12 Medullary Thyroid Carcinoma

Lars-Erik Tisell and Hakan Ahlman

Sahlgrenska University Hospital, Goteborg, Sweden

1 BACKGROUND In 1959 Hazard and colleagues dened medullary thyroid carcinoma (MTC) as a separate disease with specic clinical and pathological features. They found that the tumor was characterized by solid nonfollicular growth pattern, presence of amyloid in the stroma, and high incidence of lymph node metastases [1]. Within the next 10 years MTC was recognized to originate from the parafollicular C cells, secrete calcitonin, and occur in both sporadic and hereditary forms (26).The disease has a wide clinical spectrum ranging from aggressive tumors to rather indolent disease. In contrast to other thyroid diseases, MTC occurs almost equally in both sexes (7). In a study from the National Cancer Registry in Sweden, the agestandardized annual incidence of all MTC, sporadic and hereditary, was 2.1 per million inhabitants during 19701980. During this period MTC constituted 5.2% of all reported thyroid carcinomas in Sweden. Sporadic MTC was rather evenly distributed in the country, which speaks against environmental factors as causative agents. Hereditary MTC was more conned to certain regions, reecting the location of identied families and dierences in screening activity. Population-based surveys in the United States and Canada showed that MTC constituted 410% of the thyroid carcinomas. Data from the Thyroid Cancer Registry in Japan showed 1.55% of MTC among the patients with thyroid malignancies registered from 1977 to 1980.

MTC can occur in four dierent settings: (1) in sporadic form, (2) as the single component in a hereditary disease, familial MTC (FMTC), (3) in the hereditary syndrome multiple endocrine neoplasia syndrome type 2A (MEN-2A), associated with parathyroid disease and pheochromocytoma, and (4) in the hereditary syndrome MEN-2B associated with pheochromocytoma and a specic phenotype characterized by marfanoid habitus, mucosal ganglioneuromas, and intestinal ganglioneuromatosis. Seventy-ve percent of the patients with MTC have sporadic disease and 25% hereditary disease.

2 GENETICS 2.1 Hereditary MTC Syndromes MEN-2 is an autosomal dominant genetic disorder, which can be clinically manifested as the MEN-2A syndrome (MTC 100%, pheochromocytoma 50%, and parathyroid neoplasia 1020%). In 1961 Sipple (2) described six patients with both thyroid carcinoma and pheochromocytoma. Williams et al. (3) recognized that such thyroid tumors were of medullary type. In 1965 Schimke and Hartmann (4) suggested a single gene inheritance of MTC and pheochromocytoma, and 3 years later Steiner et al. (6) proposed that familial occurrence of MTC, pheochromocytoma, and parathyroid tumors should be designated MEN-2. Among

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the hereditary types of disease, MEN-2A is the most frequent syndrome (68%), followed by the MTC-only syndrome (FMTC) (21%) (8). A minority of patients suer from the MEN-2B syndrome (11%). Later, variants of the MEN-2A syndrome were recognized, i.e., MEN-2A associated with cutaneous lichen amyloidosis or with Hirschsprungs disease (911). In 1966 Williams and Pollock (12) described the MEN-2B syndrome (MTC 100%, marfanoid habitus and intestinal ganglioneuromatosis/mucosal neuromas nearly 100%, and pheochromocytoma 50%) (Fig. 1). These patients have no parathyroid disease. All these syndromes are caused by germline mutations of the RET proto-oncogene, and aected individuals will develop multifocal bilateral MTC with almost complete penetrance usually at a young age. The other syndrome features have incomplete penetrance. 2.2 Genetic Background In 1987 the causative RET proto-oncogene was mapped to chromosome 10 (13,14), and several RET mutations were thereafter described in kindreds with MEN-2 syndromes and FMTC (1520). The large RET protooncogene comprises 21 exons and codes for a tyrosine kinase receptor with a cadherin-like extracellular region, which is cysteine-rich close to the cell membrane, and an

intracellular tyrosine kinase domain (21). Hereditary MTC is mainly caused by mutations in the cysteine-rich extracellular region or in the intracellular kinase domain and involves 6 exons (Fig. 2). The classic MEN-2A syndrome is usually associated with mutations in the extracellular region of RET, i.e., codon 634 (7585%) and codons 609, 611, 618, and 620 (altogether 1015%). On the other hand, the MEN-2B syndrome is associated with mutations in the intracellular kinase domain, i.e., codon 918 (95%) and rarely codon 883 (Fig. 2) (22). Somatic point mutations of RET are rather unusual in sporadic MTC (2530%) (23). Codon 918 is most commonly aected. Patients with this mutation have aggressive tumors and short survival in analogy with its germline counterpart, which causes the MEN-2B syndrome (24). The codon 918 mutation may be of importance for tumor progression, frequently combined with a codon 836 polymorphism (25). Somatic point mutations have also been reported for exons 10, 11, 13, 14, and 15 at low frequency (23). Furthermore, base pair deletions of exon 11 seem to be common in sporadic MTC, which may lead to impaired RET function (26,27). If mutation analysis was regularly performed in cases with apparently sporadic MTC, hereditary disease may be revealed in 68% (28). The molecular basis for development of sporadic MTC is still largely unknown. The diverging clinical courses seen in spo-

Figure 1 Two patients with the MEN-2B syndrome (codon 918 mutation) with (left) or without (right) phenotypic features. The left panel shows characteristic mucosal ganglioneuromas of the lips and tongue. The right panel shows a massive MTC at clinical presentation in a young patient.

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nisms: (1) gain of function, e.g., the most common extracellular mutation at codon 634 causes dimerization of the RET/GFR a-1 receptor in the absence of ligand leading to continuous intracellular signaling; (2) altered substrate recognition, e.g., the most common intracellular mutation at codon 918 causes activation of the intracellular signaling pathways in the absence of receptor dimerization. To date, three additional GFR-like receptors and three additional ligands (neurturin, perseptin, and artemin) have been identied as important for nerve growth and maturation (29). Like GDNF, they bind to RET in complex with the membrane-bound components GFRa-2 to -4. Mutations of GDNF homologues and their receptors do not seem to be involved in MEN-2A (30), but occur frequently in both sporadic and familial Hirschsprungs disease (31).
Figure 2 Schematic illustration of RET with mutations associated with MEN-2A and -2B indicated. FMTC and MEN-2A are mainly associated with the same mutations in the cysteine-rich domain. FMTC can also be associated with mutations in codons 768, 791, and 891 in the tyrosine kinase domains (not shown).

2.4 Consequences of Genetic Testing With the rapid progress of our knowledge about RET mutations and hereditary MTC, the concept of prophylactic total thyroidectomy in individuals at risk has developed. The timing of this surgical procedure has been much discussed and also relates to more aggressive clinical phenotypes seen with certain genotypes. It must be emphasized that the clinical experience with some of these rare mutations is still limited and guidelines for treatment are only tentative at this stage. An attempt to stratify the risks in variants of hereditary MTC according to the experience of M.D. Anderson Cancer Center is presented in Table 1 together with treatment recommendations discussed at the international MEN workshops (32). The ideal age for intervention has not been settled unequivocally, but in general most experts want to intervene arround the age of 5 years in patients with MEN-2A or FMTC, but in infancy in MEN-2B patients

radic MTC patients may indicate a complex multifactorial pathogenesis. 2.3 RET/GFR A Receptor Under physiological circumstances the ligand glial cell derived neurotrophic factor (GDNF) binds to a receptor system, consisting of the GDNF receptor (=GFR a-1) and the extracellular domain of RET, which in turn triggers dimerization of the receptor, autophosphorylation of RET, and activation of two intracellular kinase signaling pathways (22). Mutations of RET can cause tumor transformation via at least two mechaTable 1 Risk score High Intermediate Low Clinical manifestation/RET mutation MEN-2B /codon 883, 918 or 922 Codon 611, 618, 620, or 634 Codon 609, 768, 790b, 791b, 804 or 891
a

Recommended treatment Total thyroidectomy + central node dissection mandatory within the rst year of life Total thyroidectomy + central node dissection recommended within the rst 5 years of life No consensus: Total thyroidectomy can be performed within the rst 5 years of life, or at later age, or at the rst abnormalities at continued provocation tests

Germline transmission through several generations is less common, but testing recommended on all children at risk irrespective of presence of the MEN-2B phenotype, or not. Since individuals with de novo mutations have no family history of MEN-2B, testing is recommended on all subjects with phenotypic features. b No deaths from MTC have been observed in patients with these mutations.

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(33,34). In patients with MEN-2A, the clinical course of MTC is quite variable and resembles sporadic MTC, e.g., patients with metastases can have stable disease while others rather rapidly develop skeletal metastases and hormonally induced diarrhea and die of metastatic growth in the central neck and airways. On the other hand, the onset of MTC in MEN-2B is very early, and young patients may present with a cervical mass and incurable metastatic disease. Patients with FMTC have more indolent tumor disease and may live well even with elevated calcitonin levels. Many are cured by thyroidectomy alone. In several series on preventive thyroidectomy it was shown that RET mutation carriers had foci of MTC despite normal calcitonin levels, i.e., provocation tests underestimated the histopathological ndings. Some of the surgical procedures should therefore be considered therapeutic rather than preventive. Furthermore, children with abnormal provocation tests frequently had microscopic MTC at surgery, a tumor entity with metastatic potential. Accordingly, 1520% recurrent disease may appear after long-term follow-up in children subject to thyroidectomy due to early diagnosed MTC by biochemical standards (3537). In one series from the Netherlands gene-carrying children (518 years old) from MEN-2A kindreds with normal calcitonin testing all had foci of MTC in their surgical specimens (38). In a large MEN-2A screening study from 7 kindreds, the gene carriers were oered total thyroidectomy. Among the operated patients, all with elevated calcitonin levels had macro/microscopic MTC and all with normal calcitonin had macro/ microscopic MTC or C-cell hyperplasia. No metastases were identied in any of the central lymph nodes dissected in the entire patient material, and the stimulated calcitonin levels were normal after surgery (39). In early series on prophylactic thyroidectomy in children with veried RET mutations, no signs of recurrent disease have been noted with an observation up to 3 years (34). There is now consensus that children at risk should undergo genetic testing at an early age. The testing should rely on two peripheral blood samples, drawn and analyzed on separate occasions to avoid testing errors and sample mix-up. After extraction of DNA from lymphocytes, RET regions are amplied by PCR and mutations detected by direct sequencing, analyses of restriction sites, and gel shifts. The future follow-up will be focused on recurrence rates after prophylactic thyroidectomy, i.e., stimulated calcitonin levels at regular intervals should be performed combined with screening for pheochromocytoma and hyperparathy 2004 by Marcel Dekker, Inc.

roidism. We still recommend that FMTC patients be medically managed like MEN-2A patients with attention to development of pheochromocytoma and parathyroid disease, since FMTC may potentially represent one end of the MEN-2A spectrum with low penetrance of the disease mutation (40).

3 PATHOLOGY The typical tumor presents as a rm, gray-white mass, usually well demarcated and sometimes encapsulated. The cell of origin for MTC is the C cell which, can be identied by immunohistochemical staining for calcitonin. C cells comprise about 0.1% of the thyroid epithelial cells (41). The C cells are located within individual follicles, being sandwiched between the basement membrane and the follicular epithelium either as single cells or in small groups (41,42). The tumor may grow in trabecular sheets or in insular nests, separated by brous tissue. Most of the normal C cells are located deep within the lateral thyroid lobes along the upper two thirds of their central axis. The C-cell hyperplasia includes focal, diuse, and nodular hyperplasia. Nod-

Figure 3 The proband of a family with the MEN-2A syndrome (codon 618 mutation) at clinical presentation with an advanced MTC, lymph node metastases, and inltrating growth in structures of the neck and mediastinum.

ular hyperplasia is present when the lumen of the follicle is obliterated by proliferating C cells. Early MTC represents the stage when C cells break through the basement membrane and invade the interstitium (41,42). The size of a MTC at clinical presentation can vary from a few mm to large tumors that extend from the mandible down into mediastinum (Fig. 3). In most cases MTC is initially located within the regions of highest C-cell concentration. In familial MTC the tumors are often bilateral and multicentric and associated with bilateral C-cell hyperplasia. Microscopically, MTC is composed of polygonal, or spindle-shaped, cells with granular eosinophilic cytoplasm. Amyloid (a calcitonin gene product) may occur in the stroma but is no prerequisite for the diagnosis. The method to establish the diagnosis is immunocytochemical staining for calcitonin, but the tumor also stains for the carcinoembryonic antigen CEA and chromogranin A and several other substances, e.g., histaminase, serotonin, adrenocorticotropic hormone (ACTH), calcitonin gene-related peptide (CGRP), corticotropin-releasing factor (CRF), and vasoactive intestinal peptide (VIP). Deposits of calcium in the stroma can occur in the thyroid tumor, and in exceptional cases calcied hepatic metastases can be revealed on plain abdominal lms (Fig. 4). Calcied tumor masses are usually associated with advanced dis-

ease, but even with this sign long survival may occur. Mixed tumor variants (MTCfollicular thyroid carcinoma and MTCpapillary thyroid carcinoma) are rare. The diagnosis can be made when two independent tumors are ruled out. The clonal properties of the two components dier, and some tumors can be regarded as MTC with surrounding thyroid hyperplasia (43). Except for bilaterality and multicentricity, there are no histological or histochemical dierences between hereditary and sporadic MTC.

4 CALCITONIN AND CEA, PHYSIOLOGY, AND TUMOR MARKERS The existence of a calcium-lowering factor was rst postulated by Coop and colleagues (44). Experimentally they perfused the regional neck vessels, supplying the parathyroids and thyroids, with blood of varying calcium concentrations and found that hypercalcemic perfusion suppressed the systemic calcium levels. First they believed that the parathyroids produced this new factor. Further studies showed that the hypocalcemic factor, now termed calcitonin, was a thyroid hormone originating from the parafollicular C cells. There is a close correlation between the number of C cells and the tissue content of calcitonin. Acute elevations of the serum calcium concentration stimulate the release of stored calcitonin. Calcitonin is a 32-amino-acid peptide hormone, which suppresses the serum calcium concentration, presumably through its action on osteoclast activity. Hypercalcemia increases the circulating levels of gastrin, which also elicits release of calcitonin in order to maintain normocalcemia. Pentagastrin is a synthetic peptide, sharing the active carboxy-terminal tetrapeptide of gastrin, which is used for pharmacological release of calcitonin (45). MTC cells express gastrin (CCK-B) receptors, which is a prerequisite for both the physiological and the pharmacological stimulation of the calcitonin release (46). Determination of serum concentrations of calcitonin is used as a diagnostic test for MTC. To increase the sensitivity of this test, the calcitonin concentrations are determined both before and after i.v. infusion of calcium (2 mg/kg/min) followed by a bolus dose of pentagastrin (0.6 Ag/kg). After introduction of the more reliable immunoradiometric assays (with a detection limit of 24 ng/L and an upper normal reference limit of 20 ng/L), we routinely use the pentagastrin test, but still use the combined stimulation test in cases with borderline elevations of calcitonin concentrations after stimulation with pentagastrin alone.

Figure 4 Plain abdominal lms of a MEN-2B patient with calcied MTC metastases in the liver.

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4.1 False-Negative Calcitonin Tests In patients with residual MTC after earlier operations, 63% had undetectable basal serum calcitonin concentrations, although their stimulated calcitonin values were elevated (47). Therefore, when serum calcitonin concentrations are tested, the stimulation test should be used to avoid false-negative tests. False-negative calcitonin tests can also occur in patients with less dierentiated MTC. The calcitonin values of such a patient are given in Table 2. He presented with a large sporadic MTC that was visualized by somatostatin receptor scintigraphy. In our experience, patients with positive somatostatin receptor scintigraphies have aggressive tumors and poor prognosis (48). The preoperative test showed a high basal serum calcitonin concentration, which was increased by only 12% after injection of calcium and pentagastrin. The CEA levels were raised to 6 Ag/L. At operation a large tumor (75 g) was found that inltrated structures in the neck and upper mediastinum, including one inferior laryngeal nerve, the esophagus, and the cervical and brachial nerve plexa. A total thyroidectomy was done with an extensive microdissection of the neck and upper mediastinum (see below). Forty-six out of 82 lymph nodes contained tumor with perinodal growth. Tumor tissue remained after the operation. Microscopic examination revealed the typical features of a less dierentiated MTC, i.e., cellular and nuclear polymorphism, frequent mitoses, areas with necrosis, no amyloid, and a heterogeneous distriTable 2 False-Negative Calcitonin Stimulation Test in a Patient with Less Dierentiated MTC and Residual Disease After Surgery Serum calcitonin (ng/L) Month/year 2/86 2/86 10/86 5/87 4/88 5/89 9/90 11/91 3/92
a

bution of calcitonin-poor C cells. To our surprise, the postoperative calcitonin test was normal and at later check-ups the CEA value was normalized. CEA has a long half-life; it takes at least 2 months after a tumor reduction before CEA is normal. During the following 4 years the calcitonin values increased very little. No stimulation of serum calcitonin concentrations was noted by combined i.v. injections of calcium and pentagastrin. In 1991 a small increase in the stimulated serum calcitonin concentration occurred. The following year the patient developed distant metastases in the lungs and liver, and he died shortly thereafter. In this patient the severity of disease was better reected by the CEA values than by the calcitonin concentrations. It must be noted that CEA is not MTC-specic; normal and hyperplastic C cells do not contain CEA, and not all MTC cells stain for CEA. In patients with aggressive MTC, an increase in serum concentrations of CEA can occur despite stable serum calcitonin concentrations; an increase in CEA can even be associated with decreased calcitonin levels. The calcitonin tests are usually the most ecient for the diagnosis and follow-up of patients with MTC, but CEA may be useful to identify a subset of patients with poor prognosis. 4.2 False-Positive Calcitonin Tests C-cell hyperplasia not related to MEN-2 occurs in 5 10% of the normal population and is especially common in children younger than 6 years and in individuals older than 50 years. Such individuals can have borderline increased calcitonin levels that cannot be distinguished from the neoplastic state that precedes MTC (49). After the introduction of genetic testing, it was revealed that a few MEN-2A family members with Ccell hyperplasia had undergone thyroidectomy due to false-positive stimulated calcitonin tests. The genetic analysis proved that they were not gene carriers (50). Patient serum may contain anti-IgG antibodies (heterophilic antibodies), which are capable of reacting with antibodies used in the assay. This may cause spuriously elevated calcitonin values in an immunoradiometric assay. The interference can be eliminated by addition of nonimmune mouse or bovine serum. Therefore, when a patient presents with unexpectedly high serum calcitonin concentrations, the laboratory should be consulted (51). 4.3 Other Pitfalls Hypercalcitoninemia can occur in patients with neuroendocrine tumors other than MTC, e.g., gastroenter-

Basal 17,000a 300a 440a 470a 840a 860a 31b 64b 356b

Peak 19,000a 290a 420a 400a 800a 880a 52b 146b 732b

CEA (Ag/L)c 6 5 5.3 5.5 12 25 85 240

Values determined by a radioimmunoassay, upper normal limit 300 ng/L. b Values determined by an immunoradiometric assay, upper normal limit 20 ng/L. c CEA determined with an immunouorometric assay, upper normal limit 5 Ag/L.

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opancreatic endocrine tumors, pheochromocytomas, and paragangliomas. Contrary to previous opinion, it has been found that the calcitonin release from these tumors can be enhanced by i.v. injections of pentagastrin to a similar degree as seen in MTC. These tumors were indicated as the source of calcitonin by immunocytochemical studies and by normalization of the serum calcitonin concentration after tumor excision (52,53). It is thus important to know that pentagastrin-stimulated calcitonin release does not always indicate the presence of MTC. Nowadays the screening programs for early detection of MTC in members of families with hereditary disease are based on genetic testing (34,39). However, the stimulated calcitonin tests still have an important role in the diagnosis of sporadic MTC (75% of all cases) and in the follow-up after surgery in all MTC patients.

5 PROGNOSIS AND RISK FACTORS In one series with 116 MEN-2A patients, 36 family members had been diagnosed before the screening era; 29 of these patients died of pheochromocytoma and the other 7 died of MTC. Out of 80 patients who had been diagnosed by screening, 2 died of pheochromocytoma and 7 of MTC (38). This shows that the proportion of deaths by pheochromocytoma was substantially reduced by the screening programs. Nowadays, very few patients with hereditary disease die of pheochromocytoma, and most of the disease-specic mortality in MEN-2A and MEN-2B is due to MTC. 5.1 Patient-Related Prognostic Factors

all types of MTC (8). In a large study including 741 patients from the German MTC Register (54), the 5and 10-year adjusted survival rates for all stages of MTC were 81% and 64%, respectively (Table 4); similar gures have been reported by other investigators. In a univariate analysis the stage of disease at diagnosis, type of disease (sporadic or familial), age at diagnosis, and gender were relevant prognostic factors to identify groups with high or low risk, respectively, e.g., young female patients with familial disease diagnosed at early stage had the best prognosis. The most essential factor that inuenced survival was the stage of disease at the time of diagnosis. In a multivariate analysis adjusted for tumor stage, the signicant dierence in relative hazard between patients with sporadic and those with familial disease disappeared. From these ndings it was suggested that once a MTC has become clinically manifest, its course may not dier biologically between sporadic and familial cases. The generally better prognosis seen in MEN-2A patients than in sporadic cases may be related to the stage at which the disease was detected rather than to inherent dierences in biological behavior of the tumor. The mean age at diagnosis for the sporadic cases was 50 years, with the highest incidence in the fth decade and the mean age for the familial cases was 33 years, with the highest incidence in the fourth decade (54). The MEN-2B patients may thus have the most malignant MTC tumors partly as a result of the early onset of disease. Screening of MEN-2B families has led to earlier MTC operations; consequently, in recent MEN-2B series the MTC appeared to be less aggressive than predicted from earlier experience (55,56). 5.2 Morphological Prognostic Factors

According to the study by Saad et al. (7), the most important factors that inuence the prognosis are the type and stage of MTC. MEN-2A patients had a better survival rate than those with sporadic disease (Table 3). MEN-2B is known to be the most aggressive form of MTC, while FMTC has the most favorable prognosis of
Table 3 Importance of MTC Type to Postoperative Survival Authors (Ref.) Saad et al. (7) Treatment period 194483 Type of MTC Sporadic Familial Sporadic Familial

In a study of 241 patients the histopathological characteristics and nuclear DNA content of MTC tumors were evaluated as prognostic factors (57). The following tumor characteristics indicate good prognosis: high frequency ( > 50%) of calcitonin-immunoreactive cells,

No. of patients 125 30 559 182 (81%) (19%)a (75%) (25%)

Age (yr) at presentation 46 32 50 33

5- and 10-year survival (%) 74 and 55 100 and 94 79 and 62 88 and 72

Raue et al. (54)

a

196791

Five patients with MEN-2B syndromes excluded.

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Table 4 Importance of MTC Stage to Postoperative Survival Survival rates (%) Authors (Ref ) Saad et al. (7)a Survival after 5 years Survival after 10 years Raue et al. (54)b Survival after 5 years Survival after 10 years
a b

No. of patients 161

Treatment period 194483

I 92 82

II 89 80 81 77

III 58 23 75 60

IV 40 25 50 37

All 78 61 81 64

741

196791 100 74

Mean age at diagnosis = 44 years. Mean age at diagnosis = 46 years.

presence of amyloid in the tumor, and intact tumor capsule. There were two- or threefold dierences in hazard rate between patients with, or without, these tumor characteristics. Also the nuclear DNA content is a strong predictor of the outcome in MTC. The importance of calcitonin immunoreactivity and the amyloid content was tested in multivariate analyses adjusted for the mentioned prognostic factors and also for stage of the disease, heredity, age, sex, tumor size, and treatment. According to these analyses, the relative hazard for calcitonin immunoreactivity and amyloid content changed only marginally, which indicates that these parameters are independent prognostic factors. Now that gene carriers of the MEN-2A and FMTC syndromes can be identied in childhood and even in infancy by genetic testing, thyroidectomy can be done before MTC has developed and the prognosis for these cases of familial MTC will be excellent (34). About half of the MEN-2B gene carriers who have inherited the mutation will benet from the early genetic testing. The diagnosis of the sporadic cases and the MEN-2B cases with de novo mutations will be discussed in Sec. 7.

6 ECTOPIC CUSHINGS SYNDROME An ectopic Cushings syndrome occurs in about 4% of patients with MTC (58). In two thirds of these patients the diagnosis of MTC precedes with several years the discovery of the Cushings syndrome. In the other patients the two diseases are detected simultaneously. At presentation they have the signs and symptoms usually seen with the nonectopic Cushings syndrome; in addition, about a third of the cases have watery diarrhea, often with 1015 stools a day. Such diarrhea can also occur in other MTC patients with large tumor burden. The exact cause of the diarrhea is not known, but calcitonin, prostaglandins, serotonin, and VIP have
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been suggested as etiological substances. In some cases the diarrhea can be abolished, or palliated, by tumor reduction (59). Also, medication with the somatostatin analogue octreotide can palliate the diarrhea (6062). Patients with the ectopic Cushings syndrome are characterized by rapid onset of symptoms, progressive clinical course, and often radiographically evident tumors. They usually have hypokalemic alkalosis and severe muscle wasting and weakness. The diagnosis is established by very high levels of serum and urinary cortisol and no suppression of ACTH secretion by the high dose (8 mg) of dexamethasone. In preparation for surgery the hypokalemic alkalosis should be corrected. In patients with hypercortisolism the risk for thromboembolic complications is high and prophylactic measures should be taken. Radical extirpation of the MTC with metastases would be the optimal solution, but this can be done only in exceptional cases. Ectopic Cushing is in the great majority of cases a late symptom associated with advanced dissemination of the tumor. Therefore, in most patients the treatment of choice is laparoscopic bilateral adrenalectomy. Most patients have been exposed to high levels of corticosteroids. Therefore, they need high-dose glucocorticoid coverage during surgery and postoperatively. The corticosteroid dose should be tapered over several weeks. After the patients have recovered from adrenalectomy, cytoreductive surgery can be considered. In individual cases we have seen survival exceeding 5 years after liver resection, but on the whole the prognosis is dismal. The long duration of hypercortisolism before diagnosis of a Cushings syndrome would be shortened and the prognosis improved if all MTC patients with persistent disease after surgery were not only regularly checked for the serum concentrations of calcitonin and CEA, but also for serum potassium and urinary levels of steroids. Ectopic Cushing can occur in both sporadic and hereditary MTC; one of our patients had a cys-

teine-to-glycine mutation at codon 634 of the RET protooncogene. She was 31 years old when diagnosed with ectopic Cushing.

7.3 MTC as Part of MEN-2B Syndrome The MEN-2B syndrome is a rare condition (11% of familial MTC). About half of the patients with MEN2B syndromes have hereditary disease and can be diagnosed by genetic screening of aected kindreds. Half of the MEN-2B patients have de novo mutations (66), and many of them will be diagnosed rst when they have got symptoms of MTC or pheochromocytoma. Others will be diagnosed due to the characteristic phenotype or due to other symptoms that may occur in the MEN-2B syndrome, e.g, intestinal problems. These symptoms can start during infancy rst as constipation, later as constipation, diarrhea, and megacolon. They can also present with symptoms of skeletal abnormalities, e.g., scoliosis, or with problems from oral and ocular ganglioneuromas. Delayed puberty is another symptom of MEN-2B. The physician who attends patients with these symptoms should be aware of the MEN-2B syndrome so that these patients can be be diagnosed earlier by genetic testing and be oered a thyroidectomy leading to less morbidity and longer survival. The sooner MEN-2B patients are diagnosed, the better the outcome; the optimum time for surgery is during infancy. However, that early it is dicult to clinically diagnose a patient with de novo mutations, since the typical phenotype is not yet so apparent. Figure 1 shows the typical sign of thick bumpy lips due to mucosal ganglioneuromas in an adult patient; these signs were still absent in the teenage patient. Samaan et al. (67) reported an infant case who had thyroid surgery at the age of 3 months; in this case the suspicion of a MEN-2B syndrome came up because of failure to thrive, possible intestinal obstruction, and a rectal biopsy showing ganglioneuromas. The diagnosis was further strengthened when thickening of the corneal nerves was detected. This is a typical sign of MEN-2B that usually does not appear before 2 years of age. On suspicion of MEN-2B syndrome, the diagnosis can today be done directly by genetic testing.

7 PREOPERATIVE DIAGNOSIS 7.1 Fine Needle Aspiration Biopsy With routine stains most MTC cells are polygonal, or spindle-shaped, often with eccentric nuclei, and appear larger than normal follicular cells. With May-Grun waldGiemsa staining, characteristic red granulation of the cytoplasm can be found in a minority of the cells. Amyloid can be seen both intra- and extracellularly, staining bluish-grey or violet (63). To establish the MTC diagnosis, immunocytochemical staining for calcitonin should be done. No examination of a thyroid nodule is complete without ne needle aspiration biopsy (FNAB). This examination is especially important in the diagnostic work-up of sporadic MTC. With correct diagnosis, an appropriate thyroid operation can be planned. In patients with recurrent MTC, FNAB can verify the nature of lesions that have been detected by other means. In case of nonpalpable metastases, the biopsies can be guided by ultrasonography or by CT. A cytological diagnosis of MTC necessitates calcitonin and calcium studies as well as biochemical testing to rule out pheochromocytoma and hyperparathyroidism. 7.2 Sporadic MTC The diagnosis of sporadic MTC must continue to rely on clinical observations and the awareness of the physician. Up to 90% of the patients with palpable MTC have lymph node metastases (64). Therefore MTC should be suspected in patients with palpable thyroid tumors and lymph node metastases. A few patients with sporadic MTC are incidentally diagnosed at surgery for colloid goiter or hyperparathyroidism. Such tumors are usually small (<1 cm). More than 95% of sporadic MTC are palpable, and they can be diagnosed by FNAB, complemented with basal and pentagastrinstimulated calcitonin tests. Forty percent of MEN-2A gene carriers will not have presented with symptoms before the age of 70 (65). Therefore, the family history is not always reliable. This is one reason why genetic tests should also be recommended to patients with apparently sporadic MTC. Some MEN-2A patients have de novo mutations; such patients will also benet from a policy with genetic testing for all patients with apparently sporadic MTC (28).
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8 PREOPERATIVE WORK-UP 8.1 Work-Up Before a Primary Operation The routine work-up before surgery for patients with MTC includes genetic testing to identify patients with hereditary disease. Calcitonin tests are done to roughly estimate the amount of tumor tissue and to establish the diagnosis in sporadic cases. Serum concentrations of CEA are determined to alert the physician if the disease

takes a more aggressive turn. Cytological verication of the tumor type is done in all sporadic cases. Since a vocal cord paralysis can occur preoperatively as a result of aggressive tumor growth, a laryngoscopy with examination of the vocal cord movements should be performed. Our ambition is to do neck operations even in patients with distant metastases in order to avoid, or delay, tumor inltration into vital structures. In patients with advanced primary tumors, preoperative tracheoscopies and esophagoscopies are done with possibility for biopsies. In advanced primary cases, many of the studies discussed in the next section will be used. 8.2 Work-Up Before a Repeat Operation Before a repeat operation an investigation of the vocal cord movements is mandatory, because the nding of a palsy of an inferior laryngeal nerve will inuence the design of the operation towards a less radical operation on the nonaected side. Before surgery for persistent or recurrent MTC, we try to localize the tumors and diagnose possible distant metastases. The rst localizing procedure is a careful palpation of the neck and FNAB of all suspect lesions. Ultrasonography can be used preoperatively and intraoperatively in the neck to localize hypoechoic metastases down to a size of 5 mm. For preoperative morphological verication, FNAB should be performed on suspect lesions. These investigations are complemented by contrast-enhanced CT and/or MRI, especially when searching for liver, lung, and skeletal metastases. High sensitivity has been reported for selective venous catheterization with blood samplings for determination of serum calcitonin concentrations. However, this procedure can localize a tumor to a region, but not to a distinct site. MTC may have high expression of somatostatin receptors and can therefore be visualized by octreotide scintigraphy. In one study, 22 MTC patients who had persistently increased serum calcitonin concentrations after previous surgery were investigated by octreotide scintigraphy. Fifteen tumor sites were localized by octreotide scintigraphy in 11 of the patients. The smallest tumor that was visualized by the scintigraphy had a volume of 0.5 cm3. Nine other tumor sites were found by other means. Half of the known lymph node metastases in the neck and upper mediastinum and 6 of 7 distant metastases were visualized by scintigraphy. Because of its capacity to detect distant metastases, we recommend octreotide scintigraphy before repeat operations. The growth rate of MTC can be monitored by measuring the increase in serum calcitonin concentrations over time. The patients with positive scintigraphies had a higher annual increase in
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Figure 5 Octreotide scintigraphy in two patients with aggressive MTC. Left panel shows unilateral uptake of the radionuclide after primary surgery and several reoperations. After scintigraphy the surgical exploration was limited to the right side. Right panel shows multifocal uptakes in the right upper neck, mediastinum, and along the right clavicle.

calcitonin than the other patients. This shows that a high density of somatostatin receptors is compatible with a high tumor growth rate. Tumor-associated symptoms and death of MTC occurred only in patients with scintigraphically visualized tumors. This means that a positive octreotide scintigraphy is a bad prognostic factor (48) (Fig. 5). In an interesting study, Tung et al. (68) found by laparoscopy small (<5 mm) liver metastases in 7 of 36 examined patients who had persistent high calcitonin values after previous MTC operations. These metastases had not been revealed by CT and MRI scans. In a patient with such small metastases, we should not hesitate to do a neck operation if there were macroscopic tumors in the neck. We should further evaluate the liver lesions with the intention to perform cytoreduction if possible.

9 SURGICAL TREATMENT 9.1 Primary Operations As prophylaxis against thrombosis, all patients have s.c. injections with low molecular weight heparin. For surgery the patient is placed in the supine position with a large piece of foam padding placed under the shoulders and upper chest to avoid pressure sores. For optimal access during the operation, the head and neck are bent moderately backwards and placed on a vacuum pillow with adjustable pressure. The arms are positioned along the body and the anesthesiologist stationed at the foot of the operation table. These arrangements make it possible for the surgeon to shift position from

the head of the patient or to the right or left side when needed in order to get optimal access to the operation eld. To facilitate the dissection, magnifying glasses can be used. The operation is started with a transverse incision about 45 cm above the jugulum. The superior and inferior aps are created. The superior ap is freed up to the hyoid bone and the inferior down to the sternum. The aps are freed laterally on both sides. We almost never use longitudinal incisions, since they are associated with a worse cosmetic result. Both recurrent nerves should be dissected free to their entrance into the larynx and the lymph nodes close to the nerves are excised. The whole thyroid with the pyramidal lobe and adjacent lymph nodes down to the innominate vein should be removed en bloc. After this has been done, the operation eld is thoroughly searched for remaining lymph nodes; it is checked that no thyroid tissue or lymph nodes remain on the trachea. We also clean the anterior surface of the carotid artery and jugular vein from lymph nodes and soft tissue. Lateral neck dissections are done in case of palpable primary tumors or palpable lymph node metastases. Then the fascia over the carotid artery and the anterior jugular vein is opened, the vagus exposed, and the lymph nodes along the two vessels extirpated. This dissection continues up to the level where the accessory nerve passes over the internal jugular vein beneath the posterior belly of the digastric muscle. The lower limit for this dissection are the subclavian vessels. Sometimes it is possible to extirpate lymph node metastases located in the mediastinum below the right subclavian artery from the cervical incision. In these cases we continue the mediastinal clearance after a sternal split has been done. After the jugular vein and carotid artery have been cleaned, we dissect laterally from the jugular vein under the sternocleidomastoid muscle and over the cervical plexus down to the supraclavicular fossa. We also follow the accessory nerve to clean the posterior triangle. All tissue specimens are sent for histopathological examination with information about the exact site of each specimen. If a reoperation becomes necessary, the pathology report is a valuable tool for the planning of a new operation. Four parathyroids are identied, if possible, and they are usually autotransplanted into muscle tissue. 9.2 Reoperations

disease, as shown by a mean annual increase in calcitonin concentrations of about 100% in 36 of 40 patients with residual MTC followed over 6 years (47). It is not unusual that patients with residual MTC survive for more than 20 years but still ultimately die of MTC. It has been shown that patients with residual MTC can have their increased serum calcitonin conentrations normalized by a repeat operation in about 30% of cases (59,64,6971). In a study by Moley et al. (59) reoperation resulted in normalization of the plasma calcitonin concentrations in 28% of the patients and in a decrease of calcitonin by 40% or more in another 42%. The design of the repeat operation depends on the information from the localization studies, from the operative notes, and from the pathology report of the previous operation. If the previous operation was done by a nonspecialized surgeon, we usually do a systematic reoperation on both sides of the neck; in other cases the operation can be done more selectively. A repeat operation for MTC is much more demanding than a primary operation mainly due to scar tissue. The operation starts with a laborious dissection to restore the anatomy. To be successful the surgeon must have an anatomical knowledge out of the ordinary. The best chance to cure the patient is at the rst operation. Therefore, this operation should be done by a surgeon with experience of thyroidectomy and extensive lymph node dissections. The young girl with a hereditary MEN-2B syndrome shown in Figure 1 had primary surgery for MTC 15 years ago. She had bilateral thyroid tumors, and a total thyroidectomy was done with central and lateral lymph node clearance on both sides of the neck; 129 lymph nodes were excised, including 8 metastases with perinodal growth. Two parathyroids were identied and transplanted into muscle tissue. Her serum calcitonin concentrations dropped from about 110,000 to 230 ng/L (upper normal limit < 300 ng/L). Eight years ago she was diagnosed with bilateral pheochromocytomas; she had bilateral resections of the tumors leaving in situ the normal parts of the adrenals. Today, 15 years after the thyroid operation, she still has normal stimulated serum calcitonin concentrations, normal adrenocortical function, and no signs of recurrent pheochromocytoma. She also has a normal serum concentration of parathyroid hormone but regularly takes some extra calcium.

10 NONSURGICAL TREATMENT Few patients with lymph node metastases have their calcitonin values normalized by a lymph node dissection (33). Many patients with residual MTC do well for many years. However, MTC is generally a progressive
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Surgical treatment is always the primary choice. In cases with local recurrence reoperation is recommended. MTC is not responsive to radioiodine, since the tumor

cells are not derived from the thyroid follicle and lack the iodine pump. MTC is not very sensitive to external irradiation; prospective studies are lacking. In one large retrospective series, patients with this type of treatment actually had worse outcome (72). External irradiation is frequently associated with long-term side eects, e.g., dryness of airway and oral mucosa. Futhermore, surgical treatment after external irradiation can be very dicult to perform. On the other hand, external irradiation can be valuable in the treatment of skeletal metastases (73). Chemotherapy with single agents has no proven eect in patients with advanced disease. Combinations of cytotoxic agents used for other types of neuroendocrine tumors also had limited success (74,75). The best partial response rate (15%) was seen for 5-FU and streptozotocin alternating with dacarbazine (76). Since MTC can be visualized scintigraphically by anti-CEA antibodies labeled with radionuclide, radioimmunotherapy with 131I antibodies has been attempted. Antiproliferative eects were seen in half of the patients with acceptable side eects from the bone marrow (77). In our own diagnostic studies of thyroid neoplasias, we used 111In-labeled octreotide with preferential binding to somatostatin receptors of subtypes 2 and 5. The MTC tumors with the worst prognosis were the ones that were visualized scintigraphically (48). The tumor-to-blood activity concentration ratios were favourable for radiotherapy as well as for lymph node metastases studied after dissection into tumor-free or tumor-bearing parts (78). Octreotide can also be used to alleviate hormonal symptoms in advanced disease, but tachyphylaxis may develop rather rapidly (62). Addition of interferon a-2b can potentiate the therapeutic eects at the cost of drug-related toxicity (79). Novel medical or radiopharmaceutical treatment strategies are clearly required.

familial cases. To improve the prognosis for sporadic MTC, these patients should be referred for primary surgery to centers with expertise in the disease.

ACKNOWLEDGMENT This work was supported by grants from the Swedish MRC (5220). REFERENCES
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