1
|
de Groot JW, Links TP, Hofstra RM, Plukker JT. An introduction to managing medullary thyroid cancer. Hered Cancer Clin Pract 2006; 4:115-25. [PMID: 20223015 PMCID: PMC4177236 DOI: 10.1186/1897-4287-4-3-115] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2006] [Accepted: 07/27/2006] [Indexed: 02/05/2023] Open
Abstract
MTC is a rare neuroendocrine thyroid tumour accounting for 3% to 10% of all thyroid malignancies. It can occur in a sporadic and a hereditary clinical setting. Hereditary MTC may either occur alone (familial MTC, FMTC) or as part of multiple endocrine neoplasia (MEN) type 2A, or MEN 2B. These disorders are due to germline mutations in the RET (REarranged during Transfection) gene. In carriers of MEN 2B-associated RET mutations, prophylactic thyroidectomy is indicated before the first year of life. In the case of MEN 2A-associated germline RET mutations with a high-risk profile, total thyroidectomy is warranted before the age of 2 years and certainly before the age of 4 years. At that age the risk of invasive MTC and metastases is acceptably low. Depending on the type of RET mutation, thyroidectomy can take place at an older age in patients with a lower risk profile. In case of elevated basal or stimulated serum calcitonin, preventive surgery including total thyroidectomy and central compartment dissection should be performed regardless of age. When MTC presents as a palpable tumour, total thyroidectomy should be combined with extensive lymph node dissection of levels II-V on both sides and level VI to prevent locoregional recurrences.
Collapse
|
2
|
Abstract
PURPOSE OF REVIEW Diagnostic methods and treatment options for differentiated and medullary thyroid carcinoma are continuously influenced by new trends and techniques. Our review therefore displays the most recent clinical practices for diagnosis and operative treatment of differentiated and medullary thyroid carcinoma. RECENT FINDINGS Among the new diagnostic methods, high-resolution ultrasonography plays an important role for both the evaluation of thyroid nodules and the detection of enlarged suspicious cervical lymph nodes. The results of ultrasound will definitely influence operative decisions. A second step to diagnose medullary thyroid carcinoma is calcitonin measurement before surgery, which is sensitive and specific enough to detect medullary thyroid carcinoma in patients with thyroid nodules. Surgical treatment for differentiated or medullary thyroid carcinoma mostly consists of total or near-total thyroidectomy. An additional central or lateral modified-radical neck dissection might help to reduce local recurrence, especially in medullary carcinoma, but still does not influence significantly the survival rates. Monitoring of the recurrent laryngeal nerve during surgery is used increasingly. According to the newest literature, however, compared with visual identification of the laryngeal nerve, it cannot be considered as superior. SUMMARY Diagnosis and treatment of thyroid carcinoma are still subjected to changes and the different options of surgical treatment in particular will be continuously discussed in the future.
Collapse
MESH Headings
- Biomarkers/blood
- Carcinoma, Medullary/diagnosis
- Carcinoma, Medullary/genetics
- Carcinoma, Medullary/mortality
- Carcinoma, Medullary/surgery
- Carcinoma, Papillary, Follicular/diagnosis
- Carcinoma, Papillary, Follicular/genetics
- Carcinoma, Papillary, Follicular/mortality
- Carcinoma, Papillary, Follicular/surgery
- Humans
- Prognosis
- Survival Rate
- Thyroid Neoplasms/diagnosis
- Thyroid Neoplasms/genetics
- Thyroid Neoplasms/mortality
- Thyroid Neoplasms/surgery
- Thyroidectomy/adverse effects
- Vocal Cord Paralysis/etiology
- Vocal Cord Paralysis/prevention & control
Collapse
Affiliation(s)
- Theresia Weber
- Department of Surgery, University of Heidelberg, Heidelberg, Germany.
| | | | | |
Collapse
|
3
|
Abstract
Thyroid microcarcinoma, defined as a thyroid tumor measuring 1 cm or less, is an extremely indolent tumor. Papillary microcarcinoma, the most common subtype, is often identified incidentally in a thyroid removed for benign clinical nodules or diffuse processes (eg, thyroiditis). In this clinical situation, over 99% are cured by simple lobectomy. In the less common scenario, the microcarcinoma is the primary lesion to a lymph node metastasis presenting clinically as a neck mass; in this situation, the tumor should be treated as a clinical cancer. Other rare microcarcinomas can occur and, of these, the most recently described is micromedullary carcinoma. In the familial setting, these lesions are identified in prophylactic thyroidectomies and are not unexpected findings. However, when found as sporadic tumors, their implications are still unknown. The histologic features, pathologic mimics, and molecular facets of these microscopic neoplasms are discussed in this review.
Collapse
Affiliation(s)
- Zubair W Baloch
- Department of Pathology and Laboratory Medicine, University of Pennsylvania Medical Center, 3400 Spruce Street, Philadelphia, PA 19104, USA.
| | | |
Collapse
|
4
|
Heizmann O, Haecker FM, Zumsteg U, Müller B, Oberholzer M, Oertli D. Presymptomatic thyroidectomy in multiple endocrine neoplasia 2a. Eur J Surg Oncol 2005; 32:98-102. [PMID: 16325365 DOI: 10.1016/j.ejso.2005.10.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2005] [Accepted: 10/20/2005] [Indexed: 11/30/2022] Open
Abstract
AIMS To evaluate the value of prophylactic total thyroidectomy in multiple endocrine neoplasia 2a (MEN 2a), based on results of genetic testing, in a presymptomatic early stage of the disease. METHODS Fourteen presymptomatic patients genetically diagnosed and surgically treated at our centre. We analysed age, gender, location of the RET mutation, calcitonin tests, surgery, histologic findings, TNM classification, and postoperative follow-up. RESULTS The 14 patients belonged to two families with MTC (MEN 2a). Median age was 16 years. The RET mutation was located in codon 618 and 634. Basal calcitonin (CT) levels were normal in all patients. Twelve had pathologic peak CT measurements. Total thyroidectomy was performed in all and associated central neck dissection in 12 patients. Pathohistologic assessment showed C-cell hyperplasia in all specimens and 11 MTCs; the median size of the tumours was 0.2 cm; two patient had lymph-node metastases. According to TNM, three had stage 0, nine had stage I, one had stage II, and one had stage III disease. Postsurgery basal and peak CT values were normal in all but one patients, indicating a biochemical curative rate of 95%. Calcitonin determination did not distinguish between MTC and C-cell hyperplasia. CONCLUSION Prophylactic thyroidectomy based on genetic testing allows identification and treatment of patients at an early stage of the disease. Pathologic peak CT values are markers for the presence of microscopic MTC and should be considered in selecting operative procedures for these patients.
Collapse
Affiliation(s)
- O Heizmann
- Departement Chirurgie, Allgemeinchirurgische Klinik, Universitätsspital Basel, Spitalstrasse 21, CH-4031 Basel, Switzerland.
| | | | | | | | | | | |
Collapse
|
5
|
Abstract
AIM To report the role of different imaging methods in staging individuals with multiple endocrine neoplasia 2A (MEN2A) or familial medullary thyroid carcinoma (FMTC). MATERIAL AND METHODS Fourteen newly diagnosed gene carriers underwent cervical ultrasound scanning (US), cervical and mediastinal CT, MRI and whole-body meta-[131I]iodobenzylguanidine (MIBG) scintigraphy and [18F]fluorodeoxyglucose (FDG) PET scanning. RESULTS US identified seven true primary cancer. CT and MRI located only tumors > or =5 mm in diameter. MIBG scintigraphy and FDG PET could not identify MTC foci within the thyroid. Whole-body FDG PET identified two true-positive and one false-positive lymph node metastases. MIBG scintigraphy did not identify lymph node metastases. Total thyroidectomy was performed in 12 cases, and subtotal thyroidectomy in two subjects. CONCLUSIONS Whole-body FDG PET and cervical US help stage individuals carrying mutant genes verifying MEN2A or FMTC.
Collapse
Affiliation(s)
- A Boér
- Department of Head and Neck Surgery, National Institute of Oncology, Budapest, Hungary
| | | | | | | | | | | | | | | | | | | |
Collapse
|
6
|
Szinnai G, Meier C, Komminoth P, Zumsteg UW. Review of multiple endocrine neoplasia type 2A in children: therapeutic results of early thyroidectomy and prognostic value of codon analysis. Pediatrics 2003; 111:E132-9. [PMID: 12563086 DOI: 10.1542/peds.111.2.e132] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The aim of this study was first to investigate whether early total thyroidectomy (ETT; 1-5 years of age) can prevent medullary thyroid carcinoma with persistent or recurrent disease (PRD) in pediatric patients with multiple endocrine neoplasia type 2A (MEN-2A) and second, to evaluate the strength of codon analysis in children with MEN-2A as prognostic parameter. METHODS Case reports and review of the literature for pediatric patients with MEN-2A were conducted. Inclusion criteria were age (0-20 years) and histologic degree of C-cell disease (normal = N, C-cell hyperplasia = CCH, medullary thyroid carcinoma = MTC, metastatic MTC = MMTC). To evaluate therapeutic results of ETT (1-5 years) versus late total thyroidectomy (LTT; 6-20 years), age-dependent histologic stages of C-cell disease and postoperative occurrence of PRD were compared. Prognostic value of specific codons, age-dependent histologic distribution, and long-term outcome were analyzed. RESULTS In a total of 260 cases, 42 (16%) underwent ETT, and 218 (84%) underwent LTT. Histologic analysis showed significant difference between ETT versus LTT (57% vs 76%) regarding malignant stage of C-cell disease (of combined rate of MTC and MMTC). Long-term outcome was documented in 74 patients (28%). During a median follow-up period of 2 years (range: 0-15 years), 21 of 65 of the LTT group versus 0 of 9 of the ETT group suffered PRD. Information about codon analysis was available in 150 patients (58%). Mutated codons were c634 (63%), c618 (19%), c620 (9%), and c804 (6%). Codon-related histologic analysis resulted in prognostic differences: 81% of patients with c634-mutation had MCT or MMTC in contrast to c804 (44%), c618 (34%), and c620 (7%). Fifteen of 17 MMTC and 7 of 9 PRD occurred in patients with c634-mutation. CONCLUSIONS 1) ETT until 5 years of age in MEN-2A gene carriers results in significant reduction of MTC and MMTC in favor of CCH and improved disease-free long-term outcome. 2) Codon analysis is an important prognostic factor. Timing of TT could be individualized based on codon-specific prognosis. Until more detailed knowledge is available, consequent genetic and biochemical screening is mandatory for appropriate individual timing of ETT before age of 5 years.
Collapse
MESH Headings
- Adolescent
- Adult
- Age Factors
- Carcinoma, Medullary/genetics
- Carcinoma, Medullary/pathology
- Carcinoma, Medullary/prevention & control
- Carcinoma, Medullary/secondary
- Child
- Child, Preschool
- Codon/genetics
- Drosophila Proteins
- Genetic Predisposition to Disease/genetics
- Humans
- Hyperparathyroidism/epidemiology
- Hyperparathyroidism/genetics
- Infant
- Multiple Endocrine Neoplasia Type 2a/diagnosis
- Multiple Endocrine Neoplasia Type 2a/genetics
- Multiple Endocrine Neoplasia Type 2a/pathology
- Multiple Endocrine Neoplasia Type 2a/surgery
- Multivariate Analysis
- Neoplasm Recurrence, Local/genetics
- Neoplasm Recurrence, Local/pathology
- Neoplasm Recurrence, Local/prevention & control
- Neoplasm Staging
- Neoplasms, Ductal, Lobular, and Medullary/genetics
- Neoplasms, Ductal, Lobular, and Medullary/pathology
- Neoplasms, Ductal, Lobular, and Medullary/prevention & control
- Pheochromocytoma/epidemiology
- Pheochromocytoma/genetics
- Prognosis
- Proto-Oncogene Proteins/genetics
- Proto-Oncogene Proteins c-ret
- Receptor Protein-Tyrosine Kinases/genetics
- Thyroid Neoplasms/genetics
- Thyroid Neoplasms/pathology
- Thyroid Neoplasms/surgery
- Thyroidectomy/methods
- Treatment Outcome
Collapse
Affiliation(s)
- Gabor Szinnai
- Department of Pediatric Endocrinology, University Children's Hospital, Basel, Switzerland
| | | | | | | |
Collapse
|
7
|
Fitze G, Schierz M, Bredow J, Saeger HD, Roesner D, Schackert HK. Various penetrance of familial medullary thyroid carcinoma in patients with RET protooncogene codon 790/791 germline mutations. Ann Surg 2002; 236:570-5. [PMID: 12409662 PMCID: PMC1422614 DOI: 10.1097/00000658-200211000-00006] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To describe a genotype-phenotype correlation in MEN2 families with germline mutations of codons 790/791 and discuss options for the therapeutic management of gene carriers. SUMMARY BACKGROUND DATA Heredity of MEN2 syndromes is caused by a heterozygous germline mutation in the protooncogene. Rare mutations of codons 790/791 associated with incomplete penetrant MEN2A/FMTC phenotype were reported in five families, contraindicating the prophylactic thyroidectomy for the genetically affected children. METHODS Forty-five patients with a putative sporadic MTC were screened for germline mutations by direct DNA sequencing. Family members of identified index cases underwent genetic analysis. Gene carriers were examined clinically and biochemically, and all gene carriers underwent prophylactic thyroidectomy. RESULTS Five index patients were identified, four of whom harbored mutations in codons 790/791 and one in codon 634. In the kindreds, four L790F carriers and one Y791F carrier were detected. The thyroid gland histology of L790F carriers revealed medullary thyroid carcinoma in two patients (aged 29 and 50 years) and C-cell hyperplasia in two additional patients (aged 9 and 16 years). The Y791F carrier had a normal histology. CONCLUSIONS Codon 790/791 mutations had diverse penetrance. Whereas prophylactic thyroidectomy in children is a justifiable approach for codon 790 mutation carriers, the indication for thyroidectomy should depend on the clinical course of codon 791 carriers.
Collapse
Affiliation(s)
- Guido Fitze
- Departments of Pediatric Surgery, General Surgery, Nuclear Medicine, and Surgical Research, University of Technology Dresden, Dresden, Germany.
| | | | | | | | | | | |
Collapse
|
8
|
Rodríguez GJM, Balsalobre MD, Pomares F, Torregrosa NM, Ríos A, Carbonell P, Glower G, Sola J, Tébar J, Parrilla P. Prophylactic thyroidectomy in MEN 2A syndrome: experience in a single center. J Am Coll Surg 2002; 195:159-66. [PMID: 12168961 DOI: 10.1016/s1072-7515(02)01220-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Genetic study of the RET proto-oncogene has modified the management, treatment, and prognosis of medullary thyroid carcinoma (MTC), multiple endocrine neoplasia 2A (MEN 2A), for patients with less advanced tumor stages. Classically, the diagnosis was based on an increase in basal and poststimulus peak calcitonin (bCT and pCT). Prophylactic thyroidectomy, based on results of genetic testing, may reduce recurrences in MTC. STUDY DESIGN Of 82 MTC (MEN 2A) patients genetically diagnosed and surgically treated at our center, 22 received a prophylactic thyroidectomy (RET +, bCT and pCT with normal values and asymptomatic). We analyzed age, gender, phenotype, RET mutation, cervical ultrasound, laboratory tests (bCT, pCT, and CEA), surgery, histologic data, TNM, and followup. RESULTS The 22 patients belonged to 8 families with MTC (MEN 2A). Mean age was 15.2 years (range 5 to 36 years). The RET mutation in 21 patients was Cys-->Tyr and in the remaining patient both in codon 634 in exon 11. The median values of bCT and pCT were 38 pg/mL (range < 15 to 75 pg/mL) and 148.5 pg/mL (range < 15 to 250 pg/mL), respectively. Total thyroidectomy was performed in 8 patients (age < or = 10 years) and associated central neck dissection in 14 patients (age> 10 years). Histologic study showed 7 C-cell hyperplasias and 15 MTCs (8 bilateral); the median size was 0.2 cm (range < 0.1 to 0.7cm); 1 patient had metastatic adenopathies. According to TNM, 7 were stage 0, 14 were stage I, and 1 was stage III. Postsurgery bCT and pCT values were normal in all patients, with a curative rate of 100%. MTC patients compared with C-cell hyperplasia patients were older on average, had higher mean bCT, mean pCT, and mean CEA. CONCLUSIONS Prophylactic thyroidectomy based on genetic testing allows identification and treatment of patients at an early stage of the disease and decreases recurrence rates. pCT values above the upper limit of normal may be markers for the presence of MTC and should be considered in selecting operative procedures for these patients.
Collapse
|
9
|
Lecube A, Hernandez C, Oriola J, Galard R, Gémar E, Mesa J, Simó R. V804M RET mutation and familial medullary thyroid carcinoma: report of a large family with expression of the disease only in the homozygous gene carriers. Surgery 2002; 131:509-14. [PMID: 12019403 DOI: 10.1067/msy.2002.123006] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Only 9 families with familial medullary thyroid carcinoma due to V804M mutation have been reported until now. We describe a large kindred with not only heterozygous but also homozygous members with the V804M mutation. This is, to our knowledge, the first report of a homozygous RET mutation. METHODS Fifty-three members from 4 successive generations of a family with a high level of consanguinity underwent genetic analysis. The pentagastrin provocative test and biochemical screening to rule out either hyperparathyroidism or pheochromocytoma were performed only on gene carriers of the mutation. RESULTS Twenty-six gene carriers for V804M mutation were identified (4 homozygous and 22 heterozygous). Three of 4 homozygous patients underwent total thyroidectomy. In 1 patient neither medullary thyroid carcinoma nor C-cell hyperplasia was detected, and in another patient only 3 small foci of C-cell hyperplasia were found on the histologic examination. The pentagastrin stimulation test result was within the normal range in all the heterozygous gene carriers and, consequently, thyroidectomy was not indicated. The screening for both hyperparathyroidism and pheochromocytoma was negative in all patients. CONCLUSIONS In the family reported, the V804M mutation in heterozygous patients seems not to be enough to express the full disease. This finding strongly supports the concept of the indolent behavior of V804M RET proto-oncogene mutation. In addition, our results suggest that when counseling for preventive total thyroidectomy, the specific mutation of RET proto-oncogene and also the natural history of the disease within a particular family should be considered.
Collapse
Affiliation(s)
- Albert Lecube
- Department of Endocrinology, Hospital Vall d'Hebron, Barcelona, Spain
| | | | | | | | | | | | | |
Collapse
|
10
|
Scheuba C, Kaserer K, Weinhäusl A, Pandev R, Kaider A, Passler C, Prager G, Vierhapper H, Haas OA, Niederle B. Is medullary thyroid cancer predictable? A prospective study of 86 patients with abnormal pentagastrin tests. Surgery 1999; 126:1089-95; discussion 1096. [PMID: 10598192 DOI: 10.1067/msy.2099.102268] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND The aim of this prospective study was to distinguish biochemically between C-cell hyperplasia (CCH) and medullary thyroid cancer (MTC) before surgery. METHODS Eighty-six consecutive patients with an abnormal stimulated calcitonin level (> 100 pg/mL) underwent thyroidectomy and lymph node dissection. In sporadic MTC, histopathologic findings and postoperative biochemical outcomes were documented prospectively and correlated with preoperative basal and stimulated calcitonin levels. RESULTS Analysis of variance revealed a highly significant difference in basal/stimulated calcitonin levels (P < .0001), with a comparison of CCH (n = 39 patients) and sporadic MTC (n = 38 patients). With a comparison of sporadic MTC N0 M0 (n = 25 patients) and N1 M0/1 (n = 12 patients), the basal calcitonin level was significantly different (P < .05). There was a close correlation between the n-log of basal/stimulated calcitonin level and the n-log of the tumor volume; there were also different distributions of the n-log of basal/stimulated calcitonin level among CCH, MTC N0, and MTC N1. Assuming that a basal calcitonin level of more than 64 pg/mL and/or a stimulated calcitonin level of more than 560 pg/mL implies MTC, 31 of 38 patients with sporadic MTC were detected before surgery. Three patients were predicted false positive (neoplastic CCH). Patients with stimulated calcitonin levels of less than 129 pg/mL had CCH only. Patients with basal calcitonin levels of less than 22 pg/mL and sporadic MTC (7/38 patients) were node negative. CONCLUSIONS All patients with abnormal pentagastrin tests showed C-cell pathologic evidence. Sporadic MTC was predicted in 81% of the patients; CCH or N0 was predicted in 36% of the patients. Central neck dissection is recommended to avoid difficult reoperations. Lateral neck dissection is possible "on demand."
Collapse
Affiliation(s)
- C Scheuba
- Department of Surgery, St Anna Children's Hospital, Vienna, Austria
| | | | | | | | | | | | | | | | | | | |
Collapse
|