Surgical intervention in children with multiple endocrine neoplasia type 2

Pediatric head and neck manifestations associated with multiple endocrine neoplasia syndromes

INTRODUCTION

Multiple endocrine neoplasia (MEN) syndromes are a group of hereditary cancer syndromes that can predispose children to endocrine neoplasms developing within the head and neck.

OBJECTIVE

To examine the neoplastic manifestations of MEN type 1 (MEN1) and MEN type 2 (MEN2) in the pediatric head and neck.

METHODS

Single-institution, retrospective review of pediatric MEN between 2005 and 2022.

RESULTS

Fifty-three children were genetically confirmed with MEN (15 MEN1, 34 MEN2A, and 4 MEN2B), while three patients received clinical diagnoses of MEN1. The male to female ratio was essentially equal (1.15:1), and a documented family history of cancer was present in 89% (50/56). After multidisciplinary evaluation, a familial MEN diagnosis was confirmed in 91% (51/56). The mean ages of initial presentation and surgical intervention were 8.9 years (SD 5) and 9.8 years (SD 4.8), respectively. Although patients with MEN2 received surgery earlier than patients with MEN1 (8.7 vs 12.7 years), surgical patients with MEN2 in this cohort were older relative to current American Thyroid Association (ATA) guidelines primarily due to late presentation. Thyroid malignancies were identified in 36% (9/25) of thyroidectomy specimens (21 MEN2A, 4 MEN2B), with medullary thyroid carcinoma (MTC) present in five MEN2A patients and three MEN2B patients (89%), and papillary thyroid carcinoma (PTC) present in one MEN2A patient (11%). Nearly 90% (8/9) of thyroid malignancies were occult, with some occurring earlier than predicted by current guidelines (ATA-MOD and ATA-H). Central neck dissections were performed in 24% (2 MEN1, 2 MEN2A, and 4 MEN2B), with two MEN2B (50%) demonstrating cervical lymph node (LN) metastases. Additional histopathologic findings included C-cell hyperplasia in 57% (12/21) of MEN2A thyroidectomy patients. Of the eight MEN1 parathyroidectomy patients, four demonstrated parathyroid hyperplasia and four presented with parathyroid adenoma.

CONCLUSION

Nearly 60% required head and neck procedures. While MEN1 guidelines were appropriate for our cohort, we identified patients with MEN2 that developed MTC earlier than expected based on current ATA guidelines, including children in categories considered lower risk. In conjunction with a multidisciplinary approach, pediatric head and neck surgeons should be aware of the potential need for earlier surgical intervention in the pediatric MEN2 population.

Prophylactic thyroidectomies in MEN2 syndrome: Management and outcomes

AIM OF THE STUDY

The aim of the study was to evaluate the outcomes of prophylactic thyroidectomies performed in an academic setting in the context of multiple endocrine neoplasia type 2 (MEN2) syndrome.

METHODS

A chart review of patients <18years old who underwent prophylactic thyroidectomy for a MEN2 syndrome at a children's hospital between 2006 and 2015 was performed.

MAIN RESULTS

The study included 21 patients (57% female) with a mean age of 6.2±2.5years. All patients were asymptomatic at first evaluation. Nineteen had MEN2A syndrome with RET proto-oncogene mutations identified. The remaining two were RET-negative with familial medullary thyroid cancer (FMTC). One patient had a concomitant Hirschsprung disease. Of the 11 patients who had RET proto-oncogene mutations ranked as Moderate Risk for medullary thyroid cancer (MTC) (American Thyroid Association), one had a microcarcinoma on the resected specimen, and the others had C-Cell Hyperplasia. Among the 8 patients who had RET proto-oncogene mutations ranked as High Risk level for MTC, all had microcarcinoma. Of the nine patients with microcarcinoma, three underwent surgery after 5years of age. No microcarcinoma exceeded 6mm. There were no permanent complications. Six patients experienced transient hypocalcemia, of which only one was symptomatic. No patients had lymph node involvement, and no recurrence was noted during the follow-up period.

CONCLUSIONS

Of 21 children with familial thyroid cancer syndrome who underwent a prophylactic thyroidectomy, nine had microcarcinoma. This study highlights the need for a complete familial history, including FMTC history and mandatory preventive surgical approach.

LEVEL OF EVIDENCE

III.

Diagnosis and management of pediatric endocrine neoplasms

PURPOSE OF REVIEW

To guide the clinician in the diagnostic evaluation of endocrine neoplasms, to distinguish between benign and malignant and determine when surgical referral is indicated.

RECENT FINDINGS

Thyroid nodules are uncommon but malignant in as many as 27% of patients. Fine needle aspiration should be considered in adolescents, in which accuracy is as high as 90%; surgical resection should be undertaken in all preadolescents (<13 years) with a thyroid nodule. Prognosis for most primary thyroid malignancies is favorable. Primary hyperparathyroidism is rare and due to an adenoma in up to 70% of patients. Surgical resection carries a cure rate of 95% with the use of intraoperative parathyroid hormone assays. Adrenal neoplasms cover a wide spectrum of disorder. They are functional in 95% of patients and require a thorough diagnostic evaluation prior to surgical resection. Malignant lesions of the adrenal gland carry a poor prognosis when complete surgical resection cannot be achieved. Carcinoids are rare neuroendocrine neoplasms, primarily of the appendix, associated with carcinoid syndrome in 10% of patients. The indolent course warrants aggressive surgical control.

SUMMARY

Endocrine neoplasms are unusual in the pediatric population. Their presence should raise concern about a multiple endocrine neoplasia syndrome and appropriate diagnostic and endocrine work-up. Most neoplasms will require surgical resection.

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