Medullary Thyroid Carcinoma in a Patient with MEN 1 Syndrome. Case Report and Literature Review

Abstract

Medullary thyroid cancer (MTC) is typically associated with multiple endocrine neoplasia type 2 syndrome (MEN 2), but not with multiple endocrine neoplasia type 1 (MEN 1). We report a very rare case of MTC in a patient with MEN 1 syndrome. A 60-year-old Caucasian woman with sporadic MEN 1 syndrome was admitted in October 2018 for recurrent hyperparathyroidism unresponsive to medical therapy. Her medical history included the diagnosis of a non-functioning pancreatic neuroendocrine tumor (NF-pNET) of the head of the pancreas 1.5 cm in size in 2001, and subtotal parathyroidectomy for uncontrolled hyperparathyroidism due to bilateral parathyroid hyperplasia in the same year. This history prompted genetic studies, and MEN 1 syndrome was confirmed. Family screening was performed in first-degree relatives, with negative results. Other typical clinical manifestations of MEN 1 syndrome were ruled out. In November 2018, the patient underwent excision of the residual left inferior parathyroid, extended to include the left thyroid lobe, for recurrent uncontrolled hyperparathyroidism. The pathologist identified MTC and adenoma of the parathyroid gland. Genetic tests were performed to identify any RET mutation, with negative results. The patient underwent total thyroidectomy about 6 months later, and the subsequent histological report showed only focal reactive C-cell hyperplasia of the thyroid. A literature review identified only three previously published cases of MTC coexisting with MEN 1 syndrome. This association may have two etiological hypotheses: either a sporadic MTC arising in a patient with MEN 1 syndrome, or a rare case of medullary cancer linked to a MEN 1 gene mutation.

Keywords: MEN 1 gene; RET gene; multiple endocrine neoplasia type 1; multiple endocrine neoplasia type 2; thyroid cancer; thyroidectomy.

Figure 1

MIBI-Technetium subtraction scintigraphy, with evidence of left inferior parathyroid tracer uptake.

Figure 2

Histopathology of resected medullary thyroid cancer (MTC). Microscopically, it revealed polygonal cells with pale cytoplasm surrounded by fibrosis, collagen and amyloid tissue. H&E staining, (A). On immunohistochemistry, MTC was positive for Chromogranin (B), and CEA (C), and slightly positive for calcitonin (D). Magnification 40x (A); 100x (B); 200x (C and D).