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Dralle H, Weber F, Lorenz K, Machens A. [30 years of prophylactic thyroidectomy for hereditary medullary thyroid cancer : A milestone in translational medicine]. CHIRURGIE (HEIDELBERG, GERMANY) 2024:10.1007/s00104-024-02105-x. [PMID: 38806713 DOI: 10.1007/s00104-024-02105-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/03/2024] [Indexed: 05/30/2024]
Abstract
Medullary thyroid cancer (MTC) is the most frequent manifestation of multiple endocrine neoplasia type 2 (MEN2) that determines the oncological outcome. Germline mutations in the rearranged during transfection (RET) protooncogene, a tumor suppressor gene on chromosome 10q11.2, were identified 30 years ago as the genetic basis of MEN2 and published in 1993 and 1994. These seminal findings gave rise to the concept of prophylactic thyroidectomy for asymptomatic gene mutation carriers based on a positive RET gene test, which has become the standard of care ever since. Clinical genetic investigations showed genotype-phenotype correlations with respect to the individual gene mutation regarding the penetrance and onset of MTC and to a lesser extent also with respect to the other components of MEN2, pheochromocytoma and primary hyperparathyroidism. From this a clinically relevant risk stratification could be derived. Initially, the optimal timing of prophylactic thyroidectomy was primarily based on the RET genotype alone, which was not sufficient for a precise age recommendation and subsequently required additional consideration of calcitonin serum levels for fine tuning. Calcitonin levels first show the risk of lymph node metastasis when they exceed the upper normal limit of the assay independent of carrier age and RET mutation. Routine calcitonin screening of patients with nodular thyroid disease, screening of families on identification of MEN2 index patients, and pre-emptive thyroidectomy in carriers of gene mutations with normal calcitonin levels have led to the fact that nowadays, 30 years after the first description of the gene mutations causing the disease, the life-threatening hereditary MTC has become curable: a shining example for the success of translational transnational medical research for the benefit of patients.
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Affiliation(s)
- Henning Dralle
- Klinik für Allgemein‑, Viszeral-und Transplantationschirurgie, Sektion Endokrine Chirurgie, Universitätsmedizin Essen, Hufelandstr. 55, 45147, Essen, Deutschland
| | - Frank Weber
- Klinik für Allgemein‑, Viszeral-und Transplantationschirurgie, Sektion Endokrine Chirurgie, Universitätsmedizin Essen, Hufelandstr. 55, 45147, Essen, Deutschland.
| | - Kerstin Lorenz
- Klinik für Viszeral‑, Gefäss- und Endokrine Chirurgie, Universitätsmedizin Halle, Ernst Grube Str. 40, 06097, Halle (Saale), Deutschland
| | - Andreas Machens
- Klinik für Viszeral‑, Gefäss- und Endokrine Chirurgie, Universitätsmedizin Halle, Ernst Grube Str. 40, 06097, Halle (Saale), Deutschland
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Machens A, Lorenz K, Huessler EM, Stang A, Weber F, Dralle H. Temporal trends in referrals of RET gene carriers for neck surgery to a tertiary surgical center in the era of international management guidelines. Endocrine 2023; 80:100-110. [PMID: 36456885 PMCID: PMC9715418 DOI: 10.1007/s12020-022-03273-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 11/21/2022] [Indexed: 12/04/2022]
Abstract
PURPOSE Thirty years into the genomic era, this study sought to explore events that helped transform the clinical landscape of hereditary medullary thyroid cancer (MTC). METHOD This retrospective analysis of prospectively collected data included all RET carriers referred to a tertiary center for neck surgery that was performed between 1986 and 2021, using descriptive statistics and Poisson regression analysis. RESULTS Altogether, 496 RET carriers were referred for thyroidectomy (388 carriers) or neck reoperation (108 carriers). Of these, 44 carriers had highest risk mutations (p.Met918Thr), 164 carriers high risk mutations (p.Cys634Arg/Gly/Phe/Ser/Trp/Tyr/insHisGluLeuCys), 116 carriers moderate-high risk mutations (p.Cys609/611/618/620/630Arg/Gly/Phe/Ser/Tyr) and 172 carriers low-moderate risk mutations (p.Glu768Asp, p.Leu790Phe, p.Val804Leu/Met, or p.Ser891Ala). Three event clusters drove referral numbers upward: a string of first reports of causative RET mutations between 1993 and 1998; the international consensus guidelines for diagnosis and therapy of MEN type 1 and type 2 in 2001; and the revised American Thyroid Association guidelines for the management of medullary thyroid carcinoma in 2015. Referrals for neck reoperation declined sluggishly over 30 years, ending in 2018. Index patients continued to be referred into 2021. Referrals for thyroidectomy, grouped in 5-year increments, peaked in 1996-2000 for carriers of highest and high risk mutations, and in 2006-2010 for carriers of moderate-high and low-moderate risk mutations, some 10 years later. CONCLUSION International management guidelines are critical in building and increasing the pressure towards screening of sporadic-appearing disease and offspring of known gene families by encompassing the complete disease spectrum early on.
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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.
| | - Kerstin Lorenz
- Medical Faculty, Department of Visceral, Vascular and Endocrine Surgery, Martin Luther University Halle-Wittenberg, Ernst-Grube-Str. 40, D-06097, Halle (Saale), Germany
| | - Eva-Maria Huessler
- Institute of Medical Informatics, Biometry and Epidemiology, University Hospital Essen, Essen, Germany
| | - Andreas Stang
- Institute of Medical Informatics, Biometry and Epidemiology, University Hospital Essen, Essen, Germany
- Department of Epidemiology, School of Public Health, Boston University, Boston, MA, USA
| | - Frank Weber
- Department of General, Visceral and Transplantation Surgery, Division of Endocrine Surgery, University of Duisburg-Essen, D-45122, Essen, 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, Division of Endocrine Surgery, University of Duisburg-Essen, D-45122, Essen, Germany
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Carneiro VCG, Gifoni ACLVC, Rossi BM, da Cunha Andrade CEM, de Lima FT, de Campos Reis Galvão H, da Rocha JCC, da Silva Barreto LS, Ashton‐Prolla P, Guindalini RSC, de Farias TP, Andrade WP, de Sousa Fernandes PH, Ribeiro R, Lopes A, Tsunoda AT, Azevedo BRB, Marins CAM, de Albuquerque Oliveira Uchôa DN, Dos Santos EAS, Coimbra FJF, Filho FAD, de Oliveira Lopes FC, Fernandes FG, Ritt GF, Laporte GA, Guimaraes GC, Feitosa e Castro Neto H, dos Santos JC, de Carvalho Vilela JB, Junior JGM, da Cunha JR, Milhomem LM, da Silva LM, de Freitas Maciel L, Ramalho NM, Nunes RL, de Araújo RG, de Assunção Ehrhardt R, Bocanegra RED, Junior TCS, de Oliveira VR, Surimã WS, de Melo Melquiades M, de Castro Ribeiro HS, Oliveira AF. Cancer risk‐reducing surgery: Brazilian Society of Surgical Oncology Guideline Part 2 (Gastrointestinal and thyroid). J Surg Oncol 2022; 126:20-27. [DOI: 10.1002/jso.26813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 01/18/2022] [Accepted: 01/19/2022] [Indexed: 01/27/2023]
Affiliation(s)
- Vandré C. G. Carneiro
- Surgey, Gynecology, Oncology Instituto de Medicina Integral Professor Fernando Figueira Recife Brazil
- Department of Pelvic Surgery, Hereditary Cancer Program Hospital de Câncer de Pernambuco Recife Brazil
- Department of Oncogenetic, Oncology Oncologia D'or Rio de Janeiro Brazil
| | | | - Benedito M. Rossi
- Oncogenetic, Surgical Oncology Hospital Sírio Libanês São Paulo Brazil
| | | | - Fernanda T. de Lima
- Department of Oncogenetic Hospital Israelita Albert Einstein São Paulo Brazil
- Department of Oncogenetic UNIFESP‐EPM São Paulo Brazil
| | | | - Jose C. C. da Rocha
- Department of Oncogenetic, Abdominal Surgery A.C. Camargo Cancer São Paulo Brazil
| | | | | | | | | | - Wesley P. Andrade
- Department of Surgery Hospital Beneficência Portuguesa São Paulo Brazil
- Department of Surgery Hospital Oswaldo Cruz São Paulo Brazil
- Department of Surgery Hospital Santa Catarina São Paulo Brazil
| | | | - Reitan Ribeiro
- Department of Surgical oncology Hospital Erasto Gaertner Curitiba Brazil
| | - Andre Lopes
- Department of Surgical Oncology São Camilo Oncologia São Paulo Brazil
| | - Audrey T. Tsunoda
- Department of Surgical oncology Hospital Erasto Gaertner Curitiba Brazil
- Department of Surgery Pontifícia Universidade Católica do Paraná Curitiba Brazil
| | - Bruno R. B. Azevedo
- surgical oncology Oncoclínicas Curitiba Brazil
- Department of Surgery Pilar Hospital Curitiba Brazil
| | - Carlos A. M. Marins
- Department of Head and neck, oncological surgery INCA Rio de Janeiro Brazil
- Department of Surgery Hospital Federal dos Servidores do Estado Rio de Janeiro Brazil
| | | | | | - Felipe J. F. Coimbra
- Department of Oncogenetic, Abdominal Surgery A.C. Camargo Cancer São Paulo Brazil
| | | | | | | | | | - Gustavo A. Laporte
- Department of Surgery Santa Casa de Misericórdia de Porto Alegre Porto Alegre Brazil
| | | | | | | | | | - Jorge G. M. Junior
- Department of Surgery Santa Casa de Misericórdia de Porto Alegre Porto Alegre Brazil
- Department of Surgery Hospital Santa Rita Porto Alegre Brazil
| | | | - Leonardo M. Milhomem
- Department of Surgery Hospital das Clínicas da Universidade Federal de Goiás Goiânia Brazil
| | - Luciana M. da Silva
- Department of Pelvic Surgery, Hereditary Cancer Program Hospital de Câncer de Pernambuco Recife Brazil
| | | | - Nathalia M. Ramalho
- Surgey, Gynecology, Oncology Instituto de Medicina Integral Professor Fernando Figueira Recife Brazil
- Department of Oncogenetic, Oncology Oncologia D'or Rio de Janeiro Brazil
| | - Rafael L. Nunes
- Department of Surgery GNDI Notredame Intermédica Hospital Salvalus São Paulo Brazil
| | - Rodrigo G. de Araújo
- Department of Pelvic Surgery, Hereditary Cancer Program Hospital de Câncer de Pernambuco Recife Brazil
| | | | | | | | | | | | | | - Heber S. de Castro Ribeiro
- Department of Oncogenetic, Abdominal Surgery A.C. Camargo Cancer São Paulo Brazil
- SBCO 2021‐2023 BBSO presidente Rio de Janeiro Brazil
| | - Alexandre F. Oliveira
- Department of Surgery Universidade Federal de Juiz de Fora Juiz de Fora Brazil
- SBCO 2019‐2021 BBSO presidente Rio de Janeiro Brazil
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Multiple Endocrine Neoplasia in Childhood: An Update on Diagnosis, Screening, Management and Treatment. ENDOCRINES 2022. [DOI: 10.3390/endocrines3010007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Multiple endocrine neoplasia (MEN) is a group of heterogenous syndromes characterized by the occurrence of two or more endocrine gland tumors in a patient or related individuals in the same family. They are inherited in an autosomal dominant fashion and are highly penetrant. There are three types of MEN syndromes: MEN type 1 (MEN1), MEN type 2 (MEN2), and MEN type 4 (MEN4). MEN2 is further divided into MEN2A, MEN2B (formerly known MEN3), and familial medullary thyroid carcinoma (FMTC). Although MEN syndromes are rare, it is crucial to identify individuals at risk for potentially life-threatening neoplasias. This review article provides an update on each MEN syndrome, its genetics, diagnosis, and management in children.
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Tausanovic KM, Zivaljevic VR, Zorić GV, Jovanovic MD, Stepanovic BG, Milenkovic MG, Paunovic IR. Predictive value of calcium test for preoperative diagnosis of medullary thyroid carcinoma in patients with moderately elevated basal calcitonin. Endocr Pract 2021; 27:1077-1081. [PMID: 34216799 DOI: 10.1016/j.eprac.2021.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 06/19/2021] [Accepted: 06/22/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Medullary thyroid carcinoma (MTC) can be very aggressive, and the early diagnosis is based on the routine measurement of serum calcitonin (CT) and on the RET genetic testing for hereditary forms. Basal serum CT concentrations (bCT) are helpful in the early detection of MTC, while it is still unclear whether they can be used also for the differential diagnosis between MTC and C cell hyperplasia (CCH). Since false-positive results can be gained with the basal measurement of calcitonin, a provocative test to evaluate stimulated calcitonin (sCT) is often needed. AIM The objective of this study was to investigate the utility of calcium gluconate test for CT in distinguishing MTC from CCH, a precancerous condition in hereditary forms of MTCs, but with unclear significance in sporadic MTCs. METHOD A total of 74 patients underwent the calcium loading test before thyroidectomy, and basal and stimulated calcitonin levels were compared with histological results by receiver operating characteristic (ROC) plot analyses. RESULTS A peak of calcitonin after stimulation with calcium gluconate of 388.4 pg/ml was able to significantly distinguish patients with MTC from patients with CCH and patients without C cell pathology, with 81.8% sensitivity and 36.5% specificity. Basal calcitonin of 16.1 pg/ml was able to distinguish these two group of patients with 90% sensitivity. CONCLUSION High dose calcium test is potent procedure that can be applied for differential diagnosis of MTC and CCH. Reference ranges for calcium sCT levels and CT thresholds in different group of patients have been identified.
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Affiliation(s)
- Katarina M Tausanovic
- Center for Endocrine surgery, University Clinical Center of Serbia, Koste Todorovica 8, 11000 Belgrade, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia, Doktora Subotica 8, 11000 Belgrade, Serbia.
| | - Vladan R Zivaljevic
- Center for Endocrine surgery, University Clinical Center of Serbia, Koste Todorovica 8, 11000 Belgrade, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia, Doktora Subotica 8, 11000 Belgrade, Serbia
| | - Goran V Zorić
- Center for Endocrine surgery, University Clinical Center of Serbia, Koste Todorovica 8, 11000 Belgrade, Serbia
| | - Milan D Jovanovic
- Center for Endocrine surgery, University Clinical Center of Serbia, Koste Todorovica 8, 11000 Belgrade, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia, Doktora Subotica 8, 11000 Belgrade, Serbia
| | - Boban G Stepanovic
- Center for Endocrine surgery, University Clinical Center of Serbia, Koste Todorovica 8, 11000 Belgrade, Serbia
| | - Marija G Milenkovic
- Emergency Center, University Clinical Center of Serbia, Pasterova 2, 11000 Belgrade, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia, Doktora Subotica 8, 11000 Belgrade, Serbia
| | - Ivan R Paunovic
- Center for Endocrine surgery, University Clinical Center of Serbia, Koste Todorovica 8, 11000 Belgrade, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia, Doktora Subotica 8, 11000 Belgrade, Serbia
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Machens A, Elwerr M, Lorenz K, Weber F, Dralle H. 100-Year evolution of precision medicine and surgery for multiple endocrine neoplasia type 2A. Endocrine 2020; 68:368-376. [PMID: 32100189 DOI: 10.1007/s12020-020-02232-5] [Citation(s) in RCA: 15] [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: 12/19/2019] [Accepted: 02/14/2020] [Indexed: 01/12/2023]
Abstract
PURPOSE To determine whether published disease penetrance estimates of 50% for pheochromocytoma and 20-30% for primary hyperparathyroidism in multiple endocrine neoplasia (MEN 2A), conceivably reflecting overrepresentation of index patients with completely developed MEN 2A, may be too high. METHODS Cross-sectional study of carriers at high risk of MEN 2A from a tertiary referral center. RESULTS There were 213 carriers of RET mutations in codon 634, born between 1922 and 2014. Median age of thyroidectomy was 17 years, with MTC being present in 76.5%; pheochromocytoma in 31.0% at a median of 34 years in the first, and in 18.8% at a median of 35 years in the second adrenal; and primary hyperparathyroidism in 10.8% at a median of 39 years. MTC, pheochromocytoma and primary hyperparathyroidism, stratified by year of birth, were diagnosed earlier over time: for MTC from 51 to 4 years; for pheochromocytoma from 51 to 22.5 years in the first, and from 51 to 29.5 years in the second adrenal, and for primary hyperparathyroidism from 46 to 12 years (P ≤ 0.008). This decline in age was paralleled by diminishing tumor diameters, more strongly in the thyroid (from 20 to 1.8 mm; P < 0.001) than in the adrenals (from 43 to 30 mm in the first, and from 20-57.5 to 30.5 mm in the second adrenal; statistically nonsignificant). CONCLUSIONS The lower disease penetrance estimates and sluggish decline of adrenal tumor diameters call for more widespread adoption of adrenal-sparing and parathyroid preservation surgery based on early and regular biochemical screening.
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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.
| | - Malik Elwerr
- Medical Faculty, Department of Visceral, Vascular and Endocrine Surgery, Martin Luther University Halle-Wittenberg, Ernst-Grube-Str. 40, D-06097, Halle (Saale), Germany
| | - Kerstin Lorenz
- Medical Faculty, Department of Visceral, Vascular and Endocrine Surgery, Martin Luther University Halle-Wittenberg, Ernst-Grube-Str. 40, D-06097, Halle (Saale), Germany
| | - Frank Weber
- Department of General, Visceral and Transplantation Surgery, Section of Endocrine Surgery, University of Duisburg-Essen, D-45122, Essen, 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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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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Febrero B, Rodríguez JM, Ríos A, Segura P, Pérez-Sánchez B, Torregrosa N, Hernández AM, Parrilla P. Prophylactic thyroidectomy in multiple endocrine neoplasia 2 (MEN2) patients with the C634Y mutation: A long-term follow-up in a large single-center cohort. Eur J Surg Oncol 2019; 45:625-630. [DOI: 10.1016/j.ejso.2018.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 07/12/2018] [Accepted: 09/04/2018] [Indexed: 02/05/2023] Open
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Marx SJ, Goltzman D. Evolution of Our Understanding of the Hyperparathyroid Syndromes: A Historical Perspective. J Bone Miner Res 2019; 34:22-37. [PMID: 30536424 PMCID: PMC6396287 DOI: 10.1002/jbmr.3650] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 11/14/2018] [Accepted: 11/20/2018] [Indexed: 12/19/2022]
Abstract
We review advancing and overlapping stages for our understanding of the expressions of six hyperparathyroid (HPT) syndromes: multiple endocrine neoplasia type 1 (MEN1) or type 4, multiple endocrine neoplasia type 2A (MEN2A), hyperparathyroidism-jaw tumor syndrome, familial hypocalciuric hypercalcemia, neonatal severe primary hyperparathyroidism, and familial isolated hyperparathyroidism. During stage 1 (1903 to 1967), the introduction of robust measurement of serum calcium was a milestone that uncovered hypercalcemia as the first sign of dysfunction in many HPT subjects, and inheritability was reported in each syndrome. The earliest reports of HPT syndromes were biased toward severe or striking manifestations. During stage 2 (1959 to 1985), the early formulations of a syndrome were improved. Radioimmunoassays (parathyroid hormone [PTH], gastrin, insulin, prolactin, calcitonin) were breakthroughs. They could identify a syndrome carrier, indicate an emerging tumor, characterize a tumor, or monitor a tumor. During stage 3 (1981 to 2006), the assembly of many cases enabled recognition of further details. For example, hormone non-secreting skin lesions were discovered in MEN1 and MEN2A. During stage 4 (1985 to the present), new genomic tools were a revolution for gene identification. Four principal genes ("principal" implies mutated or deleted in 50% or more probands for its syndrome) (MEN1, RET, CASR, CDC73) were identified for five syndromes. During stage 5 (1993 to the present), seven syndromal genes other than a principal gene were identified (CDKN1B, CDKN2B, CDKN2C, CDKN1A, GNA11, AP2S1, GCM2). Identification of AP2S1 and GCM2 became possible because of whole-exome sequencing. During stages 4 and 5, the newly identified genes enabled many studies, including robust assignment of the carriers and non-carriers of a mutation. Furthermore, molecular pathways of RET and the calcium-sensing receptor were elaborated, thereby facilitating developments in pharmacotherapy. Current findings hold the promise that more genes for HPT syndromes will be identified and studied in the near future. © 2018 American Society for Bone and Mineral Research.
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Affiliation(s)
- Stephen J Marx
- Office of the Scientific Director, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - David Goltzman
- Calcium Research Laboratory, Metabolic Disorders and Complications Program, Research Institute of the McGill University Health Centre, Montreal, Canada
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Alexander CL, Izquierdo RE, Figge J, Horton J. Diagnosis and Management of Thyroid Cancer. Cancer Control 2018. [DOI: 10.1177/107327489500200206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Thyroid carcinoma, which comprises the majority of endocrine malignancies, has a substantial annual morbidity and mortality based on age and other predisposing factors. Diagnosis of a growing thyroid nodule can be difficult, but ultrasonography, radionuclide scanning, and fine needle aspiration allow the majority of nodules to be properly characterized. Treatment of differentiated thyroid carcinoma remains controversial. Surgical resection continues to be the most important modality with long survival if the tumor is resected early. Newer imaging techniques have improved the diagnosis of locally recurrent or metastatic disease. Radioactive iodine ablation is indicated for patients with “high-risk” tumors or advanced age. Few patients respond to cytotoxic chemotherapy. In the past decade, advances in the screening and diagnosis of medullary thyroid carcinoma have led to earlier detection with improvement in survival.
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Affiliation(s)
| | | | - James Figge
- Endocrinology Department at Albany Medical College, Albany, NY
| | - John Horton
- Hematology/Oncology Division at H. Lee Moffitt Cancer Center & Research Institute, Tampa, Fla
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Domínguez R-T JM. Resultado de diagnóstico precoz y cirugía profiláctica en carcinoma medular hereditario del tiroides. REVISTA MÉDICA CLÍNICA LAS CONDES 2018. [DOI: 10.1016/j.rmclc.2018.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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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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14
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Abstract
Neuroendocrine tumours (NETs) are a heterogenous group of tumours arising from neuroendocrine cells in several sites around the body. They include tumours of the gastroenteropancreatic system, phaeochromocytoma and paraganglioma and medullary thyroid cancer. In recent years, it has become increasingly apparent that a number of these tumours arise as a result of germline genetic mutations and are inherited in an autosomal dominant pattern. The number of genes implicated is increasing rapidly. Identifying which patients are likely to have a germline mutation enables clinicians to counsel patients adequately about their future disease risk, and allows for earlier detection of at-risk patients through family screening. The institution of screening and surveillance programmes may in turn lead to a major shift in presentation patterns for some of these tumours. In this review, we examine the features which may lead a clinician to suspect that a patient may have an inherited cause of a NET and we outline which underlying conditions should be suspected. We also discuss what type of screening may be appropriate in a variety of situations.
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Affiliation(s)
- Triona O'Shea
- Centre of Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ, UK.
| | - Maralyn Druce
- Centre of Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ, UK
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15
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Zhang X, Yan D, Wang J, Wan H, Zhang Y, Zhang Y, He Y, Liu W, Zhang B. Is new American Thyroid Association risk classification for hereditary medullary thyroid carcinoma applicable to Chinese patients? A single-center study. Chin J Cancer Res 2017; 29:223-230. [PMID: 28729773 PMCID: PMC5497209 DOI: 10.21147/j.issn.1000-9604.2017.03.08] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Objective The American Thyroid Association (ATA) proposed a new risk classification for hereditary medullary thyroid carcinoma (MTC) in 2015. This study aimed to assess whether the new guidelines are suitable for the Chinese population, and reported our experience on prophylactic thyroidectomy. Methods A total of 73 patients from 22 families were screened as rearranged during transfection (RET) mutation carriers from 2010 to 2016 in Cancer Hospital, Chinese Academy of Medical Science; the medical history for each patient was collected. Based on the initial treatment, we identified the risk factors for poor prognosis by univariate and multivariate logistic regression. Then, 4 RET mutation carriers were enrolled for prophylactic thyroidectomy, and their pathological data and follow-up outcomes were recorded.
Results In univariate and multivariate logistic regression analyses, age at initial surgery and risk classification were significant risk factors for stage III/IV hereditary MTC at initial diagnosis. The likelihood was increased by 11.6% per year of age at initial surgery [95% confidence interval (95% CI), 1.040–1.198; P=0.002). It was 7.888 times more likely to have III/IV stage disease for ATA highest risk patients, compared to ATA moderate risk individuals (95% CI, 1.607–38.717; P=0.003). Postoperative pathological results showed all 4 multiple endocrine neoplasia type 2A (MEN2A) patients had C-cell hyperplasia (CCH); multifocal malignancies were detected in 3 of them. All 4 patients were cured biochemically, and none developed permanent hypoparathyroidism. Conclusions In Chinese individuals, hereditary MTC aggressiveness is in line with the new ATA risk classification. Germline RET gene mutation carriers should undergo prophylactic thyroidectomy according to basal serum calcitonin levels.
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Affiliation(s)
- Xiwei Zhang
- Department of Head and Neck Surgical Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100021, China
| | - Dangui Yan
- Department of Head and Neck Surgical Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100021, China
| | - Junyi Wang
- Department of Head and Neck Surgical Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100021, China
| | - Hanfeng Wan
- Department of Head and Neck Surgical Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100021, China
| | - Yongxia Zhang
- Department of Head and Neck Surgical Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100021, China
| | - Yabing Zhang
- Department of Head and Neck Surgical Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100021, China
| | - Yuqin He
- Department of Head and Neck Surgical Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100021, China
| | - Wensheng Liu
- Department of Head and Neck Surgical Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100021, China
| | - Bin Zhang
- Department of Head and Neck Surgical Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100021, China
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16
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Abstract
Medullary thyroid carcinoma (MTC) is subdivided into sporadic (75%) and hereditary (25%) forms. Several germline mutations in the RET proto-oncogene are the source of distinct clinical phenotypes in hereditary MTC including familial MTC (FMTC) and multiple endocrine neoplasia 2A (MEN 2A) and 2B (MEN 2B). The higher the penetrance of the MEN 2 phenotype the earlier the progression of MTC which forms the basis for the currently recommended codon-related concept of prophylactic thyroidectomy. In patients with sporadic MTC, routine calcitonin (CT) measurement in nodular goiter patients has been shown to reduce the frequency of advanced tumor stages. Patients with CT levels over 100 pg/ml after pentagastrin stimulation are recommended for total thyroidectomy. In patients with unexpected sporadic MTC after histological examination, completion thyroidectomy is currently only recommended when CT levels remain elevated. The extent of lymph node dissection in patients with MTC is controversial. However, with respect to lymphonodal micrometastases, systematic compartment-oriented microdissection has been shown to reduce the frequency of lymphonodal recurrence. On the other hand, to avoid unnecessary lymph node dissection, a more individualized concept is required in the future. New chemotherapeutic agents (tyrosine kinase inhibitors), therapeutic nuclids (90Yttrium-labeled octreotide), and chemoembolization of liver metastases are currently the most promising therapeutical concepts in patients with distant metastases.
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Affiliation(s)
- M Brauckhoff
- Department of General, Visceral, and Vascular Surgery, Martin-Luther-University of Halle-Wittenberg, Halle/Saale, Germany.
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17
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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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18
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Abstract
Hereditary medullary thyroid carcinoma (MTC) represents up to one-third of MTC cases and includes multiple endocrine neoplasia syndrome type 2A (and its variant familial MTC) and 2B. The aim of this paper is to provide an overview of the disease focusing on the management of hereditary MTC patients, who have already developed tumor, as well as discuss the recommended approach for asymptomatic family members carrying the same mutation. A PubMed search was performed to review recent literature on diagnosis, genetic testing, and surgical and medical management of hereditary MTC. The wide use of genetic testing for RET mutations has markedly influenced the course of hereditary MTC. Prophylactic thyroidectomy of RET carriers at an early age eliminates the risk of developing MTC later in life. Pre-operative staging is a strong prognostic factor in patients, who have developed MTC. The use of recently approved tyrosine kinase inhibitors (vandetanib, cabozantinib) holds promising results for the treatment of unresectable, locally advanced, and progressive metastatic MTC. Genetic testing of the RET gene is a powerful tool in the diagnosis and prognosis of MTC. Ongoing research is expected to add novel treatment options for patients with advanced, progressive disease.
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Affiliation(s)
- Theodora Pappa
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, The University of Chicago, Chicago, IL, USA
- Endocrine Unit, Department of Medical Therapeutics, Alexandra Hospital, Athens University School of Medicine, 80 Vassilissis Sofias Avenue, 11528, Athens, Greece
| | - Maria Alevizaki
- Endocrine Unit, Department of Medical Therapeutics, Alexandra Hospital, Athens University School of Medicine, 80 Vassilissis Sofias Avenue, 11528, Athens, Greece.
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19
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Early, Prophylactic Thyroidectomy in Hereditary Medullary Thyroid Carcinoma: A 26-year Monoinstitutional Experience. Am J Clin Oncol 2016; 38:508-13. [PMID: 24064755 DOI: 10.1097/coc.0b013e3182a78fec] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Prophylactic thyroidectomy has been encouraged for children with REarranged during Transfection (RET) germline mutations to prevent the onset, persistence, or recurrence of medullary thyroid carcinoma (MTC). The American Thyroid Association (ATA) recently published guidelines on the timing of prophylactic thyroidectomy. Our aim here was to seek information on the optimal timing of surgery for carriers of RET gene mutations with no clinical evidence of disease, bearing in mind the ATA recommendations. METHODS From 1986 to 2012, total thyroidectomy was performed at our institute on 31 carriers of RET gene mutations, 28 of them found on family screening in the post-RET era, and the other 3 under 20 years of age and classified as "early cases" in the pre-RET era. The following parameters were studied: age at surgery, MTC risk, basal calcitonin (bCT) and pentagastrin-stimulated calcitonin (sCT), surgery outcomes, and persistence of disease. RESULTS By family, the most prevalent mutation was codon 634 (30%) RET mutation. The youngest MTC patient was 5 years old. Overall, MTC was found in 68% of cases; 52% of the sample had a normal bCT and 25% had an sCT unresponsive to pentagastrin. The only factor predicting the risk of MTC at final histology was an ATA-RET risk level C. On receiver oparating curves analysis, a cutoff at age over 24 years predicted (P=0.06) a yield of MTC in the resected specimen. Interestingly, none of the patients with MTC had nodal involvement (0/21 patients with MTC). Yet, none of the patients had permanent nerve palsy, and only 1 patient had permanent hypocalcemia. bCT was normal postoperatively and during the follow-up in all but 3 patients. CONCLUSIONS It is noteworthy that the yield of cancer in removed thyroid was 100% for codon 634 (9/9 patients, 5 families) and for codons 891 and 768 (2/2 patients in each of the 2 families with those codon mutations), followed by 67% for codon 609 (4/6 patients, 1 family), and 60% for codon 618 (3/5 patients in 4 families) RET mutation. In cases of ATA-RET levels B and C, waiting for an increase in bCT and/or sCT may not guarantee that prophylactic surgery is performed before MTC develops (which would assure patients a life free of diseases and a less-invasive surgical procedure, without any need for central lymph-node dissection).
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20
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Romei C, Ciampi R, Elisei R. A comprehensive overview of the role of the RET proto-oncogene in thyroid carcinoma. Nat Rev Endocrinol 2016; 12:192-202. [PMID: 26868437 DOI: 10.1038/nrendo.2016.11] [Citation(s) in RCA: 225] [Impact Index Per Article: 28.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The rearranged during transfection (RET) proto-oncogene was identified in 1985 and, very soon thereafter, a rearrangement named RET/PTC was discovered in papillary thyroid carcinoma (PTC). After this discovery, other RET rearrangements were found in PTCs, particularly in those induced by radiation. For many years, it was thought that these genetic alterations only occurred in PTC, but, in the past couple of years, some RET/PTC rearrangements have been found in other human tumours. 5 years after the discovery of RET/PTC rearrangements in PTC, activating point mutations in the RET proto-oncogene were discovered in both hereditary and sporadic forms of medullary thyroid carcinoma (MTC). In contrast to the alterations found in PTC, the activation of RET in MTC is mainly due to activating point mutations. Interestingly, in the past year, RET rearrangements that were different to those described in PTC were observed in sporadic MTC. The identification of RET mutations is relevant to the early diagnosis of hereditary MTC and the prognosis of sporadic MTC. The diagnostic and prognostic role of the RET/PTC rearrangements in PTC is less relevant but still important in patient management, particularly for deciding if a targeted therapy should be initiated. In this Review, we discuss the pathogenic, diagnostic and prognostic roles of the RET proto-oncogene in both PTC and MTC.
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Affiliation(s)
- Cristina Romei
- Endocrine Unit, Department of Clinical and Experimental Medicine, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy
| | - Raffaele Ciampi
- Endocrine Unit, Department of Clinical and Experimental Medicine, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy
| | - Rossella Elisei
- Endocrine Unit, Department of Clinical and Experimental Medicine, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy
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21
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Management of the Parathyroid Glands During Preventive Thyroidectomy in Patients With Multiple Endocrine Neoplasia Type 2. Ann Surg 2015; 262:641-6. [PMID: 26366543 DOI: 10.1097/sla.0000000000001464] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Patients with multiple endocrine neoplasia type 2 (MEN2) have mutations in the RET protooncogene and virtually all of them will develop medullary thyroid carcinoma. Family members identified by genetic testing are candidates for preventive thyroidectomy. Management of the parathyroids during thyroidectomy is controversial. Some experts advocate total parathyroidectomy with autotransplantation, whereas others recommend preserving the parathyroids in situ. METHODS Between 1993 and 2000, we performed preventive thyroidectomies on 50 patients with MEN2A (group A). All patients had a central neck dissection (CND) combined with total parathyroidectomy and autotransplantation of parathyroid slivers to the nondominant forearm or to the neck. Between 2003 and the present, we performed 102 preventive thyroidectomies attempting to preserve the parathyroid glands in situ with an intact vascular pedicle (group B). Individual parathyroids were autotransplanted only if they appeared nonviable or could not be preserved intact. Central neck dissection was done only if the serum calcitonin was greater than 40 pg/mL. RESULTS Permanent hypoparathyroidism occurred in 3 (6%) of 50 patients in group A, compared with 1 (1%) of 102 patients in group B (P = 0.1). After total thyroidectomy, no patient in either group developed permanent recurrent laryngeal nerve injury or hyperparathyroidism. Immediate postoperative serum calcitonin levels were in the normal range (<5 pg/mL) in 100 of 102 patients in group B. No patients in either group have died. Oncologic follow-up of patients in group B is in progress. CONCLUSIONS In patients with MEN2A treated by preventive total thyroidectomy routine total parathyroidectomy with autotransplantation and CND gives excellent long-term results. However, preservation of the parathyroids in situ during preventive thyroidectomy combined with selective CND based on preoperative basal serum calcitonin levels is an effective and safe alternative that results in a very low incidence of hypoparathyroidism.
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22
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Jin LX, Moley JF. Surgery for lymph node metastases of medullary thyroid carcinoma: A review. Cancer 2015; 122:358-66. [PMID: 26539937 DOI: 10.1002/cncr.29761] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Revised: 08/14/2015] [Accepted: 09/01/2015] [Indexed: 11/06/2022]
Abstract
Medullary thyroid carcinoma (MTC) is a neuroendocrine malignancy of the thyroid C cells that occurs in hereditary and sporadic clinical settings. Metastatic spread commonly occurs to cervical and mediastinal lymph nodes. MTC cells do not concentrate radioactive iodine and are not sensitive to hormonal manipulation, and therefore surgery is the most effective option for curative therapy, reduction in tumor burden, or effective palliation. In patients undergoing preventative surgery for hereditary MTC, central lymph node dissection should be considered if the calcitonin level is elevated. Preservation of parathyroid function in these young patients is of paramount importance. In patients with established primary tumors, systematic surgical removal of lymph node basins (compartmental dissection) should be guided by ultrasound mapping of lymph node metastases and level of serum calcitonin. A "berry-picking" approach is discouraged. Newly approved targeted molecular therapies offer wider treatment options for patients with progressive or metastatic disease.
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Affiliation(s)
- Linda X Jin
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Jeffrey F Moley
- Section of Endocrine and Oncologic Surgery, Department of Surgery, Siteman Cancer Center, Washington University School of Medicine, St. Louis, Missouri.,Department of Surgery, St. Louis Veterans Affairs Medical Center, St. Louis, Missouri
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23
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Jin LX, Moley JF. Surgery for lymph node metastases of medullary thyroid carcinoma. INTERNATIONAL JOURNAL OF ENDOCRINE ONCOLOGY 2015. [DOI: 10.2217/ije.15.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Medullary thyroid carcinoma (MTC) is a neuroendocrine malignancy of the thyroid C cells, and can commonly spread to cervical and mediastinal lymph nodes. MTC cells do not concentrate radioactive iodine and are not sensitive to hormonal manipulation, and therefore surgery is the only effective option for curative therapy, reduction in tumor burden or effective palliation. In patients undergoing preventative operations for hereditary MTC, central lymph node dissection should be considered if the calcitonin level is above 40 pg/ml. Systematic removal of at-risk or involved lymph node compartments should be performed in all patients with palpable primary tumors and recurrent disease, and a ‘berry-picking’ approach should be avoided.
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Affiliation(s)
- Linda X Jin
- School of Medicine, Washington University in St Louis, 1 Brookings Dr., St Louis, MO 63130, USA
| | - Jeffrey F Moley
- Department of Surgery, Endocrine & Oncologic Surgery Section, Siteman Cancer Center, Washington University School of Medicine, 60 S Euclid Ave, St Louis, MO 63110, USA
- St. Louis Veteran's Affairs Medical Center, 1 Jefferson Barracks Rd, St Louis, MO 63125, USA
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24
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Wells SA, Asa SL, Dralle H, Elisei R, Evans DB, Gagel RF, Lee N, Machens A, Moley JF, Pacini F, Raue F, Frank-Raue K, Robinson B, Rosenthal MS, Santoro M, Schlumberger M, Shah M, Waguespack SG. Revised American Thyroid Association guidelines for the management of medullary thyroid carcinoma. Thyroid 2015; 25:567-610. [PMID: 25810047 PMCID: PMC4490627 DOI: 10.1089/thy.2014.0335] [Citation(s) in RCA: 1268] [Impact Index Per Article: 140.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION The American Thyroid Association appointed a Task Force of experts to revise the original Medullary Thyroid Carcinoma: Management Guidelines of the American Thyroid Association. METHODS The Task Force identified relevant articles using a systematic PubMed search, supplemented with additional published materials, and then created evidence-based recommendations, which were set in categories using criteria adapted from the United States Preventive Services Task Force Agency for Healthcare Research and Quality. The original guidelines provided abundant source material and an excellent organizational structure that served as the basis for the current revised document. RESULTS The revised guidelines are focused primarily on the diagnosis and treatment of patients with sporadic medullary thyroid carcinoma (MTC) and hereditary MTC. CONCLUSIONS The Task Force developed 67 evidence-based recommendations to assist clinicians in the care of patients with MTC. The Task Force considers the recommendations to represent current, rational, and optimal medical practice.
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Affiliation(s)
- Samuel A. Wells
- Genetics Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Sylvia L. Asa
- Department of Pathology, University Health Network, and Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Henning Dralle
- Department of General, Visceral, and Vascular Surgery, University Hospital, University of Halle-Wittenberg, Halle/Saale, Germany
| | - Rossella Elisei
- Department of Endocrinology, University of Pisa, Pisa, Italy
| | - Douglas B. Evans
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Robert F. Gagel
- Department of Endocrine Neoplasia and Hormonal Disorders, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Nancy Lee
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Andreas Machens
- Department of General, Visceral, and Vascular Surgery, University Hospital, University of Halle-Wittenberg, Halle/Saale, Germany
| | - Jeffrey F. Moley
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Furio Pacini
- Section of Endocrinology and Metabolism, Department of Internal Medicine, Endocrinology and Metabolism and Biochemistry, University of Siena, Policlinico Santa Maria alle Scotte, Siena, Italy
| | - Friedhelm Raue
- Endocrine Practice, Moleculargenetic Laboratory, Medical Faculty, University of Heidelberg, Heidelberg, Germany
| | - Karin Frank-Raue
- Endocrine Practice, Moleculargenetic Laboratory, Medical Faculty, University of Heidelberg, Heidelberg, Germany
| | - Bruce Robinson
- University of Sydney School of Medicine, Sydney, New South Wales, Australia
| | - M. Sara Rosenthal
- Departments of Internal Medicine, Pediatrics and Behavioral Science, University of Kentucky, Lexington, Kentucky
| | - Massimo Santoro
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Universita' di Napoli “Federico II,” Napoli, Italy
| | - Martin Schlumberger
- Institut Gustave Roussy, Service de Medecine Nucleaire, Université of Paris-Sud, Villejuif, France
| | - Manisha Shah
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University, Columbus, Ohio
| | - Steven G. Waguespack
- Department of Endocrine Neoplasia and Hormonal Disorders, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
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25
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Abstract
Medullary thyroid cancer (MTC) can vary in tumor biology and progression. The most important indicator of distant metastases, determining clinical outcome, is lymph node metastasis to the neck and mediastinum. Surgical cure is within reach in node-negative tumors or node-positive tumors with fewer than 10 lymph node metastases. From a surgical point of view, compartment-oriented lymph node dissection, clearing gross, and occult metastases are important for locoregional tumor control. The discovery of missense germline mutations in the RET proto-oncogene and the close genotype-phenotype correlation in hereditary MTC promoted the worldwide breakthrough of prophylactic thyroidectomy. The best approach to hereditary MTC affords the DNA-based/biochemical concept, which is geared at limiting prophylactic surgery to total thyroidectomy at minimal surgical morbidity before the tumor can spread beyond the thyroid capsule. To improve outcome, routine calcitonin screening in nodular thyroid disease and DNA-based screening of the offspring in RET families are effective interventions.
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Affiliation(s)
- Andreas Machens
- Department of General, Visceral and Vascular Surgery, University Hospital, Medical Faculty, University of Halle-Wittenberg, Ernst-Grube-Str. 40, 06097, Halle, Germany
| | - Henning Dralle
- Department of General, Visceral and Vascular Surgery, University Hospital, Medical Faculty, University of Halle-Wittenberg, Ernst-Grube-Str. 40, 06097, Halle, Germany.
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Nagy R. The genetics of endocrine neoplasia. Curr Probl Cancer 2014; 38:262-73. [PMID: 25497412 DOI: 10.1016/j.currproblcancer.2014.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The hereditary endocrine neoplasias are characterized by the development of benign or malignant tumors in more than one endocrine tissue. These tumors typically occur at a younger age than sporadic endocrine tumors and follow an autosomal dominant pattern of inheritance. Because of the age-related penetrance and extreme phenotypic variability both within and between families, clinicians cannot always rely on the family history to make the diagnosis. Recognition of the features of a hereditary endocrine syndrome can allow for appropriate and timely risk assessment, genetic counseling and genetic testing, and identification of at-risk family members who may benefit from early and regular screening.
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Lips CJ, Links TP, Höppener JW, Dreijerink KM, ten Kroode HF. Standards of care intended for multiple endocrine neoplasia families. INTERNATIONAL JOURNAL OF ENDOCRINE ONCOLOGY 2014. [DOI: 10.2217/ije.14.19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
In the past, the medical expenditure for multiple endocrine neoplasia families was high and the course of their disease not predictable. In a couple of decades, the prospects changed completely. The genetic origin of the diseases is well known and prevention is possible, whereas in advanced stages target-directed treatment is coming within reach. The most important change is the responsibility for these families. Initially, this was completely the task of the attending physician, whereas at this moment patients and disease gene carriers themselves have the central responsibility with respect to these diseases. Unfortunately, for them information about the disease is insufficiently available.
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Affiliation(s)
- Cornelis J Lips
- University Medical Center Utrecht, Wassenaarseweg 109, The Hague, 2596 CN, The Netherlands
| | - Thera P Links
- Department of Endocrinology, University Medical Center Groningen
| | - Jo W Höppener
- Division of Biomededical Genetics & Molecular Cancer Research, University Utrecht
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Rowland KJ, Moley JF. Hereditary thyroid cancer syndromes and genetic testing. J Surg Oncol 2014; 111:51-60. [DOI: 10.1002/jso.23769] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Accepted: 07/22/2014] [Indexed: 12/16/2022]
Affiliation(s)
- Kathryn J. Rowland
- Division of Endocrine and Oncologic Surgery; Barnes Jewish Hospital, Department of Surgery, Washington University School of Medicine; St. Louis Missouri
| | - Jeffrey F. Moley
- Division of Endocrine and Oncologic Surgery; Barnes Jewish Hospital, Department of Surgery, Washington University School of Medicine; St. Louis Missouri
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Maia AL, Siqueira DR, Kulcsar MAV, Tincani AJ, Mazeto GMFS, Maciel LMZ. Diagnóstico, tratamento e seguimento do carcinoma medular de tireoide: recomendações do Departamento de Tireoide da Sociedade Brasileira de Endocrinologia e Metabologia. ACTA ACUST UNITED AC 2014; 58:667-700. [DOI: 10.1590/0004-2730000003427] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Accepted: 07/12/2014] [Indexed: 12/20/2022]
Abstract
Introdução O carcinoma medular de tireoide (CMT) origina-se das células parafoliculares da tireoide e corresponde a 3-4% das neoplasias malignas da glândula. Aproximadamente 25% dos casos de CMT são hereditários e decorrentes de mutações ativadoras no proto-oncogene RET (REarranged during Transfection). O CMT é uma neoplasia de curso indolente, com taxas de sobrevida dependentes do estádio tumoral ao diagnóstico. Este artigo descreve diretrizes baseadas em evidências clínicas para o diagnóstico, tratamento e seguimento do CMT. Objetivo O presente consenso, elaborado por especialistas brasileiros e patrocinado pelo Departamento de Tireoide da Sociedade Brasileira de Endocrinologia e Metabologia, visa abordar o diagnóstico, tratamento e seguimento dos pacientes com CMT, de acordo com as evidências mais recentes da literatura. Materiais e métodos: Após estruturação das questões clínicas, foi realizada busca das evidências disponíveis na literatura, inicialmente na base de dados do MedLine-PubMed e posteriormente nas bases Embase e SciELO – Lilacs. A força das evidências, avaliada pelo sistema de classificação de Oxford, foi estabelecida a partir do desenho de estudo utilizado, considerando-se a melhor evidência disponível para cada questão. Resultados Foram definidas 11 questões sobre o diagnóstico, 8 sobre o tratamento cirúrgico e 13 questões abordando o seguimento do CMT, totalizando 32 recomendações. Como um todo, o artigo aborda o diagnóstico clínico e molecular, o tratamento cirúrgico inicial, o manejo pós-operatório e as opções terapêuticas para a doença metastática. Conclusões O diagnóstico de CMT deve ser suspeitado na presença de nódulo tireoidiano e história familiar de CMT e/ou associação com feocromocitoma, hiperparatireoidismo e/ou fenótipo sindrômico característico, como ganglioneuromatose e habitus marfanoides. A punção aspirativa por agulha fina do nódulo, a dosagem de calcitonina sérica e o exame anatomopatológico podem contribuir na confirmação do diagnóstico. A cirurgia é o único tratamento que oferece a possibilidade de cura. As opções de tratamento da doença metastática ainda são limitadas e restritas ao controle da doença. Uma avaliação pós-cirúrgica criteriosa para a identificação de doença residual ou recorrente é fundamental para definir o seguimento e a conduta terapêutica subsequente.
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Perros P, Boelaert K, Colley S, Evans C, Evans RM, Gerrard Ba G, Gilbert J, Harrison B, Johnson SJ, Giles TE, Moss L, Lewington V, Newbold K, Taylor J, Thakker RV, Watkinson J, Williams GR. Guidelines for the management of thyroid cancer. Clin Endocrinol (Oxf) 2014; 81 Suppl 1:1-122. [PMID: 24989897 DOI: 10.1111/cen.12515] [Citation(s) in RCA: 724] [Impact Index Per Article: 72.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Petros Perros
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne
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Abstract
INTRODUCTION While the vast majority of patients with thyroid cancer have an excellent prognosis, those with more aggressive courses experience significant morbidity and mortality. Advanced forms of thyroid cancer are typically refractory to standard therapy. Numerous agents with potential usefulness in the treatment of advanced thyroid cancer have recently come under study. AREAS COVERED This article reviews agents identified through a systematic review of the scientific literature as being under investigation for treatment of advanced thyroid cancer. A search of both PubMed and the NCI Clinical Trials website was performed to identify such agents having reached Phase II or III testing. Improved understanding of cancer cell signaling pathways has led to the identification of > 500 kinases as potential therapeutic targets. Additional agents of interest include those that inhibit neoangiogenesis, alter epigenetic factors or stimulate antitumor immune reactions. While presently available agents have shown promise in improving progression-free survival (PFS), complete responses are not seen and significant adverse side effects are encountered. EXPERT OPINION The development of numerous new anticancer agents holds the promise of treatment regimens that will extend PFS and ultimately overall survival in patients with advanced thyroid cancer. Anticipated future developments include individualized, multimodal treatment regimens based on specific tumor cell biology and driver mutations.
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Affiliation(s)
- Victor Bernet
- Medicine/Endocrinology, Mayo Clinic , 4500 San Pablo Road, Jacksonville, FL 32082 , USA
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Abstract
Medullary thyroid cancer (MTC) accounts for ~10% of thyroid carcinomas and occurs in sporadic and hereditary forms. Early diagnosis significantly impacts the clinical course, management and outcome of the disease. The identification of germline-activating mutations of the rearranged during transfection oncogene in patients with hereditary MTC led to significant progress in the diagnostic and therapeutic approach, thus improving the quality of care provided, and consequently, disease prognosis. In the present review, various aspects of genetic screening (GS) in MTC will be covered, which elucidate the value of GS in guiding clinical decision making, therapy selection and appropriate genetic counseling of the affected families. GS should be offered to every MTC patient, based on the personal and family medical history, to allow optimal clinical management and follow-up.
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Affiliation(s)
- Theodora Pappa
- a Department of Medical Therapeutics, Endocrine Unit, Athens University School of Medicine, Alexandra Hospital, Athens, Greece
| | - Maria Alevizaki
- a Department of Medical Therapeutics, Endocrine Unit, Athens University School of Medicine, Alexandra Hospital, Athens, Greece
- b Department of Endocrinology, Metabolism and Diabetes, Athens University School of Medicine, Evgenideion Hospital, Athens, Greece
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Timing and extent of thyroid surgery for gene carriers of hereditary C cell disease—a consensus statement of the European Society of Endocrine Surgeons (ESES). Langenbecks Arch Surg 2013; 399:185-97. [DOI: 10.1007/s00423-013-1139-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Accepted: 10/29/2013] [Indexed: 01/12/2023]
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Abstract
OBJECTIVE This article will review the multimodality imaging spectrum of medullary thyroid carcinoma (MTC) with an emphasis on anatomic and functional imaging. Recent advances in the molecular cytogenetics of this tumor and the impact on diagnosis, prognosis, and development of novel targeted therapy will be discussed. CONCLUSION MTC is a neuroendocrine tumor with unique clinicopathologic and radiologic features compared with other thyroid malignancies. Imaging plays an important role in the optimal management of this malignancy.
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Samimi H, Zaki dizaji M, Ghadami M, Shahzadeh fazeli A, Khashayar P, Soleimani M, Larijani B, Haghpanah V. Essential genes in thyroid cancers: focus on fascin. J Diabetes Metab Disord 2013; 12:32. [PMID: 23815863 PMCID: PMC7983713 DOI: 10.1186/2251-6581-12-32] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2013] [Accepted: 06/25/2013] [Indexed: 01/21/2023]
Abstract
Although thyroid cancers are not among common malignancies, they rank as the first prevalent endocrine cancers in human. According to the results of published studies it has been shown the gradual progress from normal to the neoplastic cell in the process of tumor formation is the result of sequential genetic events. Among them we may point the mutations and rearrangements occurred in a group of proto-oncogenes, transcription factors and metastasis elements such as P53, RAS,RET,BRAF, PPARγ and Fascin. In the present article,we reviewed the most important essential genes in thyroid cancers, the role of epithelial mesenchymal transition and Fascin has been highlighted in this paper.
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Affiliation(s)
- Hilda Samimi
- Science and Culture University, Tehran, Iran
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences, 5th floor, Dr. Shariati Hospital, North Kargar Ave, Tehran, Iran
| | - Majid Zaki dizaji
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences, 5th floor, Dr. Shariati Hospital, North Kargar Ave, Tehran, Iran
- Department of Medical Genetics, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohsen Ghadami
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences, 5th floor, Dr. Shariati Hospital, North Kargar Ave, Tehran, Iran
- Department of Medical Genetics, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Patricia Khashayar
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences, 5th floor, Dr. Shariati Hospital, North Kargar Ave, Tehran, Iran
| | - Masoud Soleimani
- Department of Hematology, Faculty of Medical Science, Tarbiat Modares University, Tehran, Iran
| | - Bagher Larijani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences, 5th floor, Dr. Shariati Hospital, North Kargar Ave, Tehran, Iran
| | - Vahid Haghpanah
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences, 5th floor, Dr. Shariati Hospital, North Kargar Ave, Tehran, Iran
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Toledo SPA, Lourenço DM, Toledo RA. A differential diagnosis of inherited endocrine tumors and their tumor counterparts. Clinics (Sao Paulo) 2013; 68:1039-56. [PMID: 23917672 PMCID: PMC3715026 DOI: 10.6061/clinics/2013(07)24] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Accepted: 03/26/2013] [Indexed: 12/15/2022] Open
Abstract
Inherited endocrine tumors have been increasingly recognized in clinical practice, although some difficulties still exist in differentiating these conditions from their sporadic endocrine tumor counterparts. Here, we list the 12 main topics that could add helpful information and clues for performing an early differential diagnosis to distinguish between these conditions. The early diagnosis of patients with inherited endocrine tumors may be performed either clinically or by mutation analysis in at-risk individuals. Early detection usually has a large impact in tumor management, allowing preventive clinical or surgical therapy in most cases. Advice for the clinical and surgical management of inherited endocrine tumors is also discussed. In addition, recent clinical and genetic advances for 17 different forms of inherited endocrine tumors are briefly reviewed.
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Affiliation(s)
- Sergio P A Toledo
- Division of Endocrinology, Endocrine Genetics Unit (LIM-25), Faculdade de Medicina da Universidade de São Paulo, São Paulo/SP, Brazil.
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Casey R, Bell M, Keane M, Smyth A. An unusual presentation of MEN2A. BMJ Case Rep 2013; 2013:bcr-2012-007171. [PMID: 23749818 DOI: 10.1136/bcr-2012-007171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 35-year-old woman presented with non-specific symptoms of fatigue and weight loss. Radiological investigations diagnosed a metastatic process and large bilateral adrenal masses. Histology from a liver biopsy and skin biopsy confirmed a diagnosis of metastatic medullary thyroid cancer. Further biochemical investigations revealed a positive 24-h urinary metanephrine collection and evidence of primary hyperparathyroidism. Genetic testing confirmed a mutant RET oncogene, confirming our clinical suspicion of multiple endocrine neoplasia type 2 (MEN2A) syndrome. The patient had no family history of endocrine disease and presented with widespread metastatic disease, making this an unusual presentation of MEN2A syndrome. Furthermore cutaneous metastases are rarely encountered in conjunction with metastatic medullary thyroid cancer. This case draws attention to the importance of genetic counselling in first-degree relatives of patients with confirmed MEN2A. This allows for timely diagnosis and reduced morbidity and mortality.
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Affiliation(s)
- R Casey
- Department of Medicine, University Hospital Galway, Galway, Ireland.
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Lolkema MP, Gadellaa-van Hooijdonk CG, Bredenoord AL, Kapitein P, Roach N, Cuppen E, Knoers NV, Voest EE. Ethical, legal, and counseling challenges surrounding the return of genetic results in oncology. J Clin Oncol 2013; 31:1842-8. [PMID: 23589552 DOI: 10.1200/jco.2012.45.2789] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
In the last decade, an overwhelming number of genetic aberrations have been discovered and linked to the development of treatment for cancer. With the rapid advancement of next-generation sequencing (NGS) techniques, it is expected that large-scale DNA analyses will increasingly be used to select patients for treatment with specific anticancer agents. Personalizing cancer treatment has many advantages, but sequencing germline DNA as reference material for interpreting cancer genetics may have consequences that extend beyond providing cancer care for an individual patient. In sequencing germline DNA, mutations may be encountered that are associated with increased susceptibility not only to hereditary cancer syndromes but also to other diseases; in those cases, disclosing germline data could be clinically relevant and even lifesaving. In the context of personal autonomy, it is necessary to develop an ethical and legal framework for how to deal with identified hereditary disease susceptibilities and how to return the data to patients and their families. Because clear legislation is lacking, we need to establish guidelines on disclosure of genetic information and, in the process, we need to balance privacy issues with the potential advantages and drawbacks of sharing genetic data with patients and their relatives. Importantly, a strong partnership with patients is critical for understanding how to maximize the translation of genetic information for the benefit of patients with cancer. This review discusses the ethical, legal, and counseling issues surrounding disclosure of genetic information generated by NGS to patients with cancer and their relatives. We also provide a framework for returning these genetic results by proposing a design for a qualified disclosure policy.
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Twigt BA, Scholten A, Valk GD, Rinkes IHMB, Vriens MR. Differences between sporadic and MEN related primary hyperparathyroidism; clinical expression, preoperative workup, operative strategy and follow-up. Orphanet J Rare Dis 2013; 8:50. [PMID: 23547958 PMCID: PMC3623824 DOI: 10.1186/1750-1172-8-50] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2012] [Accepted: 02/04/2013] [Indexed: 02/01/2023] Open
Abstract
Background Primary hyperparathyroidism (PHPT) is most commonly sporadic (sPHPT). However, sometimes PHPT develops as part of multiple endocrine neoplasia (MEN) type 1 or 2A. In all, parathyroidectomy is the only curative treatment. Nevertheless, there are important differences in clinical expression and treatment. Methods We analyzed a consecutive cohort of patients treated for sporadic, MEN1-related, and MEN2A-related PHPT and compared them regarding clinical and biochemical parameters, differences in preoperative workup, operative strategies, findings, and outcome. Results A total of 467 patients with sPHPT, 52 with MEN1- and 16 with MEN2A-related PHPT were analyzed. Patients with sPHPT were older, more often female and had higher preoperative calcium and parathyroid hormone levels, when compared with MEN1 and MEN2A patients. Minimally invasive parathyroidectomy (MIP) was performed in 367 of 467 sPHPT patients (79%). One abnormal parathyroid was found in 426 patients (91%). Two or more in 35 patients (7%). In six patients (1%) no abnormal parathyroid gland was retrieved. Of 52 MEN1 patients, eight (15%) underwent a MIP and 44 patients (85%) underwent conventional neck exploration (CNE); with resection of fewer than 3½ enlarged glands in 21 patients (40%), subtotal parathyroidectomy (SPTX, 3-3½ glands) in seventeen (33%) and total parathyroidectomy with autotransplantation (TPTX) in six (12%). Eleven patients (21%) had persistent disease, 29 (56%) recurrent PHPT and nine (17%) permanent hypoparathyroidism, mostly after TPTX. Of 16 MEN2A patients, six (38%) underwent MIP, four (25%) CNE and six (38%) selective resection of the enlarged gland(s) during total thyroidectomy. Three patients (19%) suffered from persistent PHPT and two (13%) developed recurrent disease. Conclusions Sporadic PHPT, MEN1- and MEN2A-related PHPT are three distinct entities as is reflected preoperatively by differences in gender, age at diagnosis and calcium and PTH levels. MEN2A patients are very similar to sPHPT with respect to operative approach and findings. MIP is the treatment of choice for both. MIP has low rates of persistent and recurrent PHPT and a low complication rate. The percentage of multiglandular disease and recurrences are significantly higher in MEN1 patients, demonstrating the need for a different approach. We advocate treating these patients with CNE and SPTX.
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Affiliation(s)
- Bas A Twigt
- Department of Surgical Oncology and Endocrine Surgery, University Medical Center, Utrecht, 3584CX, the Netherlands
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Dralle H, Musholt TJ, Schabram J, Steinmüller T, Frilling A, Simon D, Goretzki PE, Niederle B, Scheuba C, Clerici T, Hermann M, Kußmann J, Lorenz K, Nies C, Schabram P, Trupka A, Zielke A, Karges W, Luster M, Schmid KW, Vordermark D, Schmoll HJ, Mühlenberg R, Schober O, Rimmele H, Machens A. German Association of Endocrine Surgeons practice guideline for the surgical management of malignant thyroid tumors. Langenbecks Arch Surg 2013; 398:347-75. [PMID: 23456424 DOI: 10.1007/s00423-013-1057-6] [Citation(s) in RCA: 150] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2013] [Accepted: 01/30/2013] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Over the past years, the incidence of thyroid cancer has surged not only in Germany but also in other countries of the Western hemisphere. This surge was first and foremost due to an increase of prognostically favorable ("low risk") papillary thyroid microcarcinomas, for which limited surgical procedures are often sufficient without loss of oncological benefit. These developments called for an update of the previous practice guideline to detail the surgical treatment options that are available for the various disease entities and tumor stages. METHODS The present German Association of Endocrine Surgeons practice guideline was developed on the basis of clinical evidence considering current national and international treatment recommendations through a formal expert consensus process in collaboration with the German Societies of General and Visceral Surgery, Endocrinology, Nuclear Medicine, Pathology, Radiooncology, Oncological Hematology, and a German thyroid cancer patient support organization. RESULTS The practice guideline for the surgical management of malignant thyroid tumors includes recommendations regarding preoperative workup; classification of locoregional nodes and terminology of surgical procedures; frequency, clinical, and histopathological features of occult and clinically apparent papillary, follicular, poorly differentiated, undifferentiated, and sporadic and hereditary medullary thyroid cancers, thyroid lymphoma and thyroid metastases from primaries outside the thyroid gland; extent of thyroidectomy; extent of lymph node dissection; aerodigestive tract resection; postoperative follow-up and surgery for recurrence and distant metastases. CONCLUSION These evidence-based recommendations for surgical therapy reflect various "treatment corridors" that are best discussed within multidisciplinary teams and the patient considering tumor type, stage, progression, and inherent surgical risk.
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Affiliation(s)
- Henning Dralle
- Department of General, Visceral and Vascular Surgery, Martin Luther University Halle-Wittenberg, Ernst-Grube-Straße 40, 06097, Halle, Saale, Germany.
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Camacho CP, Lindsey SC, Melo MCC, Yang JH, Germano-Neto F, Valente FDOF, Lima TRN, Biscolla RPM, Vieira JGH, Cerutti JM, Dias-da-Silva MR, Maciel RMB. Measurement of calcitonin and calcitonin gene-related peptide mRNA refines the management of patients with medullary thyroid cancer and may replace calcitonin-stimulation tests. Thyroid 2013; 23:308-16. [PMID: 23259706 PMCID: PMC3593689 DOI: 10.1089/thy.2012.0361] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Serum calcitonin (sCT) is the main tumor marker for medullary thyroid cancer (MTC), but it has certain limitations. Various sCT assays may have important intra-assay or interassay variation and may yield different and sometimes conflicting results. A pentagastrin- or calcium-stimulation calcitonin (CT) test may be desirable in some situations. Alternatively, or in the absence of the stimulation test, mRNA detection offers the advantages of being more comfortable and less invasive; it only requires blood collection and has no side effects. The objective of this study was to investigate the applicability of measuring calcitonin-related polypeptide alpha (CALCA) gene transcripts (CT-CALCA and calcitonin gene-related peptide [CGRP]-CALCA) in patients with MTC and in relatives diagnosed with a RET mutation and to test mRNA as an alternative diagnostic tool for the calcitonin-stimulation test. METHODS Twenty-three healthy controls and 26 individuals evaluated for MTC were selected, including patients with sporadic or hereditary MTC and RET mutation-carrying relatives. For molecular analysis, RNA was extracted from peripheral blood, followed by cDNA synthesis using 3.5 μg of total RNA. Quantitative real-time polymerase chain reaction (RT-qPCR) was performed with SYBR Green and 200 nM of each primer for the two specific mRNA targets (CT-CALCA or CGRP-CALCA) and normalized with the ribosomal protein S8 as the reference gene. RESULTS We detected CALCA transcripts in the blood samples and observed a positive correlation between them (r=0.946, p<0.0001). Both mRNAs also correlated with sCT (CT-CALCA, r=0.713, p<0.0001; CGRP-CALCA, r=0.714, p<0.0001). The relative expression of CT-CALCA and CGRP-CALCA presented higher clinical sensitivity (86.67 and 100, respectively), specificity (97.06 and 97.06), positive predictive value (92.86 and 93.75), and negative predictive value (94.29 and 100), than did sCT (73.33, 82.35, 64.71, and 87.50, respectively). In addition, the CALCA transcript measurement mirrored the response to the pentagastrin test. CONCLUSION We demonstrate that the measurement of CALCA gene transcripts in the bloodstream is feasible and may refine the management of patients with MTC and RET mutation-carrying relatives. We propose considering the application of this diagnostic tool as an alternative to the calcitonin-stimulation test.
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Affiliation(s)
- Cléber P Camacho
- Laboratory of Molecular and Translational Endocrinology, Department of Medicine, Escola Paulista de Medicina, Federal University of São Paulo, São Paulo, Brazil
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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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Paternal age effect mutations and selfish spermatogonial selection: causes and consequences for human disease. Am J Hum Genet 2012; 90:175-200. [PMID: 22325359 DOI: 10.1016/j.ajhg.2011.12.017] [Citation(s) in RCA: 247] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2011] [Revised: 12/05/2011] [Accepted: 12/26/2011] [Indexed: 12/25/2022] Open
Abstract
Advanced paternal age has been associated with an increased risk for spontaneous congenital disorders and common complex diseases (such as some cancers, schizophrenia, and autism), but the mechanisms that mediate this effect have been poorly understood. A small group of disorders, including Apert syndrome (caused by FGFR2 mutations), achondroplasia, and thanatophoric dysplasia (FGFR3), and Costello syndrome (HRAS), which we collectively term "paternal age effect" (PAE) disorders, provides a good model to study the biological and molecular basis of this phenomenon. Recent evidence from direct quantification of PAE mutations in sperm and testes suggests that the common factor in the paternal age effect lies in the dysregulation of spermatogonial cell behavior, an effect mediated molecularly through the growth factor receptor-RAS signal transduction pathway. The data show that PAE mutations, although arising rarely, are positively selected and expand clonally in normal testes through a process akin to oncogenesis. This clonal expansion, which is likely to take place in the testes of all men, leads to the relative enrichment of mutant sperm over time-explaining the observed paternal age effect associated with these disorders-and in rare cases to the formation of testicular tumors. As regulation of RAS and other mediators of cellular proliferation and survival is important in many different biological contexts, for example during tumorigenesis, organ homeostasis and neurogenesis, the consequences of selfish mutations that hijack this process within the testis are likely to extend far beyond congenital skeletal disorders to include complex diseases, such as neurocognitive disorders and cancer predisposition.
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Machens A, Spitschak A, Lorenz K, Pützer BM, Dralle H. Germline RET sequence variation I852M and occult medullary thyroid cancer: harmless polymorphism or causative mutation? Clin Endocrinol (Oxf) 2011; 75:801-5. [PMID: 21711375 DOI: 10.1111/j.1365-2265.2011.04158.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Rearranged during transfection (RET) gene analysis, widely used to identify carriers at risk of medullary thyroid cancer (MTC), occasionally uncovers novel sequence 'variants of unknown clinical significance' including RET I852M. This study aimed to clarify whether RET I852M represents a harmless polymorphism or a pathogenic mutation. DESIGN Clinical investigation supported by functional characterization of I852M mutant cells in vitro. PATIENTS AND MEASUREMENTS Genotype-phenotype correlation including five kindreds from a three-generational Caucasian I852M RET family. RESULTS A node-negative occult MTC was found in the 64-year-old index patient who had increased basal and stimulated peak calcitonin levels of 190 and 13 307 ng/l, respectively. Her 4-year-old grandson had no histopathological evidence of C-cell disease although his serum calcitonin levels had increased within 5 months from 3·2 to 6·3 ng/l basally and from 17·2 to 24·5 ng/l after pentagastrin stimulation. His mother and two 11- and 1·5-year-old siblings, also carrying the gene, had normal basal and stimulated calcitonin levels and hence did not undergo surgery. Functional characterization of transfected NIH3T3 cells in vitro (cell proliferation rate; cell viability; anchorage-independent cell growth; cell migration; and invasion) indicated that I852M mutant cells have transforming and migratory activities similar to American Thyroid Association (ATA) class A V804M mutants. I852M mutants demonstrated a weaker proliferative potential than fast-proliferating ATA class C C634R mutants and revealed a weaker migratory activity compared with aggressively growing ATA class D A883F mutants. CONCLUSIONS I852M sequence variations represent genuine RET mutations, falling into ATA class A of weakly activating RET germline mutations.
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Affiliation(s)
- Andreas Machens
- Department of General, Visceral and Vascular Surgery, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany.
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Kudo T, Miyauchi A, Ito Y, Yabuta T, Inoue H, Higashiyama T, Tomoda C, Hirokawa M, Amino N. Serum calcitonin levels with calcium loading tests before and after total thyroidectomy in patients with thyroid diseases other than medullary thyroid carcinoma. Endocr J 2011; 58:217-21. [PMID: 21358115 DOI: 10.1507/endocrj.k10e-359] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Calcitonin is a very sensitive tumor marker of medullary thyroid carcinoma (MTC). Patients with MTC have usually very high levels of serum calcitonin that can be used to diagnose the disease. In order to improve diagnostic sensitivity in family members with small MTCs or to evaluate postoperative biochemical cure status, measurement of calcitonin stimulated with combined intravenous calcium gluconate and pentagastrin has been widely adopted; however, gastrin has become unavailable. Currently, a provocative test using only calcium gluconate is performed; however, the standard values for this test have not been reported. We therefore conducted calcium gluconate stimulation tests in 20 patients before and after total thyroidectomy for thyroid diseases other than MTC. Preoperatively, the mean basal calcitonin level was 24.1 pg/mL and increased to 46.9pg/mL after calcium infusion. The ratio of the peak calcitonin level to the basal value ranged from 1- to 5.23-fold, with a mean of 1.94. The ratio was higher than 3-fold in 3 patients. In 2 patients, peak calcitonin levels exceeded 100 pg/mL. Postoperatively, the mean basal level slightly decreased to 21.15pg/mL and the response to calcium stimulation markedly decreased, with the mean ratio decreasing to 1.1-fold (range, 0.86- to 1.73-fold, maximum peak level, 33 pg/mL). Thus, some subjects without MTC show response to the calcium stimulation test up to 5.24 times the ratio and a peak value of 160 pg/mL, suggesting the requirement for judicious judgment for the early diagnosis of MTC in family members; however, after total thyroidectomy, none of the subjects showed an increase of more than 2-fold or a peak value of 33pg/mL, suggesting that responses greater than 2-fold after MTC surgery might be abnormal, indicating the presence of residual tumor.
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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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Tyer NM, Braunstein GD, Frishberg D. Unusual case of multiple endocrine neoplasia type 2A syndrome without medullary thyroid carcinoma. Endocr Pract 2010; 17:e4-7. [PMID: 21134882 DOI: 10.4158/ep10157.cr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To present an unusual case of multiple endocrine neoplasia type 2A (MEN 2A) syndrome and to describe how this case differs from the typical clinical features and usual genetic variations seen in classic MEN 2A syndrome. METHODS We describe the work-up, diagnosis, and treatment course of a patient who presented with multi-focal pheochromocytomas, parathyroid adenoma, thyroid abnormalities, and a RET mutation. RESULTS A 65-year-old man with previously treated pheochromocytoma presented with a parathyroid adenoma, multiple thyroid nodules, and a RET polymorphism. C-cell hyperplasia (CCH) or medullary thyroid carcinoma (MTC) occurs with nearly 100% penetrance in patients with MEN 2A syndrome. Our patient did not have CCH or frank MTC, but he expressed the other manifestations of the MEN 2A syndrome. CONCLUSION MEN 2A syndrome is characterized by the occurrence of MTC, pheochromocytomas, and parathyroid hyperplasia or adenomas. It is inherited in an autosomal dominant fashion, and more than 80% of patients with MEN 2A have a specific substitution on codon 634 of the RET proto-oncogene. Despite the nearly 100% penetrance of MTC or CCH in patients with MEN 2A, our patient did not have this. Additionally, he exhibited a RET mutation that is uncommonly seen in classic MEN 2A syndrome. Our patient may have a MEN 2A variant or a pseudo-MEN 2A syndrome.
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Affiliation(s)
- Nicole M Tyer
- Department of Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Do the recent American Thyroid Association (ATA) Guidelines accurately guide the timing of prophylactic thyroidectomy in MEN2A? Surgery 2010; 148:1302-9; discussion 1309-10. [PMID: 21134565 DOI: 10.1016/j.surg.2010.09.020] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2010] [Accepted: 09/16/2010] [Indexed: 02/03/2023]
Abstract
BACKGROUND In 2009, the American Thyroid Association (ATA) published consensus guidelines for timing of prophylactic thyroidectomy (PrThy) for treatment of hereditary medullary thyroid cancer (MTC). The aim of this study was to assess whether the clinical guidelines outlined in the ATA recommendations added to the specific mutation risk level could predict the presence of MTC on final pathology. METHODS A retrospective study was performed of patients undergoing PrThy. We evaluated mutation-based risk levels in combination with 2009 ATA guidelines for resection. RESULTS Overall, 54 patients underwent PrThy between 1972 and 2009. The median age at PrThy was 11.5 years (range, 2-68). Only 4 patients (8%) underwent PrThy prior to age 5 years. Most patients with MTC (16/22, 73%) had a level C mutation, and the youngest age of MTC in a level C mutation carrier was 5 years. The youngest age of MTC in level A or B carriers was 15 years. The single factor that predicted an overall decreased risk of MTC at the time of PrThy was meeting all ATA mutation-based postponement guidelines for surgical intervention (P = .04). CONCLUSION ATA guidelines that includes risk assessment of RET mutation are important in predicting the presence of MTC in patients who are candidates for prophylactic thyroidectomy and in determining the timing of operative resection.
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