Familial medullary thyroid carcinoma, pheochromocytoma, and parathyroid adenoma (Sipple's syndrome). Study of a kindred

Noncardiogenic pulmonary edema as the chief manifestation of a pheochromocytoma: a case report of MEN 2A with pedigree analysis of the RET proto-oncogene

Pheochromocytomas are rare neoplasias of the adrenal medulla which generally present with paroxysmal or sustained hypertension. Cardiogenic pulmonary edema is a common feature of these tumors, but few cases have been described with noncardiogenic pulmonary edema. We report a pheochromocytoma with the principle manifestation of noncardiogenic pulmonary edema and characterize a genetic lesion associated with the disorder. A 30-year-old man was admitted with abdominal pain and breathlessness. x-Ray examination of the chest revealed a massive, diffuse infiltration of the left lung without cardiomegaly. No paroxysmal blood pressure fluctuations or heart failure were evident during the entire course, and the infiltrate and dyspnea resolved in three days without inotropic or diuretic agents. Serum norepinephrine and epinephrine levels were elevated twenty and fifty times above normal, respectively. The patient was ultimately diagnosed with multiple endocrine neoplasia type 2A (MEN 2A). Mutations in the RET proto-oncogene have been described recently in patients with MEN 2A. Mutation analysis of selected RET exonic sequences identified a germline mutation at codon 634 in exon 11 of the RET proto-oncogene. The mutation introduces a transition encoding a non-conservative substitution from TGC (Cys) to CGC (Arg) and creates a novel restriction site recognized by HhaI. We further screened for this mutation among four of the proband's relatives by HhaI restriction analysis. One asymptomatic family member was identified who subsequently elected prophylactic total thyroid removal. Histological examination of this specimen confirmed the presence of medullary thyroid carcinoma.

Multiple endocrine neoplasia syndromes

The multiple endocrine neoplasia (MEN) syndromes are characterized by autosomal dominant inheritance with a high degree of penetrance but varying expression. This review gives a classification of these syndromes and a short summary of the historical background. The pathogenesis of the disease and its possible origin in the APUD cell system are discussed together with the mechanisms underlying normal and ectopic hormone production by MEN tumors on the basis of recent findings in molecular endocrinology. The natural history and the clinical manifestations of the different syndromes are described. The sensitivity and discriminative capacity of the tests used to detect the syndromes in an early stage are compared. The choice of therapy and criteria for the timing and extensiveness of treatment are also considered. Lastly, problems associated with the ethical and legal aspects of screening, central registration, and monitoring of relatives at risk are described.

Ultrastructural and biochemical evaluation of adrenal medullary hyperplasia and pheochromocytoma in aged bulls

Pheochromocytomas and adrenal medullary hyperplasia were investigated ultrastructurally and by assaying catecholamines in tissue and urine. Three of seven bulls had concomitant thyroid C-cell neoplasms and normal parathyroid glands. Pheochromocytomas were either bilateral or unilateral, and were composed of large chromaffin cells predominantly in the storage phase of the secretory cycle. Two pheochromocytomas were composed of cells with ultrastructural characteristics of the epinephrine-secreting type and contained round secretory granules of low electron density. The norepinephrine-secreting type of chromaffin cell predominated in one pheochromocytoma and had storage granules with an electron-dense, eccentric core and a wide submembranous space. Two pheochromocytomas were composed of a mixture of epinephrine- and norepinephrine-secreting cells. Adrenal medullary hyperplasia in four bulls consisted of multinodular or diffuse areas of hyperchromatic chromaffin cells that were non-encapsulated, and compressed adjacent cortical tissue. Tissue and urinary concentrations of norepinephrine were increased in bulls with adrenal medullary hyperplasia or pheochromocytoma, but urinary vanillylmandelic acid and unconjugated epinephrine levels were not different from those of control bulls with a normal adrenal medulla.

Localization of phaeochromocytoma by computerized axial tomography

In two cases, in which patients presented with the clinical and biochemical features of phaeochromocytoma, the tumours were localized by means of computerized axial tomography (CAT) of the abdomen. More invasive methods of localization, with their attendant risks, were thus avoided. CAT scanning of the abdomen has been shown to be a safe and sensitive means of localizing phaeochromocytomas.

Spontaneous endocrine tumors in Sprague-Dawley rats

Spontaneous endocrine tumors were found in 81 of 100 Sprague-Dawley rats (42 males and 39 females) which survived for more than 2 years. Most of these tumors were medullary carcinomas of the thyroid, followed by tumors of the anterior pituitary gland, pheochromocytomas and cortical adenomas of the adrenal gland, and islet cell tumors of the pancreas. Multiple occurrence of these tumors was frequently observed. This study describes the morphology of these spontaneous endocrine tumors.

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

An acidophilic pituitary adenoma associated with primary nodular parathyroid hyperplasia and a small papillary thyroid carcinoma was discovered at the autopsy of a 44 year old female acromegalic. The thyroid carcinoma showed evidence of lymphatic spread. Several etiopathogenetic mechanisms for the non-medullary thyroid carcinomata associated with Multiple Endocrine Neoplasia (MEN) have been postulated, since the follicular epithelium of the thyroid does not belong to the neural ectoderm derivates unlike the C-cells of the thyroid, the adenohypophysis and probably the parathyroid glands. Apart from genetic influence, or coincidence, one has to rule out carcinogenic exposure or hormonal influence. Clinically speaking, one should always consider whether malignant thyroid disease coexists with hyperplastic or neoplastic parathyroid tissue.

Malignant pheochromocytoma in childhood: report of a case with familial neurofibromatosis

A 14-year-old male with familial neurofibromatosis and widely disseminated malignant pheochromocytoma is described. Current criteria for the diagnosis and management of this rare malignancy are discussed.

The APUD cell concept

Embryonic neural crest cells have been traced to the primitive entoderm where they differentiate into a family of hormone-producing cells, APUD cells. The APUD cell concept explains many otherwise seemingly dissociated clinical circumstances involving endocrine glands and hormone production by tumors.

Medullary carcinoma of the thyroid gland

One hundred thirty-nine surgically treated patients with medullary carcinoma of the thyroid gland (MTC) were seen in our institution between January, 1926 and December, 1973. The incidence of this tumor among all thyroid cancers was 8%. Twenty-nine patients had the familial form of MTC; they were subclassified, on the basis of the phenotype, into a group of 15 patients with Sipple syndrome (or multiple endocrine neoplasia (MEN) Type 2A) and a group of 14 patients with mucosal-neuroma phenotype (or MEN type 2B). Better survivorship was seen in the younger patients, in those with bilateral tumors, in familial MTC, and in patients whose tumor was confined to the thyroid gland at the initial surgery. The incidence of tumor recurrence was 34%. However, in those with adequate surgical treatment, the recurrence was only 23%. The 5- and 10-year survivorships were 80% and 67%, respectively. The best chance of cure lies in early diagnosis through the use of immunoreactive calcitonin measurement in family members at risk, and an aggressive surgical attack on the primary tumor and any cervical metastases.

The syndrome of multiple aucosal neuromas and medullary thyroid carcinoma in childhood. Importance of recognition of the phenotype for the early detection of malignancy

Recognition of the syndrome of OF MMN can identify individuals at risk for the early appearance of MTC. Three such patients are described. Each had the characteristic neuromas and facies, present since infancy. In each, MTC was found in childhood. In the last two patients, the diagnosis was made because of elevated serum CT concentrations. Venous drainage from the tumor, as well as tumor tissue itself, contained high levels of CT. Prompt recognition of persons with MMN is essential for proper investigation and treatment of the associated MTC.