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Clinical Manifestations and Diagnosis of Multiple Endocrine Neoplasia Type 2 - UpToDate
Clinical Manifestations and Diagnosis of Multiple Endocrine Neoplasia Type 2 - UpToDate
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Apr 2019. | This topic last updated: Mar 20, 2018.
INTRODUCTION
Multiple endocrine neoplasia type 2 (MEN2) is an autosomal dominant disorder with an estimated
prevalence of 1 per 30,000 in the general population. MEN2 is subclassified into two distinct
syndromes: types 2A (MEN2A) and 2B (MEN2B). Within MEN2A, there are four variants: classical
MEN2A, MEN2A with cutaneous lichen amyloidosis (CLA), MEN2A with Hirschsprung disease (HD),
and familial medullary thyroid cancer (FMTC) (table 1) [1].
The genetic defect in these disorders involves the RET proto-oncogene on chromosome 10. MEN2A
and 2B are inherited in an autosomal dominant pattern with very high penetrance. In both syndromes,
there is an occurrence of multicentric tumor formation in all organs where the RET proto-oncogene is
expressed. The thyroid, parathyroid, and adrenal glands are at risk for developing tumors that may
reduce life expectancy and quality of life. The excellent prognosis for medullary thyroid cancer (MTC)
diagnosed at its earliest stage underscores the importance of early diagnosis for sporadic and
hereditary MTC [2].
This topic will review the clinical manifestations, diagnosis, and evaluation of MEN2. The genetics
and treatment of this disorder are discussed separately. Sporadic MTC is also discussed separately.
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CLINICAL FEATURES
Multiple endocrine neoplasia type 2 (MEN2) is subclassified into two distinct syndromes: types 2A
(MEN2A) and 2B (MEN2B) (table 1) [3-6].
MEN2A — Within multiple endocrine neoplasia type 2A (MEN2A), there are four variants (table 1) [1]
(see "Classification and genetics of multiple endocrine neoplasia type 2"):
● Classical MEN2A
● MEN2A with cutaneous lichen amyloidosis (CLA)
● MEN2A with Hirschsprung disease (HD)
● Familial MTC (FMTC)
The clinical manifestations of MEN2A depend upon which organs are involved, which in turn is
dependent upon the specific RET mutation. While the penetrance of MTC is nearly 100 percent, there
is much inter- and intrafamily variability in the other manifestations of MEN2A.
FMTC is a variant of MEN2A in which there is a strong predisposition to MTC but not the other clinical
manifestations of MEN2A (or MEN2B).
Medullary thyroid cancer — MTC is a neuroendocrine tumor of the parafollicular or C cells of the
thyroid gland. Most cases of MTC (75 percent) are sporadic, but as many as 25 percent of all MTCs
are familial (table 2) [7]. Among patients with MEN2, virtually all patients develop clinically apparent
MTC, often early in life [1]. In MEN2A-associated MTC, the peak incidence of index cases is in the
third decade of life, and it is usually earlier in MEN2B. Specific RET mutations are associated with
characteristic age-specific penetrance of MTC (table 3), as well as characteristic prevalence of the
extrathyroidal manifestations. MTCs in patients with MEN2 are multicentric and concentrated in the
upper third of the thyroid gland, reflecting the normal distribution of parafollicular cells (picture 1).
If diagnosed as an index case, the clinical presentation and manifestations of MEN2-associated MTC
are similar to those of sporadic MTC, except that sporadic MTC typically presents later in life. The
most common presentation is that of a solitary thyroid nodule or cervical lymphadenopathy. Fine-
needle aspiration (FNA) biopsy shows eccentrically placed nuclei that are larger and more
pleomorphic than those of normal follicular cells. The cytoplasm may be slightly granular and is
usually configured as a tear drop or cytoplasmic tail. If the diagnosis is suspected, immunocytologic
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staining for calcitonin should be performed. (See "Medullary thyroid cancer: Clinical manifestations,
diagnosis, and staging", section on 'Diagnosis'.)
Less common presentations specific to MEN2-associated MTC include recognition during a search
initiated after an associated disease (such as pheochromocytoma or hyperparathyroidism) becomes
apparent, diarrhea caused by gastrointestinal secretion of fluid and electrolytes, and flushing due to
the secretion of other peptides by the tumor. In rare cases, MTC causes Cushing's syndrome due to
ectopic production of corticotropin (ACTH). (See "Causes and pathophysiology of Cushing's
syndrome".)
In asymptomatic patients identified through calcitonin or DNA testing, initiated due to the presence of
an associated disease or to a family history of MEN2, MTC is often diagnosed in its preneoplastic
state, C-cell hyperplasia. Basal serum calcitonin concentrations usually correlate with tumor mass
and are almost always high in patients with a palpable tumor. In patients with small tumors and those
with C-cell hyperplasia, the values may be normal but rise excessively after calcium or pentagastrin
infusion [8]. (See 'Choice of biochemical test for MTC' below.)
The presence of C-cell hyperplasia is defined based upon microscopy criteria: the presence of an
increased number of diffusely scattered C cells (≥7 per thyroid follicle), complete follicles surrounded
by C cells, or distribution of C cells beyond the normal anatomical location [1,9]. C-cell hyperplasia
can occur in a reactive (secondary) form or a neoplastic form (precursor to MTC in MEN2). Neoplastic
C-cell hyperplasia is diagnosed when nests of C cells appear to extend beyond the basement
membrane and to infiltrate and destroy thyroid follicles (picture 2) [10]. Reactive C-cell hyperplasia is
considered to be caused by a stimulus from outside the C cell and probably is not premalignant
(picture 3). Hyperparathyroidism, chronic renal insufficiency, chronic lymphocytic thyroiditis, and
follicular thyroid tumors have been associated with reactive C-cell hyperplasia [11].
As with MTC, pheochromocytomas in MEN2 occur earlier than sporadic forms. Although they may
develop as early as 8 to 12 years of age, the mean age of presentation is 25 to 32 years, depending
on the RET mutation [14-16]. It is unusual for pheochromocytoma to precede the development of
MTC and be the initial manifestation of MEN2. In patients who have undergone regular screening,
pheochromocytomas have usually become evident approximately 10 years later than C-cell
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hyperplasia or MTC [17]. Thus, pheochromocytomas in MEN2 are usually identified during screening
or through heightened vigilance for symptoms in patients with known or suspected MEN2.
Rarely, pheochromocytoma may be the first manifestation of MEN2 [18,19]. In such patients,
symptoms are similar to those in patients with sporadic pheochromocytomas and may include attacks
(paroxysms) of anxiety, headache, diaphoresis, palpitations, or tachycardia. However, in one report,
only approximately one-third had hypertension at the time of diagnosis [20]. The severity of symptoms
may depend upon the specific RET mutation [21]. The diagnosis of pheochromocytoma includes
biochemical testing and, once a diagnosis of pheochromocytoma is established, imaging studies. The
clinical manifestations and diagnosis of pheochromocytoma are reviewed in detail separately. (See
"Clinical presentation and diagnosis of pheochromocytoma".)
Other heritable syndromes associated with pheochromocytoma include von Hippel-Lindau (VHL)
syndrome, neurofibromatosis type 1, and paraganglioma syndromes. This topic is reviewed in more
detail elsewhere. (See "Pheochromocytoma in genetic disorders".)
The recurrence rate after apparently successful subtotal parathyroidectomy is less than that in
multiple endocrine neoplasia type 1 (MEN1) [28,29] and is similar to the excellent long-term results
seen in patients with nonfamilial primary hyperparathyroidism.
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There has been a suggestion that parathyroid disease in MEN2A may somehow be a consequence of
the C-cell abnormalities, based upon a low reported incidence of parathyroid disease in patients in
whom C-cell hyperplasia was detected early and treated by total thyroidectomy [30,31]. In one report,
as an example, none of 22 patients who underwent thyroidectomy developed hyperparathyroidism
after more than 10 years of follow-up [30]. Why this might occur and whether the risk is indeed lower
after thyroidectomy is not clear. It seems unlikely that hypercalcitoninemia per se is the stimulus for
the parathyroid tumors for the following reasons:
● Hyperparathyroidism is not associated with MEN2B, FMTC, or sporadic MTC, all of which can be
characterized by sustained hypercalcitoninemia.
● A particular RET mutation, Cys to Arg at codon 634, may be preferentially found in MEN2
families that have hyperparathyroidism [3,33].
These data imply that the initial stimulus to parathyroid cell proliferation in MEN2A, while often mild, is
probably related to expression of the mutant RET protein within parathyroid tissue. It is interesting in
this context, although not of direct clinical importance, that calcium suppression testing in
normocalcemic patients has suggested that mild abnormalities in parathyroid function may be
common in MEN2A [35].
Cutaneous lichen amyloidosis — CLA, also termed lichen planus amyloidosis (LPA), is a rare
skin condition and can occur both sporadically and as a familial disease. The hereditary forms are
transmitted in an autosomal dominant fashion, and an association between CLA and MEN2A has
been established in some families [36].
The skin lesion is usually described as pruritic, scaly, papular, pigmented, and located in the
interscapular region or on the extensor surfaces of the extremities (picture 6A-B) [35]. Amyloid
deposition has been documented histologically [37,38]. Keratin-like peptides have been found in the
amyloid deposits but not calcitonin-like peptides [36]. CLA is thought to result from a primary
neuropathy [38-40]. This is an attractive hypothesis with respect to CLA being a rare manifestation of
MEN2A since RET is expressed in the peripheral and central nervous system [41-43].
Several different RET codon 634 mutations have been described in MEN2A/CLA families [44,45], and
both dermal and nondermal manifestations segregate with the mutation [44]. These same RET
mutations are also found in MEN2A families without evidence of CLA, suggesting the influence of
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"modifying genes" or other factors cooperating with the RET mutation in the expression of the CLA
phenotype. CLA was also reported in a patient with a RET codon 804 mutation [46]. CLA kindreds
without MEN2A have not had demonstrable germline RET mutations [45].
The syndrome of MEN2B also includes mucosal neuromas, typically involving the lips and tongue,
and intestinal ganglioneuromas. Patients with MEN2B also have development abnormalities, a
decreased upper/lower body ratio, skeletal deformations (kyphoscoliosis or lordosis), joint laxity,
Marfanoid habitus, and myelinated corneal nerves. Disturbances of colonic function are common,
including chronic constipation and megacolon [51]. Unlike patients with Marfan syndrome, MEN2B
patients do not have ectopia lentis or aortic abnormalities [7].
DIAGNOSIS
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Multiple endocrine neoplasia type 2 (MEN2) should be suspected in any patient with medullary
thyroid cancer (MTC) or pheochromocytoma, particularly when the tumors occur at a young age (<35
years), are multicentric, or when more than one family member is affected. The diagnosis of MEN2 is
based upon the presence of the classical clinical features, family history, and genetic testing.
MEN2 — In an index patient with one or two of the classical clinical features, identification of a
germline RET mutation or the identification of the clinical features of multiple endocrine neoplasia
type 2 (MEN2) in other first-degree relatives is required to make the diagnosis of MEN2 [26].
In the absence of an autosomal dominant familial inheritance pattern or RET mutation, at least two of
the classical clinical features of MEN type 2A (MEN2A) (MTC, pheochromocytoma, primary
hyperparathyroidism) are required to make a clinical diagnosis of MEN2A.
In the absence of an autosomal dominant familial inheritance pattern or RET mutation, the majority of
classical clinical features of MEN type 2B (MEN2B) (MTC, pheochromocytoma, mucosal neuromas,
Marfanoid habitus, intestinal ganglioneuromas, myelinated corneal nerves) are required to make a
clinical diagnosis of MEN2B [26].
Although a patient with the classical clinical features of MEN2 and similar clinical features in one or
more first-degree relatives does not need RET mutation analysis for diagnosis, genetic testing (where
available) is performed in all patients with clinical MEN2 in order to identify the specific RET mutation
and facilitate family screening (table 4). There are rare families, however, with clinical features of
MEN2A in the absence of an identifiable RET mutation. (See 'Screening of family members in MEN2
kindreds' below.)
● Genetic testing – For the index patient with suspected MEN2A, all exons should be sequenced,
starting with the most commonly mutated codons in exons 10 and 11 and then, if negative,
sequentially proceeding to exons 8, 13, 14, 15, and 16 [1]. If no germline mutation is found, only
a small risk of hereditary MTC remains. In this case, sequencing the entire RET coding region is
an option to identify a RET mutation.
For the index patient with the MEN2B phenotype, initial testing should be for the RET codon
M918T mutation in exon 16 and, if negative, for the A883F mutation in exon 15. If no mutations
are identified, the entire RET coding region should be sequenced [1].
Once a germline RET mutation is identified in an index case, RET mutation analysis should also
be performed in first- and second-degree family members. The screening of family members is
discussed below. (See 'Screening of family members in MEN2 kindreds' below.)
Occasionally, older patients with MTC, a negative family history, and no clinical features of MEN2
may nonetheless harbor a cryptic germline RET mutation. Evaluation of patients with apparently
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sporadic MTC should include genetic testing for germline RET mutations. The indications for
genetic testing for the detection of unsuspected heritable MEN2 in patients with apparently
sporadic MTC or pheochromocytoma (eg, unilateral disease, a negative family history, and no
other signs or symptoms of MEN2) is reviewed separately. (See "Medullary thyroid cancer:
Clinical manifestations, diagnosis, and staging", section on 'Genetic screening in sporadic MTC'
and "Pheochromocytoma in genetic disorders", section on 'Genetic screening'.)
Familial medullary thyroid cancer variant — The familial MTC (FMTC) variant of MEN2A is
characterized by the presence of a RET germline mutation in families with MTC, or an individual with
MTC, who do not develop pheochromocytoma or primary hyperparathyroidism. Distinguishing the
FMTC variant from classical MEN2A may be difficult in small families, and therefore, rigorous criteria
for FMTC should be used in order not to miss a pheochromocytoma [52]. There should be:
EVALUATION
RET mutation analysis — For patients diagnosed with multiple endocrine neoplasia type 2 (MEN2)
based upon the classical clinical features and family history (typically medullary thyroid cancer [MTC]
and a family member with MTC), evaluation should include RET mutation analysis (if not already
performed) in order to identify the specific RET mutation to facilitate family screening (table 4). (See
'Diagnosis' above and "Medullary thyroid cancer: Clinical manifestations, diagnosis, and staging",
section on 'Genetic screening in sporadic MTC' and 'Genetic screening' below.)
If a family member is positive for the RET mutation, prophylactic thyroidectomy is indicated. The
timing of thyroidectomy is based upon the specific RET mutation and, in some cases, serum
calcitonin levels. (See "Approach to therapy in multiple endocrine neoplasia type 2", section on
'Preventive surgery'.)
Screening for MEN2-associated tumors — Patients with multiple endocrine neoplasia type 2
(MEN2) (and their affected family members) also require screening for MEN2-associated tumors. In
all patients diagnosed with MEN2, we measure plasma fractionated metanephrines (as the initial
screen for pheochromocytoma) and serum calcium (to rule out hyperparathyroidism requiring
concomitant surgical intervention). For patients with MEN2 who present with pheochromocytoma
rather than MTC, we measure serum calcitonin and obtain a thyroid and neck ultrasound to assess
for the presence of MTC.
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Screening for MEN2-associated tumors in families of the index patient is reviewed below. (See
'Monitoring for MEN2-associated tumors' below.)
For the index patient with MTC, we measure plasma fractionated metanephrines as the initial screen
for pheochromocytoma. If biochemical results are positive, adrenal imaging with computed
tomography (CT) or magnetic resonance imaging (MRI) is the next step. (See "Clinical presentation
and diagnosis of pheochromocytoma", section on 'Additional evaluation after biochemical diagnosis'.)
If the initial screening tests for pheochromocytoma are negative, it is important to evaluate for
pheochromocytoma yearly (table 5). Details of biochemical screening to detect pheochromocytomas,
including in MEN2 patients, is reviewed elsewhere. (See "Clinical presentation and diagnosis of
pheochromocytoma", section on 'High risk for pheochromocytoma'.)
If the serum calcium is elevated, we measure intact parathyroid hormone (PTH). The diagnosis is
established by finding high (or inappropriately normal) serum PTH concentrations in the presence of
hypercalcemia. (See "Primary hyperparathyroidism: Diagnosis, differential diagnosis, and
evaluation".)
If the serum calcium is normal, we measure serum calcium yearly to detect the development of
hyperparathyroidism (table 5).
Medullary thyroid cancer — Most index patients with MEN2 present with MTC and, therefore, do
not require monitoring for its development. For patients with MEN2 who present with
pheochromocytoma, we measure serum calcitonin and obtain a thyroid and neck ultrasound to
assess for the presence of MTC. If there is no evidence of MTC, we continue to screen annually
(table 6).
Additional evaluation of patients who have been diagnosed with MEN2-related MTC is similar to that
in sporadic MTC and should include measurement of serum calcitonin, carcinoembryonic antigen
(CEA), and ultrasonography of the neck (if not already performed). (See "Medullary thyroid cancer:
Clinical manifestations, diagnosis, and staging", section on 'Evaluation'.)
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Once a germline RET mutation is identified in an index case, RET mutation analysis should be
performed in first- and second-degree family members. Affected family members also require
screening for multiple endocrine neoplasia type 2 (MEN2)-associated tumors. (See 'Genetic
screening' below and 'Monitoring for MEN2-associated tumors' below.)
Advances in the molecular genetics underlying the MEN2 syndromes have resulted in DNA testing
becoming the optimal test for their detection. The role of RET DNA testing in MEN2 kindreds is better
established than testing for MEN1 mutations in multiple endocrine neoplasia type 1 (MEN1) families.
This is because identification of specific RET mutations predicts particular phenotypes (age of onset,
aggressiveness of medullary thyroid cancer [MTC], and presence or absence of other endocrine
neoplasms) and, thus, guides surveillance and management (table 3 and table 5 and table 6) [2].
In the past, pentagastrin and calcium stimulation tests were used to stimulate calcitonin secretion by
thyroid C cells and assess for the diagnosis of MTC in family members. However, RET mutation
screening is available for MEN2, and therefore, these tests have lost their clinical significance with
respect to diagnosis of MEN2 [53]. Genetic testing in known MEN2 families has several clinically
important advantages over the pentagastrin or calcium tests:
● It provides clinical benefit that should accrue from earlier surgery for known MEN2 gene carriers
as the genotype correlates with the age at initial diagnosis of MTC (table 3).
● It definitively establishes that an individual does not carry the MEN2 mutation and eliminates the
need for biochemical testing.
However, biochemical tests are still used in families who meet the clinical criteria for MEN2 but have
negative sequencing of the entire RET coding region or for families who refuse genetic testing. (See
'When RET mutation is unknown' below.)
Genetic screening — In general, the primary and most compelling purpose of genetic screening in
human tumor predisposition syndromes is to prevent disease-related morbidity and mortality that
would otherwise occur [2,26,56,57]. Genetic counseling and genetic testing for RET germline
mutations should be offered to the following groups [1]:
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● Parents whose infants or young children have the clinical characteristics of MEN type 2B
(MEN2B)
In an MEN2 family, a sample from one subject already known to be affected should be tested in order
to determine the specific RET mutation for that family. All subjects of unknown status in that family
should then be definitively genotyped. RET genotyping requires only a small blood sample and can
therefore be performed at birth or soon thereafter. At the latest, genotyping should be done before the
time at which prophylactic thyroidectomy would be performed in the event of a positive result.
● Known RET mutation present – For those with RET mutations, prophylactic thyroidectomy in
family members is timed based upon the specific DNA mutation in the RET proto-oncogene
occurring in the family (table 6). The risk-benefit equation is strengthened by the ease of thyroid
hormone replacement after thyroidectomy and the relatively low morbidity of the surgery, even in
children, when performed by high-volume surgeons [58]. The timing of prophylactic
thyroidectomy is reviewed separately. (See "Approach to therapy in multiple endocrine neoplasia
type 2", section on 'Preventive surgery'.)
● Known RET mutation absent – A family member who has not inherited the specific RET
mutation that causes that family's MTC needs no further evaluation.
Thus far, family screening efforts appear to be suboptimal, as a high proportion of patients continue to
receive less than optimal initial surgical treatment. According to the population-based Surveillance,
Epidemiology, and End Results (SEER) registry, there has been no change in stage at diagnosis or
significant improvement in survival noted over the last 30 years [59,60]. Although the SEER registry
does not contain information regarding hereditary or biochemical results, an estimated 50 percent had
a familial form of MTC (FMTC). This suggests that many MEN2/FMTC patients underwent surgery
that was less than optimal for the stage of the disease. Summary information concerning MEN2 may
be useful for counseling patients and affected families. Family alliances can provide such information:
Genetic Testing Registry (GTR) or EndocrineWeb.
Sensitivity/specificity — One potential problem relates to the rare MEN2 families with no
detectable RET mutation. In addition, as with any genetic test, other potential sources of error exist
such as sample mix-up, cross-contamination of the polymerase chain reactions used in the tests, and
DNA polymorphisms that would prevent amplification of one RET allele, a situation that could result in
a false-negative screening test. To date, however, neither false-negative nor false-positive RET tests
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have been described in MEN2 families in which a specific RET mutation was detected in an index
case.
Availability of genetic diagnosis — Genetic diagnosis of MEN type 2A (MEN2A), FMTC, and
MEN2B is readily available commercially. A list of testing laboratories is available at the MD Anderson
Cancer Center website and through the genetic testing resource Genetic Testing Registry (GTR). In
Europe, a listing of commercial laboratories can be found at the European Directory of DNA
Diagnostic Laboratories.
Clinicians should inquire as to the protocol and methodology of the offered RET DNA test. One
important issue is whether all relevant exons (exons 10, 11, and 16, and, if those are negative, exons
8, 13, 14, and 15) will be sequenced if the RET mutation in that family is unknown.
Counseling — Before blood samples are taken for DNA analysis, detailed information about the
consequences of DNA analysis must be provided to the family. Psychological support may well be
needed before DNA test results are disclosed and during follow-up after diagnosis to minimize
distress. Written consent must be obtained [61]. Given the rarity of this disease and the potential
complications of a total thyroidectomy in young children, patients should be referred to academic
centers with expertise in MEN2.
Reproductive options — Patients with MEN2 and a known familial RET mutation should be
counseled that prenatal testing and preimplantation genetic testing are available options if they
choose to pursue fertility [26]. Prenatal testing is performed in the first or second trimester via
chorionic villus sampling or amniocentesis, respectively. Preimplantation genetic diagnosis (PGD) is
done as part of in vitro fertilization (IVF); single embryonic cells are tested for the RET mutation. Only
embryos without a RET mutation are then transferred to the uterus. The various reproductive options
available to prospective parents require thoughtful discussion and genetic counseling.
Monitoring for MEN2-associated tumors — Affected family members require screening for multiple
endocrine neoplasia type 2 (MEN2)-associated tumors.
When RET mutation is known — When the RET mutation is known, monitoring for MEN2-
associated tumors is based upon the specific mutation and degree of risk it confers for MTC,
pheochromocytoma, and primary hyperparathyroidism.
Medullary thyroid cancer — Children with certain RET mutations can develop clinically
apparent MTC at an early age. The goal in patients with known RET mutations (but without clinically
apparent disease) is to perform a prophylactic thyroidectomy before MTC develops or when it is still
confined to the thyroid gland (table 6). (See "Approach to therapy in multiple endocrine neoplasia type
2", section on 'Preventive surgery'.)
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Children with the highest risk mutation (codon 918) should have thyroidectomy within the first year of
life and, therefore, do not require monitoring.
For children with high-risk mutations (codons 634, 883), we begin monitoring at age three years, and
for children with moderate risk mutations, we begin monitoring at age five years. We monitor with an
annual physical examination, neck ultrasound, and measurement of serum calcitonin. The detection
of a serum calcitonin level (basal or stimulated) above the upper limit of normal is an indication for
surgery.
There is large variability in the penetrance of pheochromocytoma among different reported kindreds,
depending upon the specific RET germline mutation. These findings help guide screening and
therapy for MEN2 patients [65-69]. As an example, compared with families with mutations in codons
634 and 918, pheochromocytomas are rare in families with mutations in codons 533, 609, 611, 618,
620, 630, 633, 666, 768, 790, 791, 804, and 891, although they do still occur.
Due to screening programs, pheochromocytomas may be diagnosed at a young age and before
symptoms are present.
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Biochemical testing — For closely related MEN2 family members who refuse DNA analysis
for themselves or their children, or for families who meet the clinical criteria for MEN2 but have
negative sequencing of the entire RET coding region, biochemical testing can be performed to detect
MEN2-related tumors. If biochemical testing is used, yearly testing starting at age five and continuing
until at least age 35 years (or until a positive test occurs) is necessary [7]. For families with a clinical
diagnosis of MTC prior to age five years, biochemical screening for MTC should begin at the
youngest age of first diagnosis.
Either a pentagastrin or a calcium stimulation test can be used to screen for C-cell hyperplasia/MTC.
Where available (not in the United States), pentagastrin is the preferred stimulation test. Testing
should also include plasma fractionated metanephrines or 24-hour urinary metanephrines and
normetanephrines (to screen for pheochromocytoma) and serum calcium (to screen for
hyperparathyroidism).
Choice of biochemical test for MTC — Owing to the unavailability of pentagastrin in many
countries, there is growing interest in the calcium stimulation test. However, there are few data using
the calcium stimulation as a confirmatory test in patients with elevated basal calcitonin levels, and
cutpoints for the discrimination of normal, C-cell hyperplasia, and medullary thyroid cancer (MTC)
have not been standardized [72]. In one study, basal and stimulated calcitonin levels were measured
in over 100 patients with thyroid disease (MTC in remission or persistence, RET gene mutation
carriers, nodular goiter) and in 16 healthy volunteers [73]. In all groups, the levels of calcitonin
stimulated by either pentagastrin or calcium were significantly correlated. In this study, calcium
stimulated calcitonin levels above 32.6 pg/mL (females) and 192 pg/mL (males) had the best
accuracy to differentiate normal subjects from patients with C-cell hyperplasia or MTC [73]. Criteria for
abnormal calcitonin values may vary in local or commercial laboratories [74].
● Pentagastrin stimulation test – The pentagastrin stimulation test uses a slow intravenous
injection of pentagastrin (0.5 mcg/kg body weight) over three minutes. Blood samples for
calcitonin are obtained at baseline and two and five minutes after pentagastrin infusion [75,76]. If
stimulated calcitonin values are ≥200 pg/mL, MTC is likely and thyroidectomy and
lymphadenectomy are required. If values are <100 pg/mL, the risk of MTC is low and periodic
monitoring of basal and stimulated serum calcitonin levels is recommended. If the stimulated
calcitonin values are between 100 and 200 pg/mL, the risk is uncertain. Such values could be
indicative of C-cell hyperplasia or micro MTC. Some advise surgery [77,78], while others
observation (following calcitonin levels) [79].
Side effects of pentagastrin include abdominal cramping, extremity paresthesia, and feeling of
warmth, lasting up to one to two minutes [76]. Pentagastrin is not available in many countries,
including the United States.
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● Calcium stimulation test – The calcium stimulation test uses an infusion of calcium gluconate
(2.5 mg elemental calcium/kg body weight over 30 seconds) administered in a fasting state (no
food after midnight) [54,76]. Blood samples for calcitonin are obtained at baseline and two and
five minutes after the stimulus. In one study, calcium-stimulated calcitonin levels above 32.6
pg/mL (females) and 192 pg/mL (males) had the best accuracy to differentiate normal subjects
from patients with C-cell hyperplasia or MTC [73].
The most common side effects are temporary flushing and feeling of warmth (98 percent) [76].
Facial paresthesias are less common (20 percent).
Links to society and government-sponsored guidelines from selected countries and regions around
the world are provided separately. (See "Society guideline links: Medullary thyroid cancer".)
● Multiple endocrine neoplasia type 2 (MEN2) is subclassified into two distinct syndromes: types
2A (MEN2A) and 2B (MEN2B) (table 1). Within MEN2A, there are four variants. The genetic
defect in MEN2 involves the RET proto-oncogene on chromosome 10. MEN2A and 2B are
inherited in an autosomal dominant pattern with very high penetrance. (See 'Introduction' above.)
● MEN2 should be suspected in any patient with MTC or pheochromocytoma, particularly when the
tumors occur at a young age (<35 years), are multicentric, or when more than one family
member is affected. The diagnosis of MEN2 is based upon the presence of the classical clinical
features, family history, and genetic testing. (See 'Diagnosis' above.)
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● In an index patient with one or two of the classical clinical features, identification of a germline
RET mutation or the identification of the clinical features of MEN2 in other first-degree relatives is
required to make the diagnosis of MEN2. (See 'MEN2' above.)
In the absence of an autosomal dominant inheritance pattern or RET mutation, at least two of the
classical clinical features of MEN2A (MTC, pheochromocytoma, primary hyperparathyroidism)
are required to make the diagnosis.
In the absence of an autosomal dominant familial inheritance pattern or RET mutation, the
majority of classical clinical features of MEN2B are required to make a clinical diagnosis of
MEN2B.
● Familial MTC (FMTC) is characterized by the presence of a RET germline mutation in families
with MTC, or an individual with MTC, who do not develop pheochromocytoma or primary
hyperparathyroidism. Distinguishing the FMTC variant from classical MEN2A may be difficult in
small families, and therefore, rigorous criteria for FMTC should be used in order not to miss a
pheochromocytoma. (See 'Familial medullary thyroid cancer variant' above.)
● For patients diagnosed with MEN2 based upon the classical clinical features and family history
(typically MTC and a family member with MTC), evaluation should include RET mutation analysis
(if not already performed) in order to identify the specific RET mutation to facilitate family
screening (table 4). (See 'RET mutation analysis' above.)
● Patients with MEN2 also require screening for MEN2-associated tumors. In all patients
diagnosed with MEN2-related MTC, we measure plasma fractionated metanephrines (as the
initial screen for pheochromocytoma in patients with MEN2A or 2B) and serum calcium (to rule
out hyperparathyroidism requiring concomitant surgical intervention in patients with MEN2A). For
patients with MEN2 who present with pheochromocytoma rather than MTC, we measure serum
calcitonin and obtain a neck ultrasound to assess for the presence of MTC. (See 'Screening for
MEN2-associated tumors' above.)
● Once a germline RET mutation is identified in an index case, RET mutation analysis should also
be performed in first- and second-degree family members. Affected family members require
screening for MEN2-associated tumors. (See 'Genetic screening' above and 'Monitoring for
MEN2-associated tumors' above.)
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Early diagnosis by screening of "at-risk" family members in MEN2 kindreds is important because
identification of specific RET mutations predicts particular phenotypes (age of onset,
aggressiveness of MTC, and presence or absence of other endocrine neoplasms) and, thus,
guides surveillance for MEN2-associated tumors and management (table 3 and table 5 and table
6). (See 'Screening of family members in MEN2 kindreds' above.)
● For those with RET mutations, prophylactic thyroidectomy in family members is timed based
upon the specific DNA mutation in the RET proto-oncogene occurring in the family (table 6). (See
"Approach to therapy in multiple endocrine neoplasia type 2", section on 'Timing of surgery'.)
REFERENCES
1. Wells SA Jr, Asa SL, Dralle H, et al. Revised American Thyroid Association guidelines for the
management of medullary thyroid carcinoma. Thyroid 2015; 25:567.
2. Frank-Raue K, Rondot S, Raue F. Molecular genetics and phenomics of RET mutations: Impact
on prognosis of MTC. Mol Cell Endocrinol 2010; 322:2.
3. Mulligan LM, Eng C, Healey CS, et al. Specific mutations of the RET proto-oncogene are
related to disease phenotype in MEN 2A and FMTC. Nat Genet 1994; 6:70.
4. Mulligan LM, Ponder BA. Genetic basis of endocrine disease: multiple endocrine neoplasia type
2. J Clin Endocrinol Metab 1995; 80:1989.
5. Hofstra RM, Landsvater RM, Ceccherini I, et al. A mutation in the RET proto-oncogene
associated with multiple endocrine neoplasia type 2B and sporadic medullary thyroid
carcinoma. Nature 1994; 367:375.
6. Donis-Keller H, Dou S, Chi D, et al. Mutations in the RET proto-oncogene are associated with
MEN 2A and FMTC. Hum Mol Genet 1993; 2:851.
7. Raue F, Frank-Raue K, Grauer A. Multiple endocrine neoplasia type 2. Clinical features and
screening. Endocrinol Metab Clin North Am 1994; 23:137.
8. Parthemore JG, Bronzert D, Roberts G, Deftos LJ. A short calcium infusion in the diagnosis of
medullary thyroid carcinoma. J Clin Endocrinol Metab 1974; 39:108.
https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-multiple-endocrine-neoplasia-type-2/print?search=MEN2&source=searc… 17/37
5/29/2019 Clinical manifestations and diagnosis of multiple endocrine neoplasia type 2 - UpToDate
9. Verga U, Ferrero S, Vicentini L, et al. Histopathological and molecular studies in patients with
goiter and hypercalcitoninemia: reactive or neoplastic C-cell hyperplasia? Endocr Relat Cancer
2007; 14:393.
10. Wolfe HJ, Delellis RA. Familial medullary thyroid carcinoma and C cell hyperplasia. Clin
Endocrinol Metab 1981; 10:351.
11. Albores-Saavedra JA, Krueger JE. C-cell hyperplasia and medullary thyroid microcarcinoma.
Endocr Pathol 2001; 12:365.
12. Siqueira DR, Ceolin L, Ferreira CV, et al. Role of RET genetic variants in MEN2-associated
pheochromocytoma. Eur J Endocrinol 2014; 170:821.
16. Rowland KJ, Chernock RD, Moley JF. Pheochromocytoma in an 8-year-old patient with multiple
endocrine neoplasia type 2A: implications for screening. J Surg Oncol 2013; 108:203.
17. Utiger RD. Medullary thyroid carcinoma, genes, and the prevention of cancer. N Engl J Med
1994; 331:870.
18. Kinlaw WB, Scott SM, Maue RA, et al. Multiple endocrine neoplasia 2A due to a unique C609S
RET mutation presents with pheochromocytoma and reduced penetrance of medullary thyroid
carcinoma. Clin Endocrinol (Oxf) 2005; 63:676.
19. Pigny P, Cardot-Bauters C, Do Cao C, et al. Should genetic testing be performed in each patient
with sporadic pheochromocytoma at presentation? Eur J Endocrinol 2009; 160:227.
20. Pomares FJ, Cañas R, Rodriguez JM, et al. Differences between sporadic and multiple
endocrine neoplasia type 2A phaeochromocytoma. Clin Endocrinol (Oxf) 1998; 48:195.
https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-multiple-endocrine-neoplasia-type-2/print?search=MEN2&source=searc… 18/37
5/29/2019 Clinical manifestations and diagnosis of multiple endocrine neoplasia type 2 - UpToDate
21. Toledo RA, Wagner SM, Coutinho FL, et al. High penetrance of pheochromocytoma associated
with the novel C634Y/Y791F double germline mutation in the RET protooncogene. J Clin
Endocrinol Metab 2010; 95:1318.
22. Neumann HP, Berger DP, Sigmund G, et al. Pheochromocytomas, multiple endocrine neoplasia
type 2, and von Hippel-Lindau disease. N Engl J Med 1993; 329:1531.
23. Webb TA, Sheps SG, Carney JA. Differences between sporadic pheochromocytoma and
pheochromocytoma in multiple endocrime neoplasia, type 2. Am J Surg Pathol 1980; 4:121.
24. Evans DB, Lee JE, Merrell RC, Hickey RC. Adrenal medullary disease in multiple endocrine
neoplasia type 2. Appropriate management. Endocrinol Metab Clin North Am 1994; 23:167.
25. Lips CJ, Minder WH, Leo JR, et al. Evidence of multicentric origin of the multiple endocrine
neoplasia syndrome type 2a (Sipple's syndrome) in a large family in the Netherlands. Diagnostic
and therapeutic implications. Am J Med 1978; 64:569.
26. American Thyroid Association Guidelines Task Force, Kloos RT, Eng C, et al. Medullary thyroid
cancer: management guidelines of the American Thyroid Association. Thyroid 2009; 19:565.
28. O'Riordain DS, O'Brien T, Grant CS, et al. Surgical management of primary
hyperparathyroidism in multiple endocrine neoplasia types 1 and 2. Surgery 1993; 114:1031.
29. Raue F, Kraimps JL, Dralle H, et al. Primary hyperparathyroidism in multiple endocrine
neoplasia type 2A. J Intern Med 1995; 238:369.
30. Gagel RF, Tashjian AH Jr, Cummings T, et al. The clinical outcome of prospective screening for
multiple endocrine neoplasia type 2a. An 18-year experience. N Engl J Med 1988; 318:478.
31. Snow KJ, Boyd AE 3rd. Management of individual tumor syndromes. Medullary thyroid
carcinoma and hyperparathyroidism. Endocrinol Metab Clin North Am 1994; 23:157.
32. Pausova Z, Soliman E, Amizuka N, et al. Role of the RET proto-oncogene in sporadic
hyperparathyroidism and in hyperparathyroidism of multiple endocrine neoplasia type 2. J Clin
Endocrinol Metab 1996; 81:2711.
https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-multiple-endocrine-neoplasia-type-2/print?search=MEN2&source=searc… 19/37
5/29/2019 Clinical manifestations and diagnosis of multiple endocrine neoplasia type 2 - UpToDate
33. Eng C, Clayton D, Schuffenecker I, et al. The relationship between specific RET proto-
oncogene mutations and disease phenotype in multiple endocrine neoplasia type 2.
International RET mutation consortium analysis. JAMA 1996; 276:1575.
34. Vierhapper H, Rondot S, Schulze E, et al. Primary hyperparathyroidism as the leading symptom
in a patient with a Y791F RET mutation. Thyroid 2005; 15:1303.
35. Heath H 3rd, Sizemore GW, Carney JA. Preoperative diagnosis of occult parathyroid
hyperplasia by calcium infusion in patients with multiple endocrine neoplasia, type 2a. J Clin
Endocrinol Metab 1976; 43:428.
36. Gagel RF, Levy ML, Donovan DT, et al. Multiple endocrine neoplasia type 2a associated with
cutaneous lichen amyloidosis. Ann Intern Med 1989; 111:802.
37. Kousseff BG, Espinoza C, Zamore GA. Sipple syndrome with lichen amyloidosis as a
paracrinopathy: pleiotropy, heterogeneity, or a contiguous gene? J Am Acad Dermatol 1991;
25:651.
38. Wong CK, Lin CS. Friction amyloidosis. Int J Dermatol 1988; 27:302.
39. Robinson MF, Furst EJ, Nunziata V, et al. Evidence for a neurologic defect in the men
2A/cutaneous lichen amyloidosis syndrome. Bone 1992; 17:91.
40. Verga U, Fugazzola L, Cambiaghi S, et al. Frequent association between MEN 2A and
cutaneous lichen amyloidosis. Clin Endocrinol (Oxf) 2003; 59:156.
41. Schuchardt A, D'Agati V, Larsson-Blomberg L, et al. Defects in the kidney and enteric nervous
system of mice lacking the tyrosine kinase receptor Ret. Nature 1994; 367:380.
42. Pachnis V, Mankoo B, Costantini F. Expression of the c-ret proto-oncogene during mouse
embryogenesis. Development 1993; 119:1005.
43. Avantaggiato V, Dathan NA, Grieco M, et al. Developmental expression of the RET
protooncogene. Cell Growth Differ 1994; 5:305.
44. Ceccherini I, Romei C, Barone V, et al. Identification of the Cys634-->Tyr mutation of the RET
proto-oncogene in a pedigree with multiple endocrine neoplasia type 2A and localized
cutaneous lichen amyloidosis. J Endocrinol Invest 1994; 17:201.
45. Hofstra RMW, Stelwagen T, Stulp RP. RET mutations in MEN 2 associated diseases. Am J Hum
Genet 1994; 55:A60.
https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-multiple-endocrine-neoplasia-type-2/print?search=MEN2&source=searc… 20/37
5/29/2019 Clinical manifestations and diagnosis of multiple endocrine neoplasia type 2 - UpToDate
46. Rothberg AE, Raymond VM, Gruber SB, Sisson J. Familial medullary thyroid carcinoma
associated with cutaneous lichen amyloidosis. Thyroid 2009; 19:651.
47. Bütter A, Gagné J, Al-Jazaeri A, et al. Prophylactic thyroidectomy in pediatric carriers of multiple
endocrine neoplasia type 2A or familial medullary thyroid carcinoma: mutation in C620 is
associated with Hirschsprung's disease. J Pediatr Surg 2007; 42:203.
48. Fialkowski EA, DeBenedetti MK, Moley JF, Bachrach B. RET proto-oncogene testing in infants
presenting with Hirschsprung disease identifies 2 new multiple endocrine neoplasia 2A
kindreds. J Pediatr Surg 2008; 43:188.
49. Moore SW, Zaahl M. Familial associations in medullary thyroid carcinoma with Hirschsprung
disease: the role of the RET-C620 "Janus" genetic variation. J Pediatr Surg 2010; 45:393.
50. Wells SA Jr, Dilley WG, Farndon JA, et al. Early diagnosis and treatment of medullary thyroid
carcinoma. Arch Intern Med 1985; 145:1248.
51. O'Riordain DS, O'Brien T, Crotty TB, et al. Multiple endocrine neoplasia type 2B: more than an
endocrine disorder. Surgery 1995; 118:936.
52. Brandi ML, Gagel RF, Angeli A, et al. Guidelines for diagnosis and therapy of MEN type 1 and
type 2. J Clin Endocrinol Metab 2001; 86:5658.
53. Lips CJ, Höppener JW, Thijssen JH. Medullary thyroid carcinoma: role of genetic testing and
calcitonin measurement. Ann Clin Biochem 2001; 38:168.
54. Lips CJ, Landsvater RM, Höppener JW, et al. Clinical screening as compared with DNA
analysis in families with multiple endocrine neoplasia type 2A. N Engl J Med 1994; 331:828.
55. Hernández G, Simó R, Oriola J, Mesa J. False-positive results of basal and pentagastrin-
stimulated calcitonin in non-gene carriers of multiple endocrine neoplasia type 2A. Thyroid
1997; 7:51.
56. Cupisti K, Wolf A, Raffel A, et al. Long-term clinical and biochemical follow-up in medullary
thyroid carcinoma: a single institution's experience over 20 years. Ann Surg 2007; 246:815.
57. Modigliani E, Cohen R, Campos JM, et al. Prognostic factors for survival and for biochemical
cure in medullary thyroid carcinoma: results in 899 patients. The GETC Study Group. Groupe
d'étude des tumeurs à calcitonine. Clin Endocrinol (Oxf) 1998; 48:265.
58. Sosa JA, Tuggle CT, Wang TS, et al. Clinical and economic outcomes of thyroid and parathyroid
surgery in children. J Clin Endocrinol Metab 2008; 93:3058.
https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-multiple-endocrine-neoplasia-type-2/print?search=MEN2&source=searc… 21/37
5/29/2019 Clinical manifestations and diagnosis of multiple endocrine neoplasia type 2 - UpToDate
59. Kebebew E, Greenspan FS, Clark OH, et al. Extent of disease and practice patterns for
medullary thyroid cancer. J Am Coll Surg 2005; 200:890.
60. Roman S, Lin R, Sosa JA. Prognosis of medullary thyroid carcinoma: demographic, clinical, and
pathologic predictors of survival in 1252 cases. Cancer 2006; 107:2134.
61. Lips CJ, Höppener JW, Van Nesselrooij BP, Van der Luijt RB. Counselling in multiple endocrine
neoplasia syndromes: from individual experience to general guidelines. J Intern Med 2005;
257:69.
62. Bae SJ, Kim DJ, Kim JY, et al. A rare extracellular D631Y germline mutation of the RET proto-
oncogene in two Korean families with multiple endocrine neoplasia 2A. Thyroid 2006; 16:609.
63. Dourisboure RJ, Belli S, Domenichini E, et al. Penetrance and clinical manifestations of non-
hotspot germline RET mutation, C630R, in a family with medullary thyroid carcinoma. Thyroid
2005; 15:668.
64. Learoyd DL, Gosnell J, Elston MS, et al. Experience of prophylactic thyroidectomy in multiple
endocrine neoplasia type 2A kindreds with RET codon 804 mutations. Clin Endocrinol (Oxf)
2005; 63:636.
65. Quayle FJ, Fialkowski EA, Benveniste R, Moley JF. Pheochromocytoma penetrance varies by
RET mutation in MEN 2A. Surgery 2007; 142:800.
66. Peppa M, Boutati E, Kamakari S, et al. Multiple endocrine neoplasia type 2A in two families with
the familial medullary thyroid carcinoma associated G533C mutation of the RET proto-
oncogene. Eur J Endocrinol 2008; 159:767.
67. Bethanis S, Koutsodontis G, Palouka T, et al. A newly detected mutation of the RET
protooncogene in exon 8 as a cause of multiple endocrine neoplasia type 2A. Hormones
(Athens) 2007; 6:152.
68. Mian C, Barollo S, Zambonin L, et al. Characterization of the largest kindred with MEN2A due to
a Cys609Ser RET mutation. Fam Cancer 2009; 8:379.
70. Jackson MB, Guttenberg M, Hedrick H, Moshang T Jr. Multiple endocrine neoplasia type 2A in a
kindred with C634Y mutation. Pediatrics 2005; 116:e468.
https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-multiple-endocrine-neoplasia-type-2/print?search=MEN2&source=searc… 22/37
5/29/2019 Clinical manifestations and diagnosis of multiple endocrine neoplasia type 2 - UpToDate
71. Kraimps JL, Denizot A, Carnaille B, et al. Primary hyperparathyroidism in multiple endocrine
neoplasia type IIa: retrospective French multicentric study. Groupe d'Etude des Tumeurs á
Calcitonine (GETC, French Calcitonin Tumors Study Group), French Association of Endocrine
Surgeons. World J Surg 1996; 20:808.
72. Kudo T, Miyauchi A, Ito Y, et al. Serum calcitonin levels with calcium loading tests before and
after total thyroidectomy in patients with thyroid diseases other than medullary thyroid
carcinoma. Endocr J 2011; 58:217.
73. Colombo C, Verga U, Mian C, et al. Comparison of calcium and pentagastrin tests for the
diagnosis and follow-up of medullary thyroid cancer. J Clin Endocrinol Metab 2012; 97:905.
74. Mian C, Perrino M, Colombo C, et al. Refining calcium test for the diagnosis of medullary thyroid
cancer: cutoffs, procedures, and safety. J Clin Endocrinol Metab 2014; 99:1656.
75. Herrmann BL, Schmid KW, Goerges R, et al. Calcitonin screening and pentagastrin testing:
predictive value for the diagnosis of medullary carcinoma in nodular thyroid disease. Eur J
Endocrinol 2010; 162:1141.
76. Doyle P, Düren C, Nerlich K, et al. Potency and tolerance of calcitonin stimulation with high-
dose calcium versus pentagastrin in normal adults. J Clin Endocrinol Metab 2009; 94:2970.
77. Daniels GH. Screening for medullary thyroid carcinoma with serum calcitonin measurements in
patients with thyroid nodules in the United States and Canada. Thyroid 2011; 21:1199.
78. Milone F, Ramundo V, Chiofalo MG, et al. Predictive value of pentagastrin test for preoperative
differential diagnosis between C-cell hyperplasia and medullary thyroid carcinoma in patients
with moderately elevated basal calcitonin levels. Clin Endocrinol (Oxf) 2010; 73:85.
79. Karges W, Dralle H, Raue F, et al. Calcitonin measurement to detect medullary thyroid
carcinoma in nodular goiter: German evidence-based consensus recommendation. Exp Clin
Endocrinol Diabetes 2004; 112:52.
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GRAPHICS
Type 2A
MEN2A classical (medullary thyroid cancer, pheochromocytoma, primary hyperparathyroidism)
Type 2B
Medullary thyroid cancer
Pheochromocytoma
Other
Mucosal neuromas
Intestinal ganglioneuromas
Marfanoid habitus
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Classification of MTC
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918 9 months
630 12 months
634 15 months
609 5 years
620 6 years
804 6 years
611 7 years
618 7 years
790 10 years
891 13 years
912 14 years
533 21 years
791 21 years
768 22 years
666 35 years
649 44 years
Data from: de Groot JW, Links TP, Plukker JT, et al. RET as a diagnostic and therapeutic target in sporadic and hereditary
endocrine tumors. Endocr Rev 2006; 27:535.
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Reproduced from: Expert Review of Endocrinology & Metabolism, September 2009, Vol. 4, No. 5,
Pages 443-465 with permission of Expert Reviews Ltd.
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C-cell hyperplasia and microcarcinomas in a 5-year-old boy with the Cys634Arg mutation.
The expanding C-cell masses disrupt the basal membrane surrounding individual thyroid
follicles (arrows).
Reproduced from: Expert Review of Endocrinology & Metabolism, September 2009, Vol. 4, No.
5, Pages 443-465 with permission of Expert Reviews Ltd.
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Multinodular pheochromocytoma: General view and cross section. A rim of cortical tissue
can be seen at the top.
Reproduced from: Expert Review of Endocrinology & Metabolism, September 2009, Vol. 4, No. 5,
Pages 443-465 with permission of Expert Reviews Ltd.
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The skin lesion is usually described as pruritic, scaly, papular, pigmented, and
located in the interscapular region or on the extensor surfaces of the extremities.
Amyloid deposition has been documented histologically.
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The skin lesion is usually described as pruritic, scaly, papular, pigmented, and
located in the interscapular region or on the extensor surfaces of the extremities.
Amyloid deposition has been documented histologically.
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All patients with sporadic MTC ? (may have consequences for target-directed treatment)
Refer to UpToDate topic on the clinical manifestations and diagnosis of multiple endocrine neoplasia type 2.
MEN2: multiple endocrine neoplasia type 2; FMTC: familial medullary thyroid cancer; MTC: medullary thyroid cancer.
Data from:
1. Brandi ML, Gagel RF, Angeli A, et al. Guidelines for diagnosis and therapy of MEN type 1 and type 2. J Clin Endocrinol
Metab 2001; 86:5658.
2. Machens A, Dralle H. Genotype-phenotype based surgical concept of hereditary medullary thyroid carcinoma. World J
Surg 2007; 31:957.
3. American Thyroid Association Guidelines Task Force, Kloos RT, Eng C, et al. Medullary thyroid cancer: Management
guidelines of the American Thyroid Association. Thyroid 2009; 19:565. Comment in Thyroid 2009; 19:1295.
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Pheochromocytoma* Hyperparathyroidism
Risk RET codon mutation Recommended age to begin Recommended age to begin
annual screening for annual screening for
pheochromocytoma ¶ hyperparathyroidism Δ
MEN2: multiple endocrine neoplasia type 2; MTC: medullary thyroid cancer; CT: computed tomography; MRI: magnetic
resonance imaging; PTH: parathyroid hormone.
* Patients with MEN2 and a diagnosis of MTC (regardless of age) must have pheochromocytoma excluded prior to
thyroidectomy.
¶ Screening test: free plasma metanephrines or normetanephrines, or 24-hour urinary metanephrines and normetanephrines.
If biochemical results positive, adrenal imaging with CT or MRI.
Δ Screening test: serum calcium and, if elevated, PTH.
Data from: Wells SA Jr, Asa SL, Dralle H, et al. Revised American Thyroid Association guidelines for the management of
medullary thyroid carcinoma. Thyroid 2015; 25:567.
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5/29/2019 Clinical manifestations and diagnosis of multiple endocrine neoplasia type 2 - UpToDate
Moderate 533, 609, 611, 618, 620, 630, 5 years Childhood or young adulthood
666, 768, 790, 804, 891, 912
Data from: Wells SA Jr, Asa SL, Dralle H, et al. Revised American Thyroid Association guidelines for the management of
medullary thyroid carcinoma. Thyroid 2015; 25:567.
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5/29/2019 Clinical manifestations and diagnosis of multiple endocrine neoplasia type 2 - UpToDate
Contributor Disclosures
Cornelis J Lips, MD, PhD Nothing to disclose Douglas W Ball, MD Nothing to disclose Marc K Drezner,
MD Nothing to disclose Jean E Mulder, MD Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must conform to
UpToDate standards of evidence.
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