Pituitary adenoma, primary parathyroid hyperplasia and papillary (non-medullary) thyroid carcinoma. A case of multiple endocrine neoplasia (MEN)

Primary hyperparathyroidism-jaw tumor syndrome: a confusing and forgotten diagnosis

Background

Primary hyperparathyroidism is caused by the excessive growth of parathormone secretion, its consequence being hypercalcemia. The parathyroid adenoma is responsible for over half of primary hyperparathyroidism cases. The mandibular tumor can be the initial sign in the case of primary hyperparathyroidism.

Case presentation

We present the case of a 33 year old patient with history of a mandibular operated tumor, repetitive pathological fractures and hypercalcemia manifestations. The level of the parathormone at the first measurement indicated a very high value. The parathyroid scintigraphy with 99mTc-MIBI (methoxy-isobutyl-isonitrile) evidenced a high uptake of the tracerin the superior mediastinum, suggestive for an ectopic parathyroid adenoma. The histopathological examination after surgery leads to the diagnosis of parathyroid adenoma.

The association between the primary hyperparathyroidism, the mandibular tumour, the clinical history and the nuclear imaging lead to the diagnosis of primary hyperparathyroidism – Jaw tumor syndrome.

Conclusion

The hyperparathyroidism - Jaw tumor syndrome has a special clinical importance because of the severe and progressive symptomatology, and because of the risk of developing neoplasia of parathyroid glands, which have a reserved prognosis.

Multiple endocrine neoplasia: how many syndromes?

The phrase multiple endocrine neoplasia (MEN) generally denotes an association of tumors so specific as to constitute a syndrome. Three well-recognized such syndromes exist. All are autosomal dominant traits and all have been tentatively mapped to specific chromosomes. Other purported endocrine tumor syndromes have been suggested either as new entities or as subtypes of the existing MEN syndromes. The evidence in favor of these contentions is examined critically. Only one "new" association, that of pheochromocytomas and islet cell tumors, seems reasonable, and even in this setting, some relatives have had manifestations of von Hippel-Lindau syndrome. There is no compelling reason why such conditions as von Hippel-Lindau syndrome, peripheral neurofibromatosis, McCune-Albright syndrome, and others should be reclassified as MEN syndromes, although awareness of their collective endocrine abnormalities is clinically important.

[HLA and thyroid cancer]

HLA typing was performed in 51 patients to analyse the pathogenetic background of differentiated and medullary thyroid carcinomas. A higher incidence of Bw62 and DR5 was observed in patients with papillary carcinoma (n = 24), DRw6 antigen in follicular carcinoma (n = 13), and DR3 antigen in patients with medullary carcinoma (n = 11). The DR3 antigen was present in one of two patients with a familial history of medullary thyroid carcinoma. Therefore, HLA typing is not suitable as a screening method for the detection of early thyroid carcinoma.

Sipple's Syndrome: Description of One Case

The case reported involves a young woman with a medullary thyroid carcinoma. Only during autopsy was it possible to show a pheochromocytoma of the left adrenal gland; multiple foci of atypical proliferation were observed, only microscopically, also in the adrenal gland. The authors emphasize the difficulty of a correct diagnosis during life and outline the necessity of an accurate screening of family members of a patient with Sipple's syndrome.