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Machens A, Lorenz K, Weber F, Dralle H. Oncological features of sporadic vs. hereditary pediatric medullary thyroid cancer. Endocrine 2024:10.1007/s12020-024-03959-1. [PMID: 39003661 DOI: 10.1007/s12020-024-03959-1] [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: 05/29/2024] [Accepted: 07/06/2024] [Indexed: 07/15/2024]
Abstract
PURPOSE No genomic data have been put forth that prove beyond a shadow of doubt that sporadic medullary thyroid cancer (MTC) occurs in infancy, childhood, and/or adolescence. METHODS This was a retrospective comparative study of consecutive patients with MTC who had neck surgery at a tertiary center over a 30-year period. RESULTS Included were 1252 patients with MTC (337 hereditary and 915 sporadic), of whom 107 (8.5%) were operated before the age of 18 yrs. Only 4 (3.7%) of the 107 pediatric patients, aged 14, 16, 17 and 17 years, had sporadic MTC. These 4 patients, 3 of whom had been referred for completion surgery, revealed much larger thyroid tumors (medians of 20 mm vs. 1.5-5 mm) than the 103 pediatric patients with hereditary MTC. As for extrathyroid extension and nodal metastases, the 4 patients with sporadic MTC were more comparable to the 37 carriers of highest-risk mutations, 31 (84%) of whom were index patients with de novo disease, than to the 66 carriers of high-risk, intermediate-risk, or low-risk RET mutations (25-38% vs. 0-8%, and medians of 9-9.5 vs. 0 node metastases after dissection of more (medians of 72-91.5 vs. 4.5-9) nodes). CONCLUSION Sporadic MTC, arising rarely, if ever, below the age of 14 years, is exceptional in infancy and childhood, and infrequent in adolescence. At diagnosis, it is almost as widely metastatic as hereditary MTC of the highest-risk category which almost always, like sporadic MTC, presents as de novo disease.
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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
| | - 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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Machens A, Lorenz K, Weber F, Dralle H. Anatomical Patterns of Nodal Spread in Unilateral Papillary and Medullary Thyroid Cancer. Thyroid 2024; 34:871-879. [PMID: 38717955 DOI: 10.1089/thy.2024.0076] [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] [Indexed: 05/22/2024]
Abstract
Background: Skip metastases, node metastases in the lateral neck sparing the ipsilateral central neck, challenge the current concept of central-to-lateral lymphatic spread. This study sought to delineate patterns of central and lateral neck involvement in unilateral papillary thyroid cancer (PTC) and medullary thyroid cancer (MTC). Methods: This was a retrospective correlative analysis of nodal patterns in surgical specimens from patients with unilateral PTC or MTC who had undergone thyroidectomy with at least ipsilateral central neck dissection between November 1994 and January 2024 at a tertiary referral center. Results: Included were 833 patients with unilateral PTC and 640 patients with unilateral MTC. Simultaneous presence or absence of node metastases was noted in ipsilateral central and lateral neck compartments in 76.6-78.1% of patients with PTC (both node positive in 27.0-54.7% and both node negative in 23.4-49.6%) and 77.3-80.0% of patients with MTC (both node positive in 26.6-33.2% and both node negative in 44.1-53.4%). Only one ipsilateral neck compartment was node positive in 21.9-23.4% of patients with PTC and 20.0-22.7% of patients with MTC. The ipsilateral central, but not the ipsilateral lateral compartment, was node positive in 8.8-16.9% with PTC and 8.6-8.8% of patients with MTC, whereas the ipsilateral lateral, but not the ipsilateral central compartment, was node positive in 6.5-13.1% with PTC and 11.3-14.1% with MTC. Ipsilateral lateral neck involvement sparing the ipsilateral central neck was 1.5-2 times more frequent in patients with node positive MTC than patients with node positive PTC (24.2-25.2% vs. 12.9-17.1%). Greater numbers of node metastases in the ipsilateral central neck compartment were associated with more frequent involvement of the ipsilateral lateral, contralateral central, and contralateral lateral neck compartments. Thyroid tumor diameter intensified nodal spread without changing nodal spread patterns. Conclusions: These histopathological findings, which need to be interpreted in light of the respective tumor biology, offer an unprecedented glimpse at the metastatic patterns of unilateral PTC and MTC. Customizing neck dissection to the patterns of nodal spread, considering operative status (initial vs. reoperative surgery) and experience with neck dissection, may require more frequent concomitant dissections of ipsilateral central and ipsilateral lateral neck compartments.
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Affiliation(s)
- Andreas Machens
- Department of Visceral, Vascular and Endocrine Surgery, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Kerstin Lorenz
- Department of Visceral, Vascular and Endocrine Surgery, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Frank Weber
- Department of General, Visceral and Transplantation Surgery, Division of Endocrine Surgery, University of Duisburg-Essen, Essen, Germany
| | - Henning Dralle
- Department of Visceral, Vascular and Endocrine Surgery, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
- Department of General, Visceral and Transplantation Surgery, Division of Endocrine Surgery, University of Duisburg-Essen, Essen, Germany
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Trivedi S, Salahuddin T, Mithi MT, Rathod P, Bandi A, Pandya SJ, Sharma M, Patel S, Warikoo V, Puj K, Salunkhe A, Patel K, Pandya S. Medullary Thyroid Carcinoma: A Single Institute Experience. Indian J Otolaryngol Head Neck Surg 2023; 75:2884-2889. [PMID: 37974849 PMCID: PMC10645935 DOI: 10.1007/s12070-023-03867-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 05/04/2023] [Indexed: 11/19/2023] Open
Abstract
Medullary thyroid carcinoma is a rare tumour that is anatomically located in the thyroid gland but is functionally a neuroendocrine tumour. It is usually a disease of older age group but manifests in a young patient in familial form. It is derived from parafollicular c cells and has a predilection for lymph node metastasis. It is associated with slow growth in thyroid gland with early nodal metastasis. Serum calcitonin is useful as a preoperative marker of disease burden and prognosis. In the preoperative period serum levels of calcitonin can guide regarding the need for compartment wise lymph node dissection and the possibility of distant metastasis. It is used as a tool of surveillance in the postoperative period. The levels of serum CEA and calcitonin and their doubling time is a useful guide in the detection of early recurrence or distant metastasis. Imaging modality useful for diagnosis is USG in a majority of patients. Thus, the initial diagnosis and preoperative assessment of medullary thyroid carcinoma is similar to other forms of thyroid cancer but further management of disease differs significantly form other forms of differentiated thyroid carcinoma or even anaplastic carcinoma. Prognosis however differs according to age, gender, presence or absence of lymph node metastasis at presentation, metastatic disease at presentation and levels of biochemical markers.
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Affiliation(s)
- Sonal Trivedi
- Department of Surgical Oncology, Gujarat Cancer Research Institute, Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat 380016 India
| | - T. Salahuddin
- Department of Surgical Oncology, Gujarat Cancer Research Institute, Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat 380016 India
| | - Mohamed Taher Mithi
- Department of Surgical Oncology, Gujarat Cancer Research Institute, Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat 380016 India
| | - Priyank Rathod
- Department of Surgical Oncology, Gujarat Cancer Research Institute, Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat 380016 India
| | - Arpit Bandi
- Department of Surgical Oncology, Gujarat Cancer Research Institute, Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat 380016 India
| | - Shashank J. Pandya
- Department of Surgical Oncology, Gujarat Cancer Research Institute, Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat 380016 India
| | - Mohit Sharma
- Department of Surgical Oncology, Gujarat Cancer Research Institute, Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat 380016 India
| | - Shailesh Patel
- Department of Surgical Oncology, Gujarat Cancer Research Institute, Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat 380016 India
| | - Vikas Warikoo
- Department of Surgical Oncology, Gujarat Cancer Research Institute, Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat 380016 India
| | - Ketul Puj
- Department of Surgical Oncology, Gujarat Cancer Research Institute, Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat 380016 India
| | - Abhijeet Salunkhe
- Department of Surgical Oncology, Gujarat Cancer Research Institute, Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat 380016 India
| | - Keval Patel
- Department of Surgical Oncology, Gujarat Cancer Research Institute, Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat 380016 India
| | - Shivam Pandya
- Department of Surgical Oncology, Gujarat Cancer Research Institute, Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat 380016 India
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Lubin DJ, Behrman DB, Goyal S, Magliocca K, Shi Q, Chen AY, Viswanathan K. Independent Validation of the International Grading System for Medullary Thyroid Carcinoma: A Single Institution Experience. Mod Pathol 2023; 36:100235. [PMID: 37270155 PMCID: PMC10528047 DOI: 10.1016/j.modpat.2023.100235] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 05/23/2023] [Accepted: 05/24/2023] [Indexed: 06/05/2023]
Abstract
Medullary thyroid carcinoma (MTC), an uncommon C cell thyroid malignancy, accounts for a disproportionate number of thyroid cancer deaths. To predict MTC clinical behavior, the recent international MTC grading system (IMTCGS) was published combining features from the Memorial Sloan Kettering Cancer Center and Royal North Shore Hospital grading systems that incorporates mitotic count, necrosis, and Ki67 proliferative index (Ki67PI). The IMTCGS appears promising, but independent validation data are limited. Here, we applied the IMTCGS to our institutional MTC cohort and assessed its ability to predict clinical outcomes. Our cohort comprised 87 MTCs (30 germline and 57 sporadic). Slides for each case were reviewed by 2 pathologists and histologic features recorded. Ki67 immunostaining was performed on all cases. Each MTC was graded with the IMTCGS based on tumor necrosis, Ki67PI, and mitotic count. Cox regression analysis was performed to assess the impact of various clinical and pathological data on disease outcomes, including overall survival (OS), disease-free survival, disease-specific survival (DSS), and distant metastasis-free survival. In our MTC cohort, 18.4% (n = 16/87) were IMTCGS high grade. IMTCGS grade was strongly prognostic for OS, disease-free survival, DSS, and distant metastasis-free survival on univariate analysis and multivariable analysis in both the entire MTC cohort and in the sporadic subset. Among the individual IMTCGS parameters, while all 3 were associated with poorer survival outcomes on univariate analysis, necrosis had the strongest association with all survival parameters on multivariable analysis, whereas Ki67PI or mitotic count was associated only with OS and DSS. This retrospective study independently demonstrates that the IMTCGS is valid for grading MTCs. Our findings support incorporating IMTCGS into routine pathology practice. IMTCGS grading may help clinicians to better predict the prognosis of MTC. Future studies may shed light on how MTC grading should impact treatment protocols.
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Affiliation(s)
- Daniel J Lubin
- Department of Pathology, Emory University Hospital Midtown, Atlanta, Georgia; Winship Cancer Institute, Emory University Hospital, Atlanta, Georgia
| | - David Blake Behrman
- Department of Pathology, Emory University Hospital Midtown, Atlanta, Georgia
| | - Subir Goyal
- Winship Cancer Institute, Emory University Hospital, Atlanta, Georgia; Biostatistics Shared Resource, Winship Cancer Institute of Emory University, Decatur, Georgia
| | - Kelly Magliocca
- Department of Pathology, Emory University Hospital Midtown, Atlanta, Georgia; Winship Cancer Institute, Emory University Hospital, Atlanta, Georgia
| | - Qiuying Shi
- Department of Pathology, Emory University Hospital Midtown, Atlanta, Georgia; Winship Cancer Institute, Emory University Hospital, Atlanta, Georgia
| | - Amy Y Chen
- Winship Cancer Institute, Emory University Hospital, Atlanta, Georgia; Division of Endocrine Surgery, Department of Otolaryngology, Emory University Hospital Midtown, Atlanta, Georgia
| | - Kartik Viswanathan
- Department of Pathology, Emory University Hospital Midtown, Atlanta, Georgia; Winship Cancer Institute, Emory University Hospital, Atlanta, Georgia.
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Jung CK, Agarwal S, Hang JF, Lim DJ, Bychkov A, Mete O. Update on C-Cell Neuroendocrine Neoplasm: Prognostic and Predictive Histopathologic and Molecular Features of Medullary Thyroid Carcinoma. Endocr Pathol 2023; 34:1-22. [PMID: 36890425 DOI: 10.1007/s12022-023-09753-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/24/2023] [Indexed: 03/10/2023]
Abstract
Medullary thyroid carcinoma (MTC) is a C-cell-derived epithelial neuroendocrine neoplasm. With the exception of rare examples, most are well-differentiated epithelial neuroendocrine neoplasms (also known as neuroendocrine tumors in the taxonomy of the International Agency for Research on Cancer [IARC] of the World Health Organization [WHO]). This review provides an overview and recent evidence-based data on the molecular genetics, disease risk stratification based on clinicopathologic variables including molecular profiling and histopathologic variables, and targeted molecular therapies in patients with advanced MTC. While MTC is not the only neuroendocrine neoplasm in the thyroid gland, other neuroendocrine neoplasms in the thyroid include intrathyroidal thymic neuroendocrine neoplasms, intrathyroidal parathyroid neoplasms, and primary thyroid paragangliomas as well as metastatic neuroendocrine neoplasms. Therefore, the first responsibility of a pathologist is to distinguish MTC from other mimics using appropriate biomarkers. The second responsibility includes meticulous assessment of the status of angioinvasion (defined as tumor cells invading through a vessel wall and forming tumor-fibrin complexes, or intravascular tumor cells admixed with fibrin/thrombus), tumor necrosis, proliferative rate (mitotic count and Ki67 labeling index), and tumor grade (low- or high-grade) along with the tumor stage and the resection margins. Given the morphologic and proliferative heterogeneity in these neoplasms, an exhaustive sampling is strongly recommended. Routine molecular testing for pathogenic germline RET variants is typically performed in all patients with a diagnosis of MTC; however, multifocal C-cell hyperplasia in association with at least a single focus of MTC and/or multifocal C-cell neoplasia are morphological harbingers of germline RET alterations. It is of interest to assess the status of pathogenic molecular alterations involving genes other than RET like the MET variants in MTC families with no pathogenic germline RET variants. Furthermore, the status of somatic RET alterations should be determined in all advanced/progressive or metastatic diseases, especially when selective RET inhibitor therapy (e.g., selpercatinib or pralsetinib) is considered. While the role of routine SSTR2/5 immunohistochemistry remains to be further clarified, evidence suggests that patients with somatostatin receptor (SSTR)-avid metastatic disease may also benefit from the option of 177Lu-DOTATATE peptide radionuclide receptor therapy. Finally, the authors of this review make a call to support the nomenclature change of MTC to C-cell neuroendocrine neoplasm to align this entity with the IARC/WHO taxonomy since MTCs represent epithelial neuroendocrine neoplasms of endoderm-derived C-cells.
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Affiliation(s)
- Chan Kwon Jung
- Department of Hospital Pathology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea.
- Cancer Research Institute, College of Medicine, The Catholic University of Korea, Seoul, 06591, Republic of Korea.
| | - Shipra Agarwal
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Jen-Fan Hang
- Department of Pathology and Laboratory Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine and Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Dong-Jun Lim
- Cancer Research Institute, College of Medicine, The Catholic University of Korea, Seoul, 06591, Republic of Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, 06591, Republic of Korea
| | - Andrey Bychkov
- Department of Pathology, Kameda Medical Center, Kamogawa, Chiba, 296-8602, Japan
| | - Ozgur Mete
- Department of Pathology, University Health Network, Toronto, ON, M5G 2C4, Canada
- Endocrine Oncology Site, Princess Margaret Cancer, Toronto, ON, M5G 2C4, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, M5G 2C4, Canada
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Saltiki K, Simeakis G, Karapanou O, Paschou SA, Alevizaki M. Metastatic medullary thyroid carcinoma (MTC): disease course, treatment modalities and factors predisposing for drug resistance. Endocrine 2023; 80:570-579. [PMID: 36626081 DOI: 10.1007/s12020-022-03296-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 12/28/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE MTC has varying clinical course. In cases with metastatic disease (meta-MTC) further therapeutic modalities (locoregional and/or Tyrosine-Kinase-Inhibitors, TKIs) are needed. Clinical features, disease progression, response to therapy and possible factors predisposing to TKIs response-resistance in meta-MTCs were investigated. METHODS Out of 338 MTC patients 54 had meta-MTC and were followed for 0.7-46 years (median 10.5); therapeutic interventions and response to therapy were recorded retrospectively. RESULTS Of 54 meta-MTC patients, 34/54 were men, 44/54 sporadic (age-at-diagnosis 47 ± 17.4 years, range: 5-78). Distant metastases at diagnosis were present in 12/54 (≥2 loci in 8/12), 7/12 received TKIs; During follow-up metastases occurred in 42/54 (within 0.6-25 years from diagnosis, median 5 yrs). Locoregional therapies were administered to 44/54 (81.5%) and TKIs to 40/54 (74.1%). Vandetanib was administered in 30 patients (24 as first-line therapy). The median progression-free-survival, PFS) was 48 months (range 4-120), partial response (PR): 26.7%, stable disease (SD): 23.3%, progressive disease (PD): 50.0%, cancer-specific survival: 44.8%, (16 in ongoing-therapy). More favorable disease course was recorded in familial-MTC compared to sporadic (p = 0.02) and in those patients with serious-adverse-events (SAEs) under treatment (p = 0.027). Those with biochemical progression under vandetanib, later showed more frequently structural progression (p = 0.007). Ten patients received cabozantinib (8/10 as second-line therapy, median PFS:11 months (3-36 months), 8/10 died). Three RET-mutant patients received selpercatinib; all showed PR. Within the total follow-up period, the response to therapy was: PR: 8/54 (14.8%), SD: 15/54 (27.8%), PD: 31/54 (57.4%), cancer-specific survival 46.3%. Mortality was higher in older patients (≥60 years) compared to younger ones (<60 yrs) (83.3 vs 45.2%, p = 0.021). Outcome was better in familial-MTC vs sporadic (PR: 50 vs 6.8%, SD: 20 vs 29.5%, PD: 30 vs 59.1%, p = 0.007). CONCLUSIONS Meta-MTCs treatment results in disease stabilization in 42.6% during a median 10.5 year follow-up. Combination of locoregional and systemic therapies may result in more favorable PFS. Family history, younger age, SAEs may predict better response; biochemical escape under TKI needs to be followed-up closely as it may indicate disease progression.
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Affiliation(s)
- Katerina Saltiki
- Endocrine Unit, Dept Clinical Therapeutics, School of Medicine, National and Kapodistrian University, Athens, Greece.
| | - George Simeakis
- Endocrine Dept, 401 General Military Hospital of Athens, Athens, Greece
| | - Olga Karapanou
- Endocrine Dept, 401 General Military Hospital of Athens, Athens, Greece
| | - Stavroula A Paschou
- Endocrine Unit, Dept Clinical Therapeutics, School of Medicine, National and Kapodistrian University, Athens, Greece
| | - Maria Alevizaki
- Endocrine Unit, Dept Clinical Therapeutics, School of Medicine, National and Kapodistrian University, Athens, Greece
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Machens A, Lorenz K, Weber F, Dralle H. Superiority of metastatic lymph node ratio over number of node metastases and TNM/AJCC N classification in predicting cancer-specific survival in medullary thyroid cancer. Head Neck 2022; 44:2717-2726. [PMID: 36065717 DOI: 10.1002/hed.27181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 08/11/2022] [Accepted: 08/18/2022] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND In medullary thyroid cancer (MTC), it is unclear which nodal classification system, metastatic lymph node ratio (MLNR), number of node metastases, or TNM/AJCC N classification, predicts cancer-specific survival best. METHODS Kaplan-Maier analysis of cancer-specific survival after operation at a tertiary center. RESULTS Included were 505 MTC patients. The spread of the survival curves was greatest after stratification by MLNR (in 0.20 increments), followed by number of node metastases (in 10-node and 20-node increments) and TNM/AJCC classification (N0, N1a, N1b). After collapsing overlapping survival curves, all adjacent curves (MLNRs ≤0.20 vs. 0.21-0.60 vs. >0.60; 0 vs. 1-20 vs. >20 node metastases; and TNM/AJCC N classification N0/N1a vs. N1b) significantly differed between each other. CONCLUSIONS In MTC, MLNR, reflecting intensity of lymphatic spread, predicts cancer-specific survival better than number of node metastases or TNM/AJCC N classification. The applicability of these findings to patients with limited neck dissection requires more research.
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Affiliation(s)
- Andreas Machens
- Department of Visceral, Vascular and Endocrine Surgery, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Kerstin Lorenz
- Department of Visceral, Vascular and Endocrine Surgery, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Frank Weber
- Department of General, Visceral and Transplantation Surgery, Section of Endocrine Surgery, University of Duisburg-Essen, Essen, Germany
| | - Henning Dralle
- Department of Visceral, Vascular and Endocrine Surgery, 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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Update on the Diagnosis and Management of Medullary Thyroid Cancer: What Has Changed in Recent Years? Cancers (Basel) 2022; 14:cancers14153643. [PMID: 35892901 PMCID: PMC9332800 DOI: 10.3390/cancers14153643] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 07/19/2022] [Accepted: 07/25/2022] [Indexed: 12/10/2022] Open
Abstract
Medullary thyroid carcinoma (MTC) is a neoplasm originating from parafollicular C cells. MTC is a rare disease, but its prognosis is less favorable than that of well-differentiated thyroid cancers. To improve the prognosis of patients with MTC, early diagnosis and prompt therapeutic management are crucial. In the following paper, recent advances in laboratory and imaging diagnostics and also pharmacological and surgical therapies of MTC are discussed. Currently, a thriving direction of development for laboratory diagnostics is immunohistochemistry. The primary imaging modality in the diagnosis of MTC is the ultrasound, but opportunities for development are seen primarily in nuclear medicine techniques. Surgical management is the primary method of treating MTCs. There are numerous publications concerning the stratification of particular lymph node compartments for removal. With the introduction of more effective methods of intraoperative parathyroid identification, the complication rate of surgical treatment may be reduced. The currently used pharmacotherapy is characterized by high toxicity. Moreover, the main limitation of current pharmacotherapy is the development of drug resistance. Currently, there is ongoing research on the use of tyrosine kinase inhibitors (TKIs), highly specific RET inhibitors, radiotherapy and immunotherapy. These new therapies may improve the prognosis of patients with MTCs.
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Koehler VF, Fuss CT, Berr CM, Frank-Raue K, Raue F, Hoster E, Hepprich M, Christ E, Pusl T, Reincke M, Spitzweg C, Kroiss M. Medullary thyroid cancer with ectopic Cushing's syndrome: A multicentre case series. Clin Endocrinol (Oxf) 2022; 96:847-856. [PMID: 34743368 DOI: 10.1111/cen.14617] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 10/04/2021] [Accepted: 10/11/2021] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Ectopic Cushing's syndrome (ECS) induced by medullary thyroid cancer (MTC) is rare, and data on clinical characteristics, treatment and outcome are limited. DESIGN Retrospective cohort study in three German and one Swiss referral centres. PATIENTS Eleven patients with MTC and occurrence of ECS and 22 matched MTC patients without ECS were included. MEASUREMENTS The primary endpoint of this study was the overall survival (OS) in MTC patients with ECS versus 1:2 matched MTC patients without ECS. RESULTS The median age at diagnosis of ECS was 59 years (range: 35-81) and the median time between initial diagnosis of MTC and diagnosis of ECS was 29 months (range: 0-193). Median serum morning cortisol was 49 µg/dl (range: 17-141, normal range: 6.2-18). Eight (73%) patients received treatment for ECS. Treatment of ECS consisted of bilateral adrenalectomy (BADX) in four (36%) patients and adrenostatic treatment in eight (73%) patients. One patient received treatment with multityrosine kinase inhibitor (MKI) to control hypercortisolism. All patients experienced complete resolution of symptoms of Cushing's syndrome and biochemical control of hypercortisolism. Patients with ECS showed a shorter median OS of 87 months (95% confidence interval [95% CI]: 64-111) than matched controls (190 months, 95% CI: 95-285). Of the nine deaths, four were related to progressive disease (PD). Four patients showed PD as well as complications and comorbidities of hypercortisolism before death. CONCLUSION This study shows that ECS occurs in advanced stage MTC and is associated with a poor prognosis. Adrenostatic treatment and BADX were effective systemic treatment options in patients with MTC and ECS to control their hypercortisolism. MKI treatment achieved complete remission of hypercortisolism and sustained tumour control in one treated case.
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Affiliation(s)
- Viktoria F Koehler
- Department of Internal Medicine IV, LMU Hospital, Ludwig-Maximilians-Universität München (LMU), Munich, Germany
- Department of Medicine I, Goethe University Hospital, Frankfurt, Germany
| | - Carmina T Fuss
- Department of Internal Medicine I, Division of Endocrinology/Diabetology, University of Würzburg, Würzburg, Germany
| | - Christina M Berr
- Department of Endocrinology I, Medical Clinic, University Medical Center Augsburg, Augsburg, Germany
| | - Karin Frank-Raue
- Private Practice of Endocrinology and Nuclear Medicine, Heidelberg, Germany
| | - Friedhelm Raue
- Private Practice of Endocrinology and Nuclear Medicine, Heidelberg, Germany
| | - Eva Hoster
- Institute for Medical Information Processing, Biometry and Epidemiology, Ludwig-Maximilians-Universität München (LMU), Munich, Germany
| | - Matthias Hepprich
- Division of Endocrinology, Diabetology and Metabolism, University Hospital of Basel, Basel, Switzerland
| | - Emanuel Christ
- Division of Endocrinology, Diabetology and Metabolism, University Hospital of Basel, Basel, Switzerland
| | - Thomas Pusl
- Department of Endocrinology I, Medical Clinic, University Medical Center Augsburg, Augsburg, Germany
| | - Martin Reincke
- Department of Internal Medicine IV, LMU Hospital, Ludwig-Maximilians-Universität München (LMU), Munich, Germany
| | - Christine Spitzweg
- Department of Internal Medicine IV, LMU Hospital, Ludwig-Maximilians-Universität München (LMU), Munich, Germany
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Adjunct Academic Appointment, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Matthias Kroiss
- Department of Internal Medicine IV, LMU Hospital, Ludwig-Maximilians-Universität München (LMU), Munich, Germany
- Department of Internal Medicine I, Division of Endocrinology/Diabetology, University of Würzburg, Würzburg, Germany
- Comprehensive Cancer Center Mainfranken, University of Würzburg, Würzburg, Germany
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10
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Saravana-Bawan B, Pasternak JD. Multiple endocrine neoplasia 2: an overview. Ther Adv Chronic Dis 2022; 13:20406223221079246. [PMID: 35237400 PMCID: PMC8882936 DOI: 10.1177/20406223221079246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 01/20/2022] [Indexed: 11/17/2022] Open
Abstract
This review article discusses the diagnosis and treatment of patients with
multiple endocrine neoplasia type 2 (MEN2). The most common tumors associated
with MEN2 are those of the parathyroid, thyroid, and adrenal glands. Additional
manifestations include characteristic clinical phenotypes or features as
described in the article. This review provides an overview of clinical
manifestations, screening, diagnosis, treatment, and surveillance of patients
with MEN2.
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Affiliation(s)
- B Saravana-Bawan
- University Health Network, University of Toronto, Toronto, ON, Canada
| | - JD Pasternak
- Section Head, Endocrine Surgery and Oncology, Division of General Surgery, Sprott Department of Surgery, Toronto General Hospital, University Health Network, 200 Elizabeth Street, Toronto, ON M5G 2C4, Canada
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11
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Carcinoembryonic Antigen Increase in a Patient with Colon Cancer Who Have Achieved Complete Remission and Negative 18F-FDG PET/CT: Don't Forget the Thyroid! ACTA ACUST UNITED AC 2021; 28:2987-2992. [PMID: 34436027 PMCID: PMC8395414 DOI: 10.3390/curroncol28040261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 07/27/2021] [Accepted: 08/04/2021] [Indexed: 11/30/2022]
Abstract
Serum carcinoembryonic antigen (CEA) is a tumor marker especially used to follow a patient with colorectal cancer. However, it is non-specific and could be increased in several cancers and some benign conditions. We report the case of a 70-year-old man followed since 2014 for a left colon adenocarcinoma with the persistence of an increased CEA. There was no evidence of recurrence, but a right lobar thyroid nodule without a significantly increased uptake was incidentally discovered on the CT scan of 18F-fluorodeoxyglucose (18F-FDG) PET/CT. We suspected a medullary thyroid carcinoma (MTC) explaining the persistent elevation of CEA. Plasma calcitonin levels were 47 ng/L (N < 10). Fine needle aspiration cytology found atypia of undetermined significance and the patient was reluctant to undergo surgery without any further exploration. We performed a 18F-fluorodihydroxyphenylalanine (18F-FDOPA) PET/CT preoperatively which revealed a punctiform focus of the right thyroid lobe corresponding to a pT1aN1aMxR0 medullary thyroid carcinoma, histopathologically confirmed. This case highlights that despite the potential usefulness of 18F-FDG PET/CT in case of an unknown source of elevated CEA this imaging may be falsely negative as in the case of MTC and should lead to further explorations.
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12
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Bartz-Kurycki MA, Oluwo OE, Morris-Wiseman LF. Medullary thyroid carcinoma: recent advances in identification, treatment, and prognosis. Ther Adv Endocrinol Metab 2021; 12:20420188211049611. [PMID: 34659736 PMCID: PMC8511962 DOI: 10.1177/20420188211049611] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 09/12/2021] [Indexed: 12/13/2022] Open
Abstract
Medullary thyroid carcinoma (MTC) is a neuroendocrine tumor that represents <5% of all thyroid malignancies and is generally more aggressive than differentiated thyroid cancer. The aim of this study is to provide an update, through review of clinical studies of patients with MTC published between January 1, 2016, and June 1, 2021, on recent advances in the diagnosis and treatment of MTC. This review focuses on updates in biochemical testing, imaging, hereditary disease, surgical management, adjuvant therapies, and prognosis. Recent advances reviewed herein have sought to diagnose MTC at earlier stages of disease, predict when patients with a hereditary syndrome may develop MTC, use functional imaging to assess for distant metastases, perform optimal initial surgery with appropriate lymphadenectomy, employ targeted systemic therapies for patients with progressive metastatic disease, and better predict patient-specific outcomes.
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Affiliation(s)
| | - Omowunmi E. Oluwo
- Department of Surgery, University of Arizona
Tucson College of Medicine, Tucson, AZ, USA
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