October 2005. ACTA ACUST UNITED AC 2007; 3:92-102. [PMID: 17237836 DOI: 10.1038/ncpendmet0396] [Citation(s) in RCA: 362] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2006] [Accepted: 09/15/2006] [Indexed: 12/19/2022]
Abstract
The First International Symposium on Pheochromocytoma, held in October 2005, included discussions about developments concerning these rare catecholamine-producing tumors. Recommendations were made during the symposium for biochemical diagnosis, localization, genetics, and treatment. Measurement of plasma or urinary fractionated metanephrines, the most accurate screening approach, was recommended as the first-line test for diagnosis; reference intervals should favor sensitivity over specificity. Localization studies should only follow reasonable clinical evidence of a tumor. Preoperative pharmacologic blockade of circulatory responses to catecholamines is mandatory. Because approximately a quarter of tumors develop secondary to germ-line mutations in any one of five genes, mutation testing should be considered; however, it is not currently cost effective to test every gene in every patient. Consideration of tumor location, presence of multiple tumors, presence of metastases, and type of catecholamine produced is useful in deciding which genes to test. Inadequate methods to distinguish malignant from benign tumors and a lack of effective treatments for malignancy are important problems requiring further resolution.
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Affiliation(s)
- Karel Pacak
- National Institute of Child Health and Development, NIH, Bethesda, MD, USA
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