Tumori, 95: 484-487, 2009
Persistent hypercalcitoninemia in patients with medullary thyroid cancer Claudia Misso1, Filippo Calzolari1, Efisio Puxeddu2, Roberta Lucchini1, Massimo Monacelli1, Camillo Giammartino2, Alessandro Sanguinetti1, Michele d’Ajello1, Mark Ragusa1, and Nicola Avenia1 1
Endocrine Surgical Unit, and 2Internal Medicine Department, University of Perugia, Perugia, Italy
ABSTRACT
Medullary thyroid carcinoma is a highly malignant and progressive disease. Surgery is the only effective treatment. Calcitonin is a significant marker for medullary thyroid carcinoma, and due to its sensitivity it represents a useful tool for the follow-up. The outcome of patients affected by medullary thyroid carcinoma depends on tumor size, lymph node involvement, and adequacy of primary surgical management. In the present study, the authors reviewed their own experience in the cure of medullary thyroid carcinoma. Forty-one patients operated for sporadic medullary thyroid carcinoma were included. Indications for surgery, inclusive of lymphectomy techniques, timing of redo surgery, and the meaning of calcitonin levels in highlighting disease are extensively discussed. Patients with elevated calcitonin levels and favorable outcome are considered, together with the various diagnostic tools to be employed during patient workup.
Introduction Calcitonin is a specific marker for medullary thyroid cancer (MTC), and because of its sensitivity, it plays a role in the postoperative follow-up. Surgery is the only effective treatment, usually achieved at primary surgery. After surgical treatment, patients can be considered disease-free when biological normalization of stimulated calcitonin is obtained. Persistent or recurrent elevation of calcitonin levels following primary surgery is suggestive of residual or recurrent MTC and represents a frequent observation in case of inadequate surgery of MTC1-5. The outcome of patients with MTC depends on tumor size, lymph node metastases, and adequacy of surgical treatment. Patients with locally invasive primary tumors rarely have postoperative normalization of stimulated calcitonin levels. In contrast, the normalization of calcitonin levels is frequently observed in lymph nodenegative patients6,7. Several authors have reported an excellent outcome for patients despite continuously elevated calcitonin without clinical or radiological evidence of residual tumor after primary surgery8,9. Although the prognosis of patients with persistent hypercalcitoninemia may be acceptable, the biochemical cure rate can be improved by using new microdissection techniques10. The management of patients with persistently elevated plasmatic calcitonin who previously had initial surgical treatment often includes a surgical re-exploration of the cervical region after ruling out the presence of distant metastases3. Some authors have suggested a conservative approach limited to the surgical excision of demonstrable recurrent disease8, whereas others have recommended a more radical approach with extensive removal of nodal and soft tissue that may or may not be macroscopically evident9-11. The aim of the present study was to evaluate the outcome of patients with a diagnosis of sporadic MTC who underwent surgical treatment in our Institution and had persistent plasmatic calcitonin levels.
Key words: calcitonin, medullary thyroid carcinoma, surgical strategy. Correspondence to: Claudia Misso, Viale degli Oleandri 9, 80131 Napoli, Italy. Tel +39-0744-205334; fax +39-0744-205334; e-mail
[email protected] Received August 13, 2007; accepted January 13, 2009.
HYPERCALCITONINEMIA IN PATIENTS WITH MEDULLARY THYROID CANCER
Methods Forty-one patients who underwent thyroid surgery for sporadic MTC at our Institution from 1995 to 2004 were evaluated. Diagnosis of MTC was based on histological review of the thyroid sections by a pathologist experienced in MTC. At the time of diagnosis, the most frequent symptoms were: solitary nodule (n = 7), a positive lymph node (n = 4), and voice changes (n = 2). The rest of the patients were asymptomatic or were involved in follow-up programs. Fine-needle aspiration cytology was performed in 16 patients and was compatible with medullary carcinoma in 13 patients. Twenty-four of the 41 cases (58%) had normal basal and pentagastrin-stimulated calcitonin levels (
