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Multiple Endocrine Neoplasia Type 1


Presentation

  • We present a case of an 8-year-old boy referred because of hypoglycemic attacks. His diagnosis was pancreatic insulinoma. Paternal grandmother died due to repeated gastroduodenal ulcerations and a paternal aunt presented similar manifestations.[ncbi.nlm.nih.gov]
Fatigue
  • We ask about general symptoms (anxious mood, depressed mood, fatigue, pain, and stress) regardless of condition. Last updated: May 13, 2019[patientslikeme.com]
  • However, most people with endocrine disease complain of fatigue and weakness. Blood and urine tests to check your hormone levels can help your doctors determine if you have an endocrine disorder.[webmd.com]
  • A person may have hyperparathyroidism for many years with no symptoms or have symptoms such as kidney stones, bone thinning, nausea and vomiting, high blood pressure (hypertension), weakness, and fatigue.[endocrineweb.com]
  • These can cause skin rashes, weight loss and diabetes mellitus as well as fatigue, shortness of breath and lightheadedness as a consequence of anaemia.[yourhormones.info]
  • HPT can cause weakened bones, pain, fatigue, and kidney stones; when associated with MEN1, HPT is more difficult to cure because all the parathyroid glands are affected by multiple tumors.[genome.gov]
Broad Thumb
  • We report a 21-year-old patient with speech problems, autistic traits, dysmorphic facial features, broad thumbs with short distal phalanges and a pancreatic gastrinoma. Array-CGH demonstrated a 0.57 Mb de novo deletion in chromosome 11q13.1.[ncbi.nlm.nih.gov]
Noncompliance
  • We decided to leave a portion of the reimplanted parathyroid gland with possible metastatic thymic carcinoid in his forearm because of the presence a widespread metastatic disease and his intellectual disability that would result in noncompliance with[ncbi.nlm.nih.gov]
Intermittent Claudication
  • The patient presented with complaints of nocturnal pain in the lower back, accompanied by numbness around the anus and intermittent claudication for approximately 1 year.[ncbi.nlm.nih.gov]
Aspiration
  • Six months later, a thyroid nodule, suspected to be a malignant neoplasia, and two hyperfunctioning parathyroid glands were detected respectively by ultrasound with fine needle aspiration cytology and 99mTc-sestamibi scan with SPECT acquisition.[ncbi.nlm.nih.gov]
  • . : DIAGNOSIS OF ENDOCRINE DISEASE: High-yield thyroid fine-needle aspiration cytology: an update focused on ancillary techniques improving its accuracy. Eur J Endocrinol. 2016; 174 (2): R53–63.[f1000research.com]
  • These include ultrasonography and rapid (on-line) hormone assay in blood or in tissue aspirates. Role of Pedigree Linkage Analysis and DNA Maps in Localization of the MEN1 Gene Dr. Francis S.[annals.org]
Nausea
  • A 53-year-old woman presented with nausea and severe primary hyperparathyroidism. Computed tomography revealed parathyroid masses, shown later to be bilateral parathyroid carcinomas and adenomas.[ncbi.nlm.nih.gov]
  • Abdominal pain may be due to dyspepsia, peptic ulcer disease, constipation, or pancreatitis, all of which more commonly occur in the presence of hypercalcaemia, as does nausea and anorexia.[endobible.com]
  • A person may have hyperparathyroidism for many years with no symptoms or have symptoms such as kidney stones, bone thinning, nausea and vomiting, high blood pressure (hypertension), weakness, and fatigue.[endocrineweb.com]
  • Symptoms due to excessive parathyroid hormone production include: Tiredness, weakness Muscle or bone pain Nausea and vomiting Indigestion, constipation Recurrent fractures due to thinning of bone Kidney stone formation leading to back pain, blood in urine[dovemed.com]
Abdominal Pain
  • Abdominal pain may be due to dyspepsia, peptic ulcer disease, constipation, or pancreatitis, all of which more commonly occur in the presence of hypercalcaemia.[endobible.com]
  • Zollinger-Ellison syndrome may include severe gastric ulcers, abdominal pain, loss of appetite, chronic diarrhea, malnutrition, and subsequent weight loss. Other non-beta islet cell tumors associated with MEN1 are discussed below.[en.wikipedia.org]
  • When I was just starting my oncology fellowship, I developed abdominal pain that felt like appendicitis, but it was actually caused by a high calcium level (hypercalcemia).[mygenecounsel.com]
  • High levels of gastrin, ulcers, inflammation of the esophagus, diarrhea and abdominal pain Headaches and changes in vision Problems with sexual function and fertility Acromegaly (enlargement of the bones) Cushing’s syndrome Excess production of breast[mdanderson.org]
Epigastric Pain
  • A 51-year-old man visited the emergency department with recurrent epigastric pain.[ncbi.nlm.nih.gov]
  • . • ZES – esophagitis, vomiting, epigastric pain, diarrhea, duodenal ulcers, jejunal ulcers • 40% manifest before age of 40. • Frequently multiple and malignant. • Pancreatic has worse prognosis due to liver metastasis. • Other poor prognostic factors[slideshare.net]
Recurrent Epigastric Pain
  • A 51-year-old man visited the emergency department with recurrent epigastric pain.[ncbi.nlm.nih.gov]
Hepatic Mass
  • Somatostatin-receptor scintigraphy with [(111)In] DTPA octreotide demonstrated a strong uptake of the radiotracer in the left lateral segment at the site of the hepatic mass.[ncbi.nlm.nih.gov]
Osteoporosis
  • At age 75, Dual Energy X-ray Absoptiometry (DEXA) revealed osteoporosis and sestamibi scan showed a left parathyroid adenoma. Criteria for parathyroidectomy were met, and she underwent parathyroidectomy.[ncbi.nlm.nih.gov]
  • These symptoms can progress into further complications, such as muscle weakness, osteoporosis, kidney stones, mental and behavioural changes.[medic8.com]
  • If left untreated,the long term effects of hypercalcaemia can include osteoporosis and renal stones. 2. Pancreatic neuroendocrine tumours May occur in up to 75% of MEN1 patients.[genomicseducation.hee.nhs.uk]
Polyuria
  • Common symptoms associated with hypercalcemia include polydipsia, polyuria, constipation, and generalized malaise.[emedicine.com]
  • The need for frequent urination (polyuria). Blocked bowels or constipation. Fatigue. These symptoms can progress into further complications, such as muscle weakness, osteoporosis, kidney stones, mental and behavioural changes.[medic8.com]
  • The commonest manifestation of this is increased thirst, followed by polyuria and nocturia. Increased urinary calcium loss also predisposes to renal stone formation and hence renal colic.[endobible.com]
Primary Amenorrhea
  • Remarkably, she also reported primary amenorrhea and was found to have an invasive pituitary lactotroph adenoma, which was treated with cabergoline and external beam radiotherapy.[ncbi.nlm.nih.gov]
Headache
  • A 35-year-old woman who had undergone bilateral inferior parathyroidectomy for primary hyperparathyroidism was referred to our hospital to evaluate the cause of irregular menses, galactorrhea, and paroxysmal headache.[ncbi.nlm.nih.gov]
  • Has the patient developed a new headache or neuralgia? Assess for red flag symptoms: headaches present on waking and worse on coughing or leaning forward are more suggestive of increased intracranial pressure.[endobible.com]
  • Local tumor expansion may cause visual disturbance, headache, and hypopituitarism. Pituitary tumors in MEN 1 patients appear to be larger and behave more aggressively than sporadic pituitary tumors.[en.wikipedia.org]
  • Mental confusion and headaches. Perspiration and palpitations. Treatments include surgery to eradicate the tumours and chemotherapy for cancerous tumours.[medic8.com]
Tonic-Clonic Seizure
  • She complained of dizziness, occasional palpitation, weakness, hunger, sweating, and generalized tonic-clonic seizure that lasted for 5 minutes early in the morning.[ncbi.nlm.nih.gov]

Workup

  • Diagnosis [ edit ] In a diagnostic workup individuals with a combination of endocrine neoplasias suggestive of the MEN1 syndrome are recommended to have a mutational analysis of the MEN1 gene if additional diagnostic criteria are sufficiently met, mainly[en.wikipedia.org]
  • Nephrolithiasis was suspected and further workup was performed.[ispub.com]
Nephrolithiasis
  • On follow-up, hypercalcemia with high parathyroid hormone (PTH) levels was detected, associated with nephrolithiasis and low bone mineral density in the spine and hip.[ncbi.nlm.nih.gov]
  • Clinical manifestations can include hypercalcemia, nephrolithiasis, and bone abnormalities (osteitis fibrosa cystica). Common symptoms associated with hypercalcemia include polydipsia, polyuria, constipation, and generalized malaise.[emedicine.com]
  • Asymptomatic hypercalcemia is the most common manifestation: about 25% of patients have evidence of nephrolithiasis or nephrocalcinosis.[en.wikipedia.org]
  • Tumours may hypersecrete hormone, causing hypercalcaemia and recurrent nephrolithiasis (hyperparathyroidism), Zollinger-Ellison syndrome (hypergastrinaemia), hypoglycaemia (hyperinsulinaemia), amenorrhoea (hyperprolactinaemia) or acromegaly (excess growth[patient.info]
Mediastinal Mass
  • She was treated with total parathyroidectomy followed by resection of the mediastinal mass with resolution of the hypercalemia.[ncbi.nlm.nih.gov]
Anterior Mediastinal Mass
  • Radiologic examination showed an anterior mediastinal mass and a parathyroid tumor. Blood analysis revealed high levels of parathyroid hormone and adrenocorticotropic hormone. Urine cortisol and 17-hydroxycorticoids levels were also elevated.[ncbi.nlm.nih.gov]
Gastrin Increased
  • : increased risk of stomach ulcers Glucagon: increased risk of diabetes mellitus Parathyroid hormone: increased risk of hypercalcemia and kidney stones Vasoactive intestinal peptide: severe diarrhea Cause Multiple endocrine neoplasia type 1 (MEN1) is[news-medical.net]
  • Gastrinomas • Elevated serum fasting gastrin. • Increased basal gastric acid secretion. • Secretin stimulated gastrin test. 25.[slideshare.net]
Hepatocellular Carcinoma
  • Recent studies indicate a general role of menin in carcinogenesis, affecting the prevalence and clinical course of common non-endocrine tumors such as breast cancer, hepatocellular carcinoma and melanoma.[ncbi.nlm.nih.gov]

Treatment

  • The prognosis might improve by preclinical tumor diagnosis and appropriated treatment.[ncbi.nlm.nih.gov]

Prognosis

  • Although prognosis is stage dependent for patients with thymoma, patients with thymic carcinoids and MEN 1 have been reported to have an extremely poor prognosis, with many patients dying of complications from thymic carcinoid rather than dying of other[ncbi.nlm.nih.gov]

Etiology

  • In addition, no etiological relationship between seminoma and MEN1 has yet been reported.[ncbi.nlm.nih.gov]
  • Authors previously reported that MEN1 mutations in such patients were etiologic factors for MEN1, but the present study is the first to demonstrate that these mutations are related to PC.[atlasofscience.org]
  • However, more research is required to investigate the etiology of the condition. MEN1 is inherited in an autosomal dominant inheritance pattern.[news-medical.net]
  • (Etiology) Multiple Endocrine Neoplasia Type 1 disorders are genetically inherited It is inherited in an autosomal dominant pattern, which means any parent with the abnormal gene can pass it on to their children - a single copy of the gene is sufficient[dovemed.com]

Epidemiology

  • Netherlands. 3 Department of Endocrine Oncology, University Medical Center Utrecht, Utrecht, The Netherlands. 4 Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands. 5 Departments of Endocrinology and Metabolism and Clinical Epidemiology[ncbi.nlm.nih.gov]
  • Cutaneous tumours are common in MEN1 and include multiple angiofibromas (previously considered pathognomonic for tuberous sclerosis), collagenomas, and lipomas. [ 4 ] Epidemiology The prevalence throughout the world is estimated to be 1 in 20,000 to 1[patient.info]
  • Epidemiology • Incidence 1 in 30,000. • M:F 1:1 • No racial or ethnic predilection. • Diagnosis before 10 years of age is rare. 6.[slideshare.net]
  • Familial carcinoid tumors and subsequent cancers: a nationwide epidemiologic study from Sweden. Int J Cancer, 94 (2001), pp. 444-448 [8] AM Oliveira, HD Tazelaar, KA Wentzlaff, NS Kosugi, N Hai, A Benson, et al. Familial pulmonary carcinoid tumors.[archbronconeumol.org]
  • Second-hit mutations in MEN1 have been documented in angiofibromas, collagenomas, and lipomas in patients with MEN1. [12, 13, 14] Epidemiology Frequency Worldwide, the frequency of MEN1 is estimated to be 1 case in 30,000 persons. [15] Race- and sex-related[emedicine.medscape.com]
Sex distribution
Age distribution

Pathophysiology

  • To gain insights into MEN1 pathophysiology, menin-interacting partners and pathways have been identified to investigate its tumor suppressor and other functions.[ncbi.nlm.nih.gov]
  • […] cohort of patients with Zollinger-Ellison syndrome due to gastrinomas, for example, the dermatological criterion of more than 3 angiofibromas or 1 or more collagenomas was sensitive (75%) and specific (95%) for the diagnosis of MEN1. [5] Background Pathophysiology[emedicine.medscape.com]

Prevention

  • Resection of the most severely affected part of the pancreas, whether left or right, associated with enucleation of concomitant macroadenomas in the preserved pancreas is recommended for the treatment of hypoglycemic/hyperinsulinemic syndrome and to prevent[ncbi.nlm.nih.gov]
  • Sometimes all four glands are completely removed to prevent recurrence or may be unintentionally removed during parathyroid surgery.[niddk.nih.gov]
  • Treatment may require regular monitoring and considerable expense, but the disease usually does not prevent an active, productive adulthood.[clevelandclinic.org]

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