13TH
INTERNATIONAL WORKSHOP ON MULTIPLE ENDOCRINE NEOPLASIA

IWMEN
2012
Final Program & Abstract Book
Liège 5-8 September, 2012

IWMEN 2012
Liège,
Belgium
13th International Workshop on
Multiple Endocrine Neoplasia
5-8, September, 2012
Palais de Congrès
Liège, Belgium

Welcome Message from the Chairman
Dear Friends and Colleagues,
It gives me the greatest pleasure to welcome you all as participants, speakers and guests to the 13th
International Workshop on Multiple Endocrine Neoplasia (IWMEN). In particular I am delighted to welcome
you to Liège, where I trust you will enjoy your stay in our inviting city.
The IWMEN is held every two years and is an ideal opportunity to update ourselves about the newest
findings in multiple endocrine neoplasia research. This year I am very pleased that we are oﬀering an
unbeatable program of Symposia and Plenary Lectures, which together cover the full spectrum of pathology,
disease and treatment. This is truly an international meeting with 29 countries represented. As such, theWorkshop is an unparalleled opportunity to meet and discuss topics of common interest with world leading
figures. I would also like to point out the range of new results being presented in Oral and Poster form
during the Workshop and we have selected 4 topics of specific interest for more complete presentation
during the Hot Topics session on Friday 7th September.
The Local Organizing Committee gratefully acknowledges the generous contribution made by the Sponsors to support us in hosting such acomplete scientific and clinical Program.
On behalf of the Local and Regional Organizing Committees and the Board of the IWMEN, I wish you a productive, insightful and rewarding
stay in Liège!

Prof. Albert Beckers
Chairman, Local Organizing Committee IWMEN 2012, Liège, Belgiumii

13th International
Workshop on Multiple
Endocrine Neoplasia
Liège, Belgium
5-8 September, 2012

© Local Organizing Committee, IWMEN 2012
Unauthorized copying, reproduction, repurposing and/or sale, rent or hire of this material
without express permission of Copyright Holder is forbidden. Abstracts contained in Chapter 4
remain the copyright of the respective authors. Images are covered by Creative Commonslicenses.
iii

IWMEN Committees
International Workshop

Regional Scientific Committee:

Local Organizing Committee:

Committee

W. W. de Herder (Netherlands)

A. Beckers – Chairman

A. Beckers (Belgium)

A. Gimenez-Roqueplo (France)

A.F. Daly – Secretary

J. Bertherat (France)

M. C. Zatelli (Italy)

P. Petrossians

M.L. Brandi (Italy)

A. Barlier (France)

L. Rostomyan

R.F. Gagel (U.S.A.)

S. Zacharieva (Bulgaria)

P. Delvenne

S.J. Marx (U.S.A.)

L. Aaltonen (Finland)

R. Hustinx

H. Dralle (Germany)

V. Rohmer (France)

E. Hamoir

B. Niederle (Austria)

E. Baudin (France)

E. Castermans

F. Raue (Germany)

N. Pellegata (Germany)

E. Cavalier

B.G. Robinson (Australia)

M. Polus

C.A. Stratakis (U.S.A.)

C. Gennigens

R.V. Thakker (U.K.)

A-S. Parent

B. Wiedenmann (Germany)4

Sponsors
The IWMEN Committees would like to thank the following for their generous
sponsorship of the Workshop:
Major Sponsors

Other sponsors

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References:
1) Ruszniewski et al., Neuroendrocrinology (2004) 80 244-251
2) Andersen, Exp. Rev. Endo. Met (2007) 2(4) 433-441
3) Caron P., Therapy (2007) 4(1) 9-29
4) Alexopoulou et al. Eur. J. of Endocrinology (2004) 151 317-324

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6

IWMEN 2012:
Practical
Information

Venue & Getting There
Palais des Congrès
The Liege convention centre has three levels, over twenty
variable halls, with the largest auditorium able to receive up to
one thousand people comfortably. Its two enormous floors oﬀer
a panoramic view of the river.
Recently renovated, the convention centre combines modern
comfort and specific hi-tech facilities.
Address

Getting there

Esplanade de l'Europe, 2
B-4020 Liège (Belgium)
Tel.: +32.4.340.38.88
Fax: +32.4.343.20.85
http://www.palaisdescongresliege.be

By train / TGV (High Speed Train)
Station "Liege Guillemins" (central station). More info on trains:www.b-rail.be (Belgium) or www.tgv-europe.be (Europe)
At Guillemins station, take the bus line TEC 17 or 38b directly to

For a Google Map of Useful Places and Sites for IWMEN 2012

Palais des Congrès (every 15 minutes). It will take about 7

Click Hereminutes, with direct access. More info on: www.infotec.be.

8By plane
Brussels International Airport (Zaventem): At the airport, you can

By car: see TRAFIROUTES for real time driving conditions

take the train to Brussels North station or to Louvain/Leuven (2Parking: There is free parking in front of the venue. However, thistrains per hour). From there, change to the train to Liège

might be full within a short time. In that case, you can park in the

Guillemins. Total duration of the journey: +/- 75 min. Price: 15€/

public parking "Mypark Médiacité" (13€ for 24 hours).

one way. More info and tickets on www.b-rail.be
At Guillemins station, take the bus line TEC 17 or 38b directly to
Palais des Congrès (every 15 minutes) or take a short taxi ride.

Car Service: Transport by car from Brussels and Local Airports

www.infotec.be.

to and from the Congress Centre/Hotels can be arranged. Please

Brussels South Charleroi Airport (Charleroi): At the airport, takecontact the Secretariat at registration@iwmen.org

the city bus Line A (stop is outside of the departure hall), whichcosts 3€ one way to Charleroi-Sud (south) train station, then the
train to Liège-Guillemins. Train departs once every hour from
5am. Last train leaves at 23:00. The trip takes approximately 1hour and 10 minutes.
At Guillemins station, take the bus line TEC 17 or 38b directly to
Palais des Congrès (every 15 minutes) or a short taxi ride.
www.infotec.be
Liège Airport (Bierset): By public transportation: Take the bus line
TEC 57 to Guillemins station. Duration: 20 minutes. Price: 1,60€.
IMPORTANT NOTE: there are about 6 connections per day.
Check the schedules on www.infotec.be. At Guillemins station,
take the bus line TEC 17 or 38b directly to Palais des Congrès(every 15 minutes) or a short taxi ride.
9

About Liège
A very lively culture with a positive-minded population, always
ready to celebrate, and a large number of restaurants all combine
to make this an essential part of any trip to Belgium.

As the most important tourist city in Wallonia, Liège has manyriches in store waiting to be discovered.

The surrounding area also oﬀers a vast array of options forwalking and tourist visits.

For full information on the city please click here

For a Google Map of Useful Places and Sites for IWMEN 2012
Click HereThe characteristic districts, the river Meuse, which transects fromSouth to North, the abrupt and wooded hills surrounding provide
a multitude of original perspectives.

10Registration and Hotels
Registration fees [EUR]
Category

Excl. VAT/IVA/TVA

HotelsIncl. VAT/IVA/TVA

For Hotel Bookings, these can be made up until August 31st,
2012 using the online Registration system at www.iwmen.org.

Participant

500.00605.00

Thereafter, attendees will need to make their own hotel
reservations directly with hotels in the city:

Fellow/Trainee

300.00363.00Registration can be completed online at www.iwmen.org up until
August 31st, 2012. Thereafter, registration can be completed onsite at the Congress Venue.

Liège Hotels
HUSA de la Couronne***Place des Guillemins, 114000 Liège+32.(0)4.340.30.00
rduran@husa.es
http://www.hoteldelacouronne.be
Best Western L'Univers***
Rue des Guillemins, 116
4000 Liège+32.(0)4.254.55.55+32.(0)4.254.55.00
univershotel@skynet.be
http://www.univershotel.be
11

Ibis Liège Centre Opéra***Place de la République Française, 41
4000 Liège
Tel. : +32.(0)4.230.33.33
Fax. : +32.(0)4.223.04.81
h0864@accor.com
http://www.ibishotel.com/fr/hotel-0864-ibis-liege-centre-opera/
index.shtml
Le Campanile***Rue J. de Laminne
4000 Liège
Tel. : +32.(0)4.224.02.72
Fax. : +32.(0)4.224.03.80
liege@campanile.com
http://www.campanile-liege.be
Le Cygne d'Argent***
Rue Beeckman, 49
4000 Liège
Tel. : +32.(0)4.223.70.01
Fax. : +32.(0)4.222.49.66
info@cygnedargent.be
http://www.hotelcygnedargent.be
La Passerelle***Chaussée des Prés, 24
4020 Liège

Tel. : +32.(0)4.341.20.20
Fax. : +32.(0)4.344.36.43
passerellehotel@skynet.beHors Château***
Rue des Drapiers, 2
4000 Liège
Tel. : +32.(0)4.250.60.68
Fax. : +32.(0)4.250.56.31
info@hors-chateau.be
http://www.hors-chateau.be
Le Petit Cygne**
Rue des Augustins, 42
4000 Liège
Tel. : +32.(0)4.222.47.59
Fax. : +32.(0)4.222.49.66
cygne@cybernet.be
Les Acteurs**
Rue des Urbanistes, 104000 Liège
Tel. : +32.(0)4.223.00.80
Fax. : +32.(0)4.221.19.48
lesacteurs@skynet.be
http://www.lesacteurs.be
Metropole**
Rue des Guillemins, 141
4000 Liège
12Tel. : +32.(0)4.252.42.93
Fax. : +32.(0)4.252.70.29
info@hotelmetropole.be
http://www.hotelmetropole.beEurotel**Rue Léon Frédéricq, 29
4020 Liège
Tel. : +32.(0)4.341.16.27
Fax. : +32.(0)4.343.07.48
eurotelliege@yahoo.fr
Les Nations*
Rue des Guillemins, 139
4000 Liège
Tel. : +32.(0)4.252.44.14
Fax. : +32.(0)4.252.44.15
info@hotellesnations.be
http://www.hotellesnations.be13Speaker Information and Posters
Oral presentations, Symposium andFor all Speakers, please bring your slides to the speakers booth

Plenary Lectures:

loaded into the Audiovisual system in advance.

at least the day before your presentation in order for them to be

All presentations should be prepared as a series of Powerpoint
slides. The format for the projection will be Windows-based PC.
To avoid problems, please check your slides and content (e.g.
images, video) for compatibility if converted from other programs
like Keynote or if using specialized formats.

Posters
Posters should be made available for viewing from 16.00 on
Wednesday 5th of September, and may be removed at the close

In order to be fair to all speakers we will have to be strict aboutof the evening session on Friday September 7th (19.40). Poster

timing and duration and the Chairs of each session have beenboards are numbered and materials will be provided to mount the

instructed to be firm about over-running of allotted time. Pleaseposter.

prepare your presentation with this in mind.

Please note that poster boards are in PORTRAIT style, withFor Oral presentations of accepted abstracts, the total time perdimensions for accommodating posters up to A0 (1189 mm highpresentation is 10 minutes, so introductions should ideally be

by 841 mm wide).

limited to a single or a couple of slides to allow you more time to
dedicate to the results and their implications. If you have any
relevant Disclosures of funding for your research, please makethem known at the beginning of your presentation. There will betime for a short question or two after each presentation.

We would encourage your presence with the posters for at least
30 minutes during the lunch breaks on the 6th and 7th of
September, in order to allow for questions and answers fromfellow attendees. You might also include a contact email or14

message on your poster should colleagues wish to follow up withquestions after the meeting is over.
Following the end of the meeting, posters that remain on theposter boards will be taken down and disposed of and we regretthat there is no possibility to keep or return posters that are
inadvertently left behind.

15

CME and AttendanceEurope (ACOE). The primary function of the ACOE is theaccreditation of European CME activities in oncology.
In relation to this function, ACOE reviews and evaluates CME
activities in the field of oncology, more specifically ACOE assess
the quality and the educational value of the scientific program of
the activity. The ACOE accreditation label provides delegateswith a guarantee of a high quality and unbiaised educational
The International Workshop on Multiple Endocrine Neoplasia is

activity.

accredited by the European Accreditation Council for Continuing
Medical Education (EACCME) to provide the following CME
activity for medical specialists. The EACCME is an institution ofPlease check at the Registration Desk for CME Assessment

the European Union of Medical Specialists (UEMS).

Forms and Information

EACCME credits are recognized by the American Medical
Association towards the Physician's Recognition Award (PRA). To
convert EACCME credit to AMA PRA category 1 credit, contact
the AMA.

Attendance Certificates can be obtained also at the Registration
Desk

The International Workshop on Multiple Endocrine Neoplasia isalso accredited by the Accreditation Council of Oncology in

16

Contact
Local Organisation

Registrations and Logistical Matters

Prof. Albert Beckers

Mr. Omer Ulger

Chairman, Local Organising Committee

Ms. Caroline Van Cauwenberghealbert.beckers@iwmen.org
Dr. Adrian Daly

MindStream International

Secretary, Local Organising Committee

Avenue Vésale 8cadrian.daly@iwmen.org

B-1300 Wavre - Belgium

University of Liège

Phone: +32.(0)10.22.40.83

Department of Endocrinology

Fax: +32.(0)10.24.70.48

CHU de Liègeo.ulger@mindstream.be

Domaine Universitaire du Sart-Tilman

Caroline Van Cauwenberghe

4000 Liège - Belgium

C.VanCauwenberghe@mindstream.be

Phone: +32.(0)4.366.70.83/84
Fax: +32.(0)4.366.72.61

registration@iwmen.org

http://www.mindstream.be17

IWMEN 2012:
Program
Day by Day

Section 1

Wednesday September 5th
Wednesday September 5th, 2012
SPECIAL FOCUS SESSION: AGGRESSIVE PITUITARY ADENOMAS & CARCINOMAS
Chairs: Philippe Chanson (Paris, France) & Albert Beckers (Liège, Belgium)
Time

Title

Presenter11.00-11.20

Pathological markers of aggression in pituitary adenomas: focus on MEN1

Jacqueline Trouillas (Lyon, France)

11.20-11.40

Are there imaging markers for pituitary tumor aggressiveness?

Jean-François Bonneville (Besançon, France)

11.40-12.00

AIP status as clinical indicator of aggressiveness in pituitary adenoma patients

Marie-Lise Jaffrain-Rea (L'Aquila, Italy)

12.00-12.20

Break

12.20-12.40

Aggression & Resistance in Somatotropinoma: Molecular Mechanisms

Marily Theodoropoulou (Münich, Germany)

12.40-13.00

Pituitary carcinoma: Current status of temozolomide

Gérald Raverot (Lyon, France)

13.00-13.35

The Liège Acromegaly Survey: First data in 3000 patients

Patrick Petrossians (Liège, Belgium)

13.35-14.15

Rational use of genetic testing in patients with pituitary adenomas and theirfamilies

Albert Beckers (Liège, Belgium)

19

Wednesday September 5th, 2012
OPENING CEREMONY
Time

15.35-15.45

Title

Presenter

Welcome to the 13th IWMEN, Liège 2012

Albert Beckers (Chairman, Local Organizing
Committee, Liège, Belgium)

F.I.R.M.O. FOUNDATION MEDAL PRESENTATION
Time

15.45-16.00

Title

Presenter

Presentation of the Parathyroid Medal to Raj Thakker, University of Oxford

Maria-Luisa Brandi (Florence)

SYMPOSIUM 1: PANCREATIC & GASTROINTESTINAL NEUROENDOCRINE TUMORS

Time

Title

Presenter16.00-16.25

S1.1: Optimum treatment regimens for advanced pancreatic neuroendocrine
tumors.

P. Ruszniewski (Hôpital Beaujon, Clichy,
France)16.25-16.50

S1.2: Pancreas-preserving pancreatectomy for neuroendocrine tumors.

H. Dralle (Univ. Halle-Wittenberg, Germany)

16.50-17.15

S1.3: Combination therapy for the management of advanced gastrointestinal
neuroendocrine tumors.

B. Wiedenmann (Charité Berlin, Germany)
20

Wednesday September 5th, 2012
PLENARY LECTURE 1
Time17.15-17.45

Title
The molecular and clinical genetics of familial and syndromic parathyroid
disorders.

Presenter
R. Thakker (Univ. Oxford, United Kingdom)

IPSEN SPONSORED SYMPOSIUM : DEFINING THE BEST CANDIDATES FOR SOMATOSTATIN ANALOGUE
TREATMENT IN NET IN 2012 AND BEYOND
Chair: Bertram Wiedenmann (Berlin, Germany)
Time

Title

Presenter

Chairman’s Welcome & Introduction

Bertram Wiedenmann (Berlin, Germany)

18.00-18.25

MEN1: a model for predicting the course of pNET

Gerlof Valk (Utrecht, The Netherlands)

18.25-18.50

Predictors of tumor response in NET patients treated with SSAs

Eric Baudin (Villejuif, France)

18.50-19.15

How will the management of NET with SSA evolve in the future?

Ivan Borbath (Leuven, Belgium)

WELCOME COCKTAIL & BUFFET 19.30
Musée d'Art moderne et d'Art contemporain (MAMAC), Liège
21

Section 2

Thursday September 6th
Thursday September 6th, 2012
SYMPOSIUM 2: MEN-1 & MENIN

Time

Title

Presenter9.00-9.25

S2.1: Update on the structure and interactions of menin

X. Hua (Univ. of Pennsylvania, USA)9.25-9.50

S2.2: Mortality in MEN-1: findings of the French registry

P. Goudet (CHU Dijon, France)

9.50-10.15

S2.3: Optimal management of parathyroid disease in MEN-1

B. Niederle (Univ. of Vienna, Austria)

Break10.15-10.30

PLENARY LECTURE 2
Time10.30-11.00

Title

Presenter

Newer pheochromocytoma and paraganglioma susceptibility genes.

M. Robledo (National Cancer Center and
CIBERER, Madrid, Spain)
22

Thursday September 6th, 2012
SYMPOSIUM 3: MULTIPLE KINASE INHIBITORS IN ENDOCRINE NEOPLASIAS

Time

Title

Presenter11.15-11.40

S3.1: Clinical experience with vandetanib for the treatment of advanced ormetastatic hereditary medullary thyroid cancer.

E. Baudin (Institut Gustave Roussy, Villejuif,
France)11.40-12.05

S3.2: Profile of cabozantinib (XL 184), an oral tyrosine kinase inhibitor in medullary R.F. Gagel (Univ. of Texas, MD Anderson
thyroid cancer and other endocrine tumors.
Cancer Center, Houston, U.S.A.)

12.05-12.30

S3.3: Integrating multiple kinase inhibitors into the clinical management ofhereditary and multiple endocrine neoplasias.

B.G. Robinson (Univ. of Syndey, Australia)

Lunch (Posters are available for viewing at this time)
12.30-14.00

PLENARY LECTURE 3
Time14.00-14.30

Title

Presenter

Improving the management of gastroenteropancreatic neuroendocrine tumors:
optimizing surgical and medical cooperation.

W.W. de Herder (Erasmus Medical Center,
Rotterdam, Netherlands)

Thursday September 6th, 2012
SYMPOSIUM 4: ADRENAL NEOPLASIA

Time

Title

Presenter

14.30-14.55

S4.1: Pathophysiology of macronodular adrenal hyperplasia

A. Lacroix (Univ. of Montreal, Canada)

14.55-15.20

S4.2: Genetics of bilateral tumors of the adrenal cortex.

J. Bertherat (Institut Cochin/Univ. of Paris,
France)15.20-15.45

S4.3: KCNJ5: from sporadic to familial hyperaldosteronism

M.C. Zennaro (Univ. of Paris/AP-HP/INSERM,
Paris, France)

Break15.45-16.00

PLENARY LECTURE 4
Time16.00-16.30

Title

Presenter

MEN4, MEN5?, MEN6?: Cyclin dependent kinase inhibitors in multiple endocrine
S. Marx (NIH, Bethesda, U.S.A.)
neoplasias.

24Thursday September 6th, 2012
SYMPOSIUM 5: PARAGANGLIOMA & PHEOCHROMOCYTOMA

Time

Title

Presenter

16.30-16.55

S5.1: Molecular classification of paraganglioma and pheochromocytoma by
integrative genomic approaches.

A.P. Gimenez-Roqueplo (Hôpital Europeen
Georges Pompidou/INSERM/ Univ. of Paris,
France)16.55-17.20

S5.2: The Paraganglioma Valley: Epidemiology of paragangliomas.

G. Opocher (Univ. of Padova, Italy)

17.20-17.45

S5.3: SDH immunohistochemistry in the diagnosis of hereditary or multiple
endocrine neoplasias.

Francine van Nederveen (Erasmus Medical
Center, Rotterdam, Netherlands)

ORAL SESSION 1 (18.00-19.20)
Time (10 min.
per
Title
presentation)

Presenter

OP1.1: Creation of a locus-specific database for mutations in the AIP gene

Giampaolo Trevellin (Bart’s, London, U.K.)

OP1.2: The clinical and genetic characteristics of patients with gigantism

Liliya Rostomyan (Univ. Liège, Belgium)

OP1.3: Should we screen MEN1 gene in addition to AIP, in young patient withisolated sporadic pituitary macroadenoma?

Anne Barlier (Hôpital de la Conception,
Marseilles, France)

OP1.4: Performance of immunohistochemistry vs. conventional genetic screening
to detect SDHx mutations in patients with pheochromocytoma and paraganglioma
from Belgium

Selda Aydin (Cliniques Universitaires SaintLuc, Brussels, Belgium)

OP1.5: Co-existence of pituitary adenoma and phaeochromocytoma/paraganglioma (PHAEO/PGL) does it represent a new syndrome with aheterogeneous genetic pathogenesis?

Judit Denes (Military Hospital, Hungarian
Defence Forces, Budapest, Hungary)25

Thursday September 6th, 2012
ORAL SESSION 1 (Continued)
Time (10 min.
per
Title
presentation)

Presenter

OP1.6: Identification of chromosome 11 parental origin in a population withendemic PGL1 syndrome

Sara Bobisse (Istituto Oncologico Veneto,
Padova, Itoly)

OP1.7: A rare gain-of-function mutation in an inhibitory uORF in the CDKN1B genecauses MEN4 phenotype

Gianluca Occhi (Univ. Padova, Padova, Italy)

26

Section 3

Friday September 7th
Friday September 7th, 2012
SYMPOSIUM 6: MEN-2 & RET

Time

Title

Presenter9.00-9.25

S6.1: Molecular genetics of RET and prognosis in MEN-2.

F. Raue (Heidelberg, Germany)

9.25-9.50

S6.2: Natural history of pheochromocytomas in MEN-2A diagnosed by familial
genetic screening.

F. Castinetti (Univ. of Marseilles, France)

9.50-10.15

S6.3: Adrenal function-preserving adrenalectomy in MEN-2.

M. Brauckhoff (Univ of Bergen, Norway)

Break10.15-10.30

PLENARY LECTURE 5
Time10.30-11.00

Title

Presenter

What can mice tell us about men(in).

C.X. Zhang (Lyon Cancer Research Center,
Lyon, France)27

Friday September 7th, 2012
SYMPOSIUM 7: PARATHYROID DISEASE

Time

Title

Presenter11.15-11.40

S7.1: Diagnostic and therapeutic challenges in parathyroid carcinoma
management.

N. Hamdy (Univ. of Leiden, Netherlands)

11.40-12.05

S7.2: Management of chronic post-surgical hypoparathyroidism.

M.L. Brandi (Univ. of Florence, Italy)

12.05-12.30

S7.3: HRPT2 genotype-phenotype correlations in parathyroid disease.

L. Groussin (Institut Cochin/Univ. of Paris 5,
France)Lunch (Posters are available for viewing at this time)
12.30-13.30

PLENARY LECTURE 6
Time13.30-14.00

Title

Presenter

Genetically-determined disorders of cAMP signaling in endocrine neoplasia
syndromes.

C. A. Stratakis (NICHD, Bethesda, U.S.A.)Friday September 7th, 2012
SYMPOSIUM 8: IMAGING
Chairs:

Time

Title

Presenter14.00-14.25

S8.1: Nuclear imaging to aid peptide receptor radiotherapy of pancreatic
neuroendocrine tumors in MEN-1.

J. Teunissen (Erasmus Medical Center
Rotterdam, Netherlands)

14.25-14.50

S8.2: Endoscopic ultrasound of the Pancreas in MEN-1 patients.

D. O'Toole (Trinity College, Dublin, Ireland)

Break14.50-15.10

ORAL SESSION 2 (15.10-17.40)
Time (10 min.
per
Title
presentation)
OP2.1: Measurements of CALCA transcripts are useful for the evaluation of
asymptomatic RET-mutation carriers and in the follow-up of patients withmedullary thyroid cancer and may replace the pentagastrin test

Presenter

Cleber Camacho (UNIFESP, Sao Paolo, Brazil)

29

Friday September 7th, 2012
ORAL SESSION 2 Continued (15.10-17.40)
Time (10 min
per
Title
presentation)

Presenter

OP2.2: The role of tyrosine kinase inhibitors in a MEN2B patient with metastatic
medullary thyroid carcinoma

Monica Tomé (Univ. Liège, Belgium)

OP2.3: Profile of patients treated for Medullary Thyroid Carcinoma at São Paulo
Medical School

Marcos Tavares (Univ. São Paulo School of
Medicine, São Paulo, Brazil)

OP2.4: Pheochromocytoma in Multiple Endocrine Neoplasia Type 2 in Japan:
Analysis of a Multicenter Database

Tsuneo Imai (Nagoya University, Nagoya,Japan)

OP2.5: A study of the Spanish national register of Multiple Endocrine Neoplasia
type 2A

Nuria Valdes (Hospital Central de Asturias,
Oviedo, Spain)

BreakOP2.6: Could the long-acting somatostatin analogues modify the therapeuticstrategy in patients with early stage MEN1-related duodenopancreatic
neuroendocrine tumors (NET)s?

Antongiulio Faggiano ("Federico II" Universityof Naples, Naples, Italy)

OP2.7: Diagnostic accuracy of chromogranin A, pancreas polypeptide andglucagon in the screening for pancreatic neuroendocrine tumors in Multiple
Endocrine Neoplasia type 1 patients

Joanne Marieke de Laat (University Medical
Center Utrecht, Utrecht, Netherlands)

OP2.8: Analysis of penetrance and clinical impact resultant of the diagnosis ofmultiple endocrine neoplasia type 1-related tumors during childhood andadolescence.

Lourenco Junior Delmar Muniz (School of
Medicine, Univ. São Paulo, São Paulo, Brazil)

OP2.9: Changing manifestations of MEN1 (Burin): increase in occurrence of
PNETs

Jane Green (Memorial University, St. John’s,
Canada)OP2.10: Functional characterization of mutations in the Multiple Endocrine
Neoplasia type 1 (MEN1) gene suggest therapeutic strategies

Geoffrey Hendy (McGill University, Montreal,
Canada)30

Friday September 7th, 2012
ORAL SESSION 2 Continued (15.10-17.40)
Time (10 min
per
Title
presentation)

Presenter

OP2.11: Association of Type-O Blood with Neuroendocrine Tumors in Multiple
Endocrine Neoplasia Type 1

Allison Weisbrod (NCI, NIH, Bethesda,
U.S.A.)

OP2.12: Comparison between managements of MEN1 and MEN2

Stephen Marx (NIH, Bethesda, U.S.A.)

OP2.13: Oncoprotein MafB is switched on in early mouse Men1 b-cell neoplastic
lesions

Mr Rémy Bonnavion (Cancer ResearchCenter-Lyon Inserm U1052/CNRS 5286,
Lyon, France)

OP2.14: Quinazoline sensitive binding sites are promising new targets forchemotherapy of neuroendocrine tumors

Robert Fuchs (Medical University of Graz,
Graz, Austria)

Break17.40-18.00

HOT TOPICS (18.00-19.40)
Time (25 min
per
Title
presentation)

Presenter

HT1: Genome-wide characterization of menin-dependent H3K4me3 in mouseembryonic stem cells undifferentiated or differentiated in vitro into islet-like
endocrine cells

Sunita Agarwal (National Institutes of Health,Bethesda, U.S.A.)

HT2: The Cdk5-p25 holoenzyme causes neuroendocrine cancer in the thyroid

James Bibb (Univ. Texas Southwestern
Medical Center, Dallas, Texas, U.S.A.)
31

Friday September 7th, 2012
HOT TOPICS (Continued)
Time (20 min
per
Title
presentation)

Presenter

HT3: Survival and natural course of patients with thymic and bronchopulmonary
neuroendocrine tumor in Multiple Endocrine Neoplasia type 1

Joanne Marieke de Laat (University Medical
Center Utrecht, Utrecht, Netherlands)

HT4: Menin is required to maintain bone mass in older mice

Geoffrey Hendy (McGill University, Montreal,
Canada)CONGRESS DINNER 20.00
Palais de Princes Evêques, Liège

32

Section 4

Saturday September 8th
Saturday September 8th, 2012
ORAL SESSION 3 (9.10-9.30)

Time (10 min
per
Title
presentation)

Presenter

OP3.1: Radiofrequency ablation of pulmonary metastases in parathyroid
carcinoma: an alternative therapy for severe refractory hypercalcemia.

Lourenco Junior Delmar Muniz (School of
Medicine, Univ. São Paulo, São Paulo, Brazil)

OP3.2: Clinical features of primary hyperparathyroidism (PHPT) in patients withparathyroid carcinoma.

Natalia Mokrysheva (Endocrinology ResearchCentre, Moscow, Russia)

33

Saturday September 8th, 2012
SPECIAL FOCUS SESSION: PARATHYROID CARCINOMA RESEARCH
Chairs: Raj Thakker (Oxford, U.K.) and Albert Beckers (Liège, Belgium)
Time

Title

Presenter

9.30-9.50

Diagnosis of parathyroid carcinoma: potential role of PTH laboratory assays

Etienne Cavalier (Univ. of Liège, Liège,
Belgium)

9.50-10.10

Molecular genetics of parathyroid carcinoma

Raj Thakker (Univ. Oxford, U.K.)

10.10-10.25

Break

10.25-10.45

Diagnosis of parathyroid carcinoma: pathological and molecular genetic
challenges

Hans Morreau/Naveen Hamdy (Univ Leiden,
Netherlands)

10.45-11.05

Therapy of parathyroid carcinoma: update on anti-PTH immunotherapy

Daniela Betea (Univ. of Liège, Liège, Belgium)

11.05-11.30

Discussion on tools for improved research and collaboration: patient databases,
tumor biobanks, common goals and purposes

Roundtable discussion

CLOSING CEREMONY
Time

11.40-11.45

Title

Presenter

Closure of the 13th IWMEN, Liège 2012

Albert Beckers (Chairman, Local Organizing
Committee, Liège, Belgium)

34

IWMEN 2012:
Abstracts

Hot Topics
HT1

H3K4me3-ChIP-Seq and gene-expression microarray. In ESCs the gene mostaﬀected by menin loss was Meg3 (maternally expressed gene 3), which showed

Genome-wide characterization of menin-dependent H3K4me3 in mouse

16-fold reduction in H3K4me3 and 14-fold reduction in gene-expression. Inembryonic stem cells undiﬀerentiated or diﬀerentiated in vitro into islet-likemenin-null ESCs 3-9-fold reduced expression of several genes at the Dlk1-Meg3

endocrine cells

locus was also observed. MEG3 is an imprinted long-non-coding-RNA that

Sunita K. Agarwal1, and Raja Jothi2 1Metabolic Diseases Branch, National
Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda,
Maryland 20892, USA 2Biostatistics Branch, National Institute of Environmental
Health Sciences, NIH, Research Triangle Park, North Carolina 27709, USAfunctions as a tumor-suppressor by p53-dependent and p53-independent
pathways. Interestingly, sporadic pituitary tumors show somatic silencing of
MEG3 and many genes at the DLK1-MEG3 locus. In PILECs the genes mostaﬀected by menin loss were Hox genes that showed 4-16-fold reduction in
H3K4me3 and 3-13-fold reduction in gene-expression. The 39 HOX genes are

Inactivation of the MEN1 gene encoding menin is causative for the MEN1

homeodomain-containing transcription factors that regulate cellular identity

syndrome and for a fraction of similar sporadic endocrine tumors. Among otherduring development, and some act as potential tumor-suppressors or oncogenes.

interactions, menin partners with histone-modifying protein-complexes. Menin isInterestingly, parathyroid tumors show abnormal expression of several HOX

found in the MLL1/MLL2-complexes that trimethylate (me3) histone-H3 atgenes. Therefore, although HOX genes were dispensable for the development oflysine-4 (K4), a histone-modification (H3K4me3) for active gene-expression.

menin-null PILECs, their abnormal expression may impact islet-tumor

Identifying genes that undergo tissue-specific menin-dependent H3K4me3 could

development. Our investigation demonstrates that WT and menin-null ESCs

provide insights into tissue-specific tumor-suppressive actions of menin as welldiﬀerentiated in vitro into PILECs could be used eﬀectively for genome-wide

as targets causative for endocrine tumorigenesis. Men1-knockout mouse

analysis of menin-dependent gene-regulation. Methods for in vitro diﬀerentiationembryonic stem cells (menin-null ESCs) display defective in vitro hematopoietic

of ESCs into MEN1 target tissues, such as the parathyroids and anterior pituitary,

diﬀerentiation. However, it is not known whether menin-null ESCs could

could be applied to generate homogeneous populations of WT and menin-null

diﬀerentiate in vitro into pancreatic islet cells or other endocrine cell-types

cells for similar studies. Such investigations will advance our understanding ofaﬀected in MEN1. We found that similar to wild-type (WT) ESCs, menin-null ESCs

molecular and cellular events associated with normal and pathological endocrine

could diﬀerentiate in vitro into pancreatic islet-like endocrine cells (PILECs). We

cell proliferation and function.

compared WT and menin-null ESCs before and after in vitro diﬀerentiation into
PILECs to identify menin-dependent H3K4me3 and gene-expression changes by

36

HT2

Moreover, both human and mouse MTC cell proliferation was dependent upon
aberrant Cdk5 activity. Phosphoproteomic analysis implicated retinoblastoma

The Cdk5-p25 holoenzyme causes neuroendocrine cancer in the thyroid
Karine Pozo*1,, Chunfeng Tan1, Florian Plattner1, Herbert Chen2, Fiemu E.
Nwariaku3, Roswitha Pfragner4, James A Bibb1,5,6 1Department of Psychiatry,
The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd,
Dallas, TX 75390-9070, 2 Endocrine Surgery Research Laboratory, Department ofSurgery and the University of Wisconsin Carbone Cancer Center, Madison, WI
53792 3 Department of Surgery, The University of Texas Southwestern Medical

protein as a critical downstream eﬀector of aberrant Cdk5 activity in proliferatingtumors. This target was validated using a novel small interfering peptide that
disrupted this mechanism. These findings suggest that targeting p25/Cdk5 or its
downstream eﬀectors may be a valuable therapeutic strategy for the treatment of
MTC and provide a new perspective on the relationship between the mechanismsof synaptic remodeling and oncogenesis.
HT3

Center 4 Institute of Pathophysiology and Immunology, Medical University of Graz,
Graz, Austria 5 Department of Neurology, The University of Texas Southwestern

Survival and natural course of patients with thymic and bronchopulmonary

Medical Center 6 The Harold B. Simmons Comprehensive Cancer Center, The

neuroendocrine tumor in Multiple Endocrine Neoplasia type 1

University of Texas Southwestern Medical Center

Joanne M. de Laat, MD1, Carolina R.C. Pieterman, MD1, Jos W.R. Twisk PhD2,

Synaptic remodeling during cognition may considered a special adaptation of theMedard F.M. van den Broek1, Ad R. Hermus, MD PhD3, Olaf M. Dekkers, MD

cell cycle. The protein kinase Cdk5 is a member of the cyclin-dependent kinase

PhD4, Wouter W. de Herder, MD PhD5, Anouk N. A. van der Horst-Schrivers, MD

family, which is highly expressed in neurons. Its activity is dependent upon

PhD 6, Madeleine L. Drent, MD PhD7, Peter H. Bisschop, MD PhD8, Bas Havekes,

association with a cofactor p35. Cdk5/p35 contributes to synaptic remodeling and

MD PhD9, Menno R. Vriens, MD PhD10, Gerlof D. Valk, MD PhD1

numerous other neuronal functions. However, when p35 is truncated by calpain,
the resulting Cdk5/p25 complex engenders aberrant activity and is neurotoxic. To

1. Dept of Internal Medicine, University Medical Center Utrecht, The Netherlands2.

model neurodegeneration, we derived an inducible transgenic mouse that

Dept of Clinical Epidemiology and Biostatistics, VU University Medical Center, The

overexpresses GFP-tagged p25 under the control of the neuronal specific enolase

Netherlands 3. Dept of Endocrinology, Radboud University Medical Center, The

promoter. Surprisingly, these mice rapidly developed medullary thyroid carcinoma

Netherlands 4. Depts of Endocrinology and Metabolism & Clinical Epidemiology,(MTC) with 100% lethality. Medullary thyroid cancer (MTC), the most common

Leiden University Medical Center, The Netherlands 5.Dept of Internal Medicine,neuroendocrine tumor, arises from calcitonin-producing parafollicular or C-cells

Erasmus Medical Center, Rotterdam, The Netherlands 6.Dept of Endocrinology,

and metastasizes frequently to regional lymph nodes, and to the lungs, liver, andUniversity Medical Center Groningen, The Netherlands 7.Dept of Internal

brain. Neurons and neuroendocrine cells share a common ontogenic linage andMedicine, Section Endocrinology, VU University Medical Center, The Netherlands

functions such as calcium-dependent secretion. The inducible/arrestable tumors

8.Dept of Endocrinology and Metabolism, Academic Medical Center, Theof our mouse model exhibit the characteristics of human MTC. They express

Netherlands9.Dept of Internal Medicine, Division of Endocrinology, Maastricht

calcitonin, are invasive and metastatic. We found that Cdk5 and p35/p25 were

University Medical Center, The Netherlands 10. Dept of Surgery, University

normally expressed in mouse and human C-cells and that their levels and Cdk5

Medical Center Utrecht, The Netherlands

activity were prevalent in both human sporadic and familial medullary tumors.
37Thymic- and bronchopulmonary neuroendocrine tumors (Th- and Bp-NET) are non

HT4

often occurring MEN1 manifestations, and available data concerning the natural
course, screening and care of patients with these tumors is limited.

Menin is required to maintain bone mass in older mice

To describe the clinical characteristics and survival of patients with Th- and Bp-

Ippei Kanazawa, Lucie Canaﬀ, Monzur Murshed and Geoﬀrey N. Hendy. McGill

NET and to assess the growth rate of Bp-NET on imaging.Longitudinal

University, Montreal, Quebec, Canada

observational study based on the Dutch national MEN1 database including morethan 90% of the total MEN1 population in the Netherlands. MEN1 patients >16
years, with a confirmed MEN 1 mutation, who were under the care of the Dutch
University Medical Centers (<1990-2010) (n=296). Linear mixed models wereapplied to assess changes over time in size of Bp-NET. Time was treated ascontinuous variable and defined in quarters. Logaritmic transformation of the sizeof the bronchopulmonary nodules was performed, because of non-normal data
distribution. MEN1 patients with histologically proven or radiologically suspected
metastasis from other NETs were excluded from the analysis. Gender, thepresence of a missense or frameshift mutation in exon 2,9 or 10 and size of BpNET ≥ or <10 mm at the first radiograph were investigated for eﬀect modification.
Prevalence and survival of Bp- and Th-NET, change in Bp-NET size over time.The
prevalence of Th-NET in MEN1 patients was 3.7%, with a 10-year survival of 25%(SE 14.8%). Ninety-one percent of patients with Th-NET were male (p=0.001).
Diagnostic screening of the thorax for Bp-NET was performed in 184 MEN1
patients (62%). Bp-NET was identified in 42 of those patients (22.8%) with a 10
year survival of 69% (SE 13.0%). Fifty-two percent of Bp-NET patients werefemale (p=0.55). Fifteen patients were operated on (36%). Tumor volume of BpNET increased 4% per quarter (p=0.0001) leading to a tumor doubling time of six
years. Bp-NET growth was significantly higher in male patients (p= 0.054). Bp-NET
growth was not significantly associated with type of mutation (p= 0.471) andbaseline tumor size (<1 or ≥ 1 cm, p= 0.816).
Th-NET was an aggressive manifestation with a poor prognosis. Bp-NET was
more common manifestation with a relatively indolent course and a good
prognosis.

Background: The tumor suppressor menin is expressed in all mouse tissues
examined, including bone, Homozygous Men1 inactivation in mice is embryoniclethal at 12 days and the small fetuses exhibit defects in cranial and facial
development, suggestive of a role for menin in bone formation. The heterozygous
Men1 phenotype is similar to that of the multiple endocrine neoplasia type 1(MEN1) syndrome in humans with endocrine tumors developing later in life.
Although previous in vitro studies have shown that menin does have an importantrole in osteoblastogenesis and osteoblast diﬀerentiation, little is known about thein vivo role of menin in bone accumulation. Methods and Results: We conditionallyinactivated Men1 in postnatal mature osteoblasts by crossing osteocalcin-Cre
mice with floxed Men1 mice to generate mice lacking Men1 exon 3 to 8 inosteoblasts (Men1osb&#8722;/&#8722; mice). Nine-month-old Men1osb&#8722;/&#8722; mice displayed significant reduction in bone mineral density by dualenergy X-ray absorptiometry and in trabecular bone volume and cortical bone
thickness by micro-computed tomography (CT) analysis. Micro-CT images
indicated abnormality of trabecular bone formation in Men1osb&#8722;/&#8722;
mice. By histomorphometric analysis bone volume/total volume, osteoblast andosteoclast number, as well as mineral apposition rate (MAR) were significantly
reduced in Men1osb&#8722;/&#8722; mice. The mRNA expression of osteoblast
genes, OPG, RANKL, BMP-2, Runx2, Osx, Dlx2, Dlx5, and cyclin-dependent
kinase inhibitors, p15, p18, p21 and p27, were all reduced, whereas that of cyclin
dependent kinases, CDK2 and CDK4, were increased in isolated osteoblasts from
Men1osb&#8722;/&#8722; mice compared to controls. These data are consistent
with the menin-deficient osteoblasts having reduced responsiveness to TGF&#946; and/or BMP-2 and loss of Smad signaling. In contrast to the knockout
mice, 12-month-old transgenic mice overexpressing the human menin cDNA in38

osteoblasts (Men1osbTG/+ mice) driven by the 2.3 kb Col1a1 promoter, showed again of bone mass by micro-CT and histomorphometric analysis. Osteoblast
number and MAR were significantly increased in Men1osbTG/+ mice. Conclusion:
Taken together, depletion of menin in the osteoblast leads to decreased osteoblastand osteoclast numbers as well as impaired bone remodeling, resulting in a
reduction in trabecular and cortical bone whereas overexpression increases bonevolume by enhancing bone formation. Therefore, maintenance of menin
expression and function in the osteoblast is important to avoid decreased bone
mass.

39

Oral Session 1
OR1.1
Creation of a locus-specific database for mutations in the AIP gene
Giampaolo Trivellin1, Katarzyna Wertheim-Tysarowska2, Plamena Gabrovska1,
Karen Stals3, Serban Radian1,4, Márta Korbonits1 1Department ofEndocrinology, Queen Mary University of London, London, UK 2Department ofMedical Genetics, Institute of Mother and Child, Warsaw, Poland 3Department of
Molecular Genetics, Royal Devon and Exeter Foundation Trust, Exeter, UK 4C.I.
Parhon Institute of Endocrinology, Bucharest, Romania
The increasing number of sequence variations reported in the human genome
and the consequent necessity to establish their clinical significance has recently
led to the creation of locus-specific databases (LSDBs). LSDBs are useful andwidely used publicly available on-line resources. Several genes causing
endocrine syndromes have LSDBs available, such as MEN1, VHL, RET, GNAS
and the SDH subunits. We are developing a curated, freely accessible AIP-LSDB
which will be soon available at http://www.fipapatients.org/aip/. The aim of thisproject is to collect reported and unpublished variants related to FIPA and theirclinical information in order to deepen our knowledge of the disease. The
database is generated using PHP and Ajax scripting languages, and MySQL
relational database management system. The core database is hosted on the
Queen Mary University of London server. Molecular defects will be named
according to the GenBank’s NG_008969.1 RefSeq strictly following HGVS
(Human Genome Variation Society) recommendations. In order to submit variantsa clinical description module which allows for a comprehensive description of thepatient’s genotype and phenotype will be provided upon free registration. The
core of the database is a graphic view of the AIP gene structure, divided in exons
and introns. The number and type of variants in each region of the gene arereported in a pop-up window while hovering with the cursor over thecorresponding fragment. After clicking on the region of interest, a detailed pop-up
window with the nucleotide and amino acid sequence opens and all the reported
variants are showed as red dots below the sequence. Clicking on each dot

enables to see all the genetic and clinical details available for that specific variant.
Moreover, the database allows for the addition of data from patients harbouring
the same variant. A flexible data selection tool for statistical analysis will be
implemented, but the user can also download all data in a CSV format andperform further statistical analyses. This database will assist clinicians as well as
researchers in the interpretation of AIP variants and in genetic counselling and will
help to avoid unnecessary testing. Moreover, we believe that the AIP-LSDB will
help to examine the structure–function and the genotype-phenotype correlations,
if any, in AIP mutation positive patients and will enable scientists worldwide tocollaborate on future research projects.

OR1.2
THE CLINICAL AND GENETIC CHARACTERISTICS OF PATIENTS WITH
GIGANTISM
Liliya Rostomyan1, Adrian F. Daly1, Maria Tichomirova1, Luciana A. Naves2,
Anne-Lise Lecoq3, Emil Nachev4, Andreas Moraitis5, Dianne Kranenburg6, Ian
Holdaway7, Caroline Sievers8, Ekaterina Sorkina9, Daria Gusakova10, Elena
Malchiodi11, Elena Nazzi12, Margaret Zacharin13, Roberto Salvatori14, Renata
Auriemma15, Jakob Dal16, Silvia Filipponi1, Irena Ilovaiskaya17, Dominique
Maiter18, Ann McCormack19, Klaus von Werder20, Françoise Borson-Chazot21,
Sandrine Laboureau Soares22, Jens Otto L. Jorgensen16, Annamaria Colao15,
Diego Ferone12, Paolo Beck-Peccoz11, Vyacheslav Pronin9, Gunter K. Stalla8,
Sebastian Neggers6, Constantine A. Stratakis5, Sabina Zacharieva4, Patrick
Petrossians1, Philippe Chanson3, Albert Beckers1 1Department ofEndocrinology, CHU de Liège, University of Liège, 4000 Liège, Belgium
2Endocrinology, University of Brasilia, Brasila, Brazil 3Endocrinology, CHU Le
Kremlin-Bicetre, Le Kremlin Bicetre, France 4Clinical Center of Endocrinology andGerontology (M.Y., S.Z.), Medical University, 1431, Sofia, Bulgaria 5Section on

40

Endocrinology Genetics, Program on Developmental Endocrinology Genetics(PDEGEN), Eunice Kennedy Shriver National Institute of Child Health & Human
Development (NICHD), National Institute of Health (NIH), Bethesda, MD 20892,
USA 6Section of Endocrinology (S.N., W.D.H.), Department of Internal Medicine,
Erasmus Medical Centre, 3015 GD Rotterdam, The Netherlands 7Department ofEndocrinology (I.H.), Greenlane Clinical Centre, 1051 Auckland, New Zealand
8Department of Endocrinology (G.K.S.), Max Planck Institute of Psychiatry, 80804
Munich, Germany 9I.M. Sechenov First Moscow State Medical University, The
Endocrinology Clinic, Moscow, Russian Federation. 10Scientific and ResearchInstitute of Urology, Moscow, Russian Federation 11Endocrinology, Fondazione
IRCCS Osp. Maggiore Policlinico Mangiagalli Regina Elena, Milan, Italy
12Department of Endocrinology and Medical Sciences, Center of Excellence for
Biomedical Research, University of Genoa, Genoa, Italy 13Murdoch Childrens
Research Institute, Royal Children's Hospital and University of Melbourne,
Parkville, Victoria, Australia. 14Division of Endocrinology (R.S.), Johns Hopkins
University School of Medicine, Baltimore, Maryland 21287, USA 15Department of
Molecular and Clinical Endocrinology and Oncology, "Federico II" University of
Naples Naples, Italy 16Department of Endocrinology and Internal Medicine, NBG/
THG, Aarhus University Hospital, Aarhus, Denmark 17Moscow Regional Research& Clinical Institute named by MF Vladimirsky, Moscow, Russian Federation
18Department of Endocrinology, St. Luc University Hospital, Université Catholiquede Louvain, B-1200 Brussels, Belgium 19Cancer Genetics Unit, Hormones andCancer Group, Kolling Institute of Medical Research, Royal North Shore Hospital,
Sydney, NSW, Australia 20Innere Medizin/Endokrinologie, Max-Planck-Institut für
Psychiatrie, München 21Endocrinology, CHU de Lyon, Lyon, France
22Département d’endocrinologie diabétologie nutrition, CHU d’Angers, 4, rue
Larrey, 49933 Angers cedex 9, France

height 196 cm [188;202]. 18 still growing patients had height 193cm [178;205].
32.8% (22/67) had tall relatives, 50% of them had features of genetic syndromes.
Age at first symptoms - 14 yr [10;17]. 92% had facial changes and/or acral
overgrowth at time of diagnosis. Age at diagnosis PA in females were younger
than in males (14.9yr vs 22yr) with delay in diagnosis of PA ? 21 yr. Most of PA
were macroadenomas (76%, even giant PA in 12%) and in 19% microadenomas
with Max tumor size- 20 mm [12;34]. In more than half of cases there was
extrasellar extension (70%) and invasion (52%). Pituitary hyperplasia in 6%. There
was no diﬀerence between men and women in GH (26.75ng/ml vs 45ng/ml,
p=0.36) and IGF-1 (258%ULN vs 314%ULN, p=0.98) levels at diagnosis. Prolactin
co-secretion observed in 42%. Median follow up on treatment was 50.5months.
87 patients were operated with the remission in 11%, Multimodal treatment
approach was in 46% with control in 20%. Overall control of the disease wasachieved in 33%. Genetic/syndromic features presented in 36% (7 FIPA, 6 AIPmut
cases, 5 McCune-Albright, 4 Klinefelter syndrome, 3 Carney complex, 1 MYHpolyposis with GHRH secretion by pheocromocytoma). Mutations in AIP gene
were found in 37.5% (9/24). Conclusion: In most of cases gigantism was due toPA, which are mostly large (with extrasellar extension and invasion in &gt;1/2 ofcases) and diﬃcult to control. Syndromic features are presented in 1/3 of cases
and AIP mutations are common in gigantism.

Objective: To analyse a large series of patients with gigantism. Design: A
multicentre retrospective study. Patients: The gigantism was considered inpatients with current/previous abnormal, progressive, excessively rapid growthvelocity for age and/or a height greater than 2 SD above normal for their
population and/or absolute height more than 200 cm or greatly (&gt;5 cm) in
excess of the calculated midparental height in the absence of constitutional tallstature. 118 patients were included. Data of patients systematically collected inselected centres was recorded in case report forms. Results: In most of cases
gigantism was due to GH-overproduction by pituitary adenomas (PA) (88%), in 4%
by pituitary hyperplasia, in 1% because of ectopic GHRH production, 4% withoutvisualisation of PA and 3% in Klinefelter syndrome. Males/Females - 93/21. 36%
of patients were taller than 200cm (max 231mm). Median age of rapid growthvelocity was 12yr. 86 patients stopped growing at age of 20yr. [18;22] with theThomas Cuny, Morgane Pertuit, Mouna Sahnoun-Fatahla, Adrian Daly, Marie
Françoise Odou, Antoine Tabarin, Marie Laure Nunes, Brigitte Delemer, Rachel
Desailloud, Véronique Kerlan, Olivier Chabre, Jean-Louis Sadoul, Muriel Cognes,
Philippe Caron, Christine Cortet-Rudelli, Anne Lienhardt, Isabelle Raingeard,
Anne-Marie Guedj, Thierry Brue, Albert Beckers, Georges Weryha, Alain Enjalbert,
Anne Barlier

OR1.3
Should we screen MEN1 gene in addition to AIP, in young patient with isolated
sporadic pituitary macroadenoma ?

Context: whereas germline mutations in the AIP gene had been extensively
studied in patient with sporadic pituitary macroadenoma, there are few datas
about the prevalence of MEN1 mutations in such population. Design: we assessed
the prevalence of both AIP and MEN1 genetic abnormalities in 174 young patients(age < 30 years) from Endocrinology Department of 16 French University HospitalCenters. Each patient was diagnosed with isolated and sporadic pituitary41

macroadenomas, namely without MEN1-associated lesion and/or familial historyof pituitary disease. The respective entire coding sequence of AIP and MEN1 wasscreened for mutation, in DNA of peripheral blood leukocytes. In case of negative
screening, multiplex ligation-dependent probe amplification was performed for
detection of large gene deletion (LGD). Results: 21/174 (12%) patients bore AIP(AIPmut, n=14) or MEN1 mutations (MEN1mut, n=7). Among pediatric patients(less than 18 yrs), it reaches 24% (11/46). According to previous report,
acromegalic patients count for most of the AIPmut population (7/14), with highprevalence of acromegalogigantism (3/6 patients). MEN1mut were identified in 4,
2 and 1 patient with prolactinomas, somatotropinomas and non –secreting
adenoma respectively. One patient was identified with de novo mutation of MEN1
in our cohort. Interestingly, 4/12 (33%) patients with non-secreting adenomas bore
AIPmut or MEN1mut, whereas none of the 8 corticotroph-adenomas and the one
single thyrotropinoma were mutated. In negative-screening patients, no LGD wereidentified. Conclusion: Beside AIP, mutations in MEN1 can be found in up to 4% ofyoung patient with isolated sporadic pituitary macroadenoma, therefore
suggesting to systematically perform this genetic analysis in such population.

OR1.4
PERFORMANCE OF IMMUNOHISTOCHEMISTRY VS. CONVENTIONAL GENETIC
SCREENING TO DETECT SDHx MUTATIONS IN PATIENTS WITH
PHEOCHROMOCYTOMA AND PARAGANGLIOMA FROM BELGIUM.
Selda Aydin, Francien H van Nederveen, Nathalie Lannoy, Francesca Severino,
Thomas Papathomas, Dominique Maiter, Marc Hamoir, Miikka Vikkula, Ronald de
Krijger, Alexandre Persu.
Background. Mutations in predisposing genes are detected in 30-40% of patientswith paraganglioma/pheochromocytoma (PGL/PHEO), including 10-20% of
mutations in SDHx genes, encoding the subunits of succinate dehydrogenase. In
Belgium, SDHx mutations are frequent, especially in head and neck PGLs (40%)(Persu et al., Horm Metab Res 2012). Immunohistochemistry (IHC) of SDHB and
SDHA subunits was shown to be a straightforward and eﬀective method to detectsuch mutations (van Nederveen at al., Lancet Oncol 2009). However this approachstill needs further validation in new cohorts. Aim. To look for the proportion of
PGL/PHEO tumors without SDHB and/or SDHA expression and to assess thesensitivity and specificity of the IHC method for detection of SDHx mutations
versus conventional genetic screening in a multicentric series of PGL/PHEOs from

Belgium. Methods. Immunohistochemistry for SDHB and SDHA was done on 75
tumors from 69 patients. In 55 patients, genetic screening for SDHx mutations had
been already performed. In 14 additional samples, genetic status was unknown at
the time of IHC. The pathologists in charge of interpreting the IHC were unawareof the results of genetic screening in either subgroup. Results. Expression of
SDHB was abolished in tumors from 42% (n=23) of patients previously genotyped
for SDHx genes. Of these, 15 were previously known to harbor mutations in SDHB
(n=3) or SDHD (n=12), while genetic screening was negative in the remaining
eight. Noteworthy, SDHB expression was abolished in all patients known to harbor
SDHx mutations. Furthermore SDHB expression was abolished in 29% (n=4) of
the 14 patients of unknown genetic status. In one of them, expression of SDHA
was also absent, suggesting the existence of a mutation in SDHA. Genetic
analysis of this additional subset is under way. Conclusion. We report the first
Belgian series of patients with PGL/PHEOs in whom the presence of SDHx
mutations was assessed both by conventional genetic analysis and IHC. As
expression of SDHB was abolished in all patients with known SDHx mutations, thesensitivity of IHC was 100%. The absence of SDHB staining in 8 patients
screened negative for SDHx genes might either reflect a lack of specificity of the
IHC method, or more likely the presence of mutations in the promoter or otherunexplored regions of the corresponding genes. In the near future, IHC might beoﬀered to all patients operated from a PHEO and/or a PGL, genetic analysis of
SDHx genes being reserved to subjects without expression of SDHB and/or SDHA
by IHC.

OR1.5
Co-existence of pituitary adenoma and phaeochromocytoma/paraganglioma(PHAEO/PGL) – does it represent a new syndrome with a heterogeneous genetic
pathogenesis?
Judit Dénes, Francesca Swords, Paraskevi Xekouki, Ajith Kumar, Eamonn Maher,
Christopher Wassif, Naomi Fersht, Stephanie Baldeweg, Damian Morris, Staﬀord
Lightman, Amar Agha, Aled Rees, Joan Grieve, Michael Powell, Cesar Luiz
Boguszewski, Cristina Preda, Jacqueline Trouillas, Nadezhda Dalantaeva, Antônio
Ribeiro- Oliveira Jr, Sian Ellard, Eleanor Rattenberry, Karen Stals, Constantine A.
Stratakis, Ashley B. Grossman, Márta Korbonits
Pituitary adenoma and PHAEO/PGL can very rarely occur in the same patient or in
the same family. One possible cause has been previously described, when these 242

tumours occur as a PHAEO/PGL which secretes GHRH and thus cause
somatotroph hyperplasia and acromegaly. However, we have hypothesised
several other mechanism which could be involved in the development of these
two tumour types together: a PHAEO/PGL gene which also causes pituitaryadenoma, a pituitary tumour gene which also causes PHAEO/PGL, a digenic
disease, a new gene(s) causing both diseases, or the development of the 2tumours together can be a pure coincidence. We found 44 cases in the literature
with this combination of diseases, but only 7 of them had a confirmed genetic
diagnosis. We studied 21 new patients with the combination of pituitary adenoma
and PHAEO/PGL. PHAEO/PGL causing genes (SDH A-D, SDHAF2, RET, VHL,
TMEM127, MAX) and pituitary adenoma genes (MEN1, AIP, p27) were sequenced
using next generation or Sanger sequencing, and loss of heterozygosity wasstudied in the tumours where available. We identified mutations in SDHB, SDHC,
SDHD, MEN1, RET and VHL in some patients and families with PHAEO/PGL andpituitary adenomas (3 SDHB, 2 VHL, 1 SDHC, 1 SDHD and 1 MEN1). Loss ofheterozygosity for the relevant gene was shown in all the cases where tissue wasavailable. These data suggest that mutations in some PHAEO/PGL and pituitarygenes can aﬀect both these tissue types.

technology and analysed the methylation pattern of the 11p15.5 region. Hybrids
were generated by PEG-mediated fusion of lymphoblastoid cell lines with mouse
RAG cell line and were cultured in a selective medium. After hybrid clones weregrown, we had determined by genotyping which were haploid for chromosome 11.
Each of these clones were characterised for the presence of the founder mutation
with an allelic discrimination taqman assay and for the methylation pattern of the
11p15.5 region with the MLPA kit ME030-B2. Using lymphoblastoid cell lines fromtwo carriers who inherited the mutation from the father and from the mother,respectively, we obtained 136 hybrid clones, among which 9 were haploid forchromosome 11. The analysis of the methylation pattern with the MLPA kit
ME030-B2 confirmed the parental origin of the chromosome 11. Using thisvalidated method, we therefore investigated a patient with an unknown
inheritance. In particular, we screened 77 hybrid clones, among which 11
maintained a single copy of chromosome 11. MLPA analysis revealed the maternal
origin of the mutation. Preliminary results indicate that this approach may be
useful to demonstrate parental origin of the SDHD mutation, allowing
paraganglioma risk estimation in individuals with unknown inheritance.

OR1.7
OR1.6
Sara Bobisse1, Beatrice Macino1, Elisa Taschin1, Elisa Casagrande 2, Daniela Di
Sarra3, Serena Demattè3, Giuseppe Opocher1-2, Francesca Schiavi1 1 Familial
Cancer Clinic and Oncoendocrinology - Veneto Institute of Oncology - Padova,
Italy 2 Department of Medicine - University of Padova - Padova, Italy 3 Internal
Medicine - Santa Chiara General Hospital - Trento, Italy
Paraganglioma syndrome type 1 (PGL1) is a rare autosomal dominant disease
with maternal imprinting characterised by the development of head-and-neckparagangliomas and pheochromocytoma, associated with germ-line mutations ofSDHD gene. We identified a PGL1 founder eﬀect caused by the SDHD c.341A>G
p.Tyr114Cys mutation. We recruited 540 individuals from 95 aﬀected kindreds:
287 carried the mutation. Of this group, 184 individuals inherited the mutationfrom the father, 77 from mother, while 26 were with an unknown inheritance. The
genetic evaluation of 4025 resident volunteers allowed to identify 59 carriers of thefounder mutation, resulting in a prevalence of 1.5% among the general population.
The identification of a large numbers of carriers with an unknown inheritancehighlights the lack of a tool to discriminate the parental origin of the mutatedchromosome. To this aim we isolated the chromosome 11 using the conversion

A rare gain-of-function mutation in an inhibitory uORF in the CDKN1B genecauses MEN4 phenotype
Gianluca Occhi, Daniela Regazzo, Giampaolo Trivellin, Francesca Boaretto, Denis
Ciato, Sergio Ferasin, Filomena Cetani, Elena Pardi, Paola De Lazzari, Márta
Korbonits, Natalia Pellegata, Giuseppe Opocher, Franco Mantero, Carla Scaroni
The CDKN1B gene encodes for the cyclin-dependent kinase inhibitor p27KIP1
that is a key player in many cell processes including proliferation anddiﬀerentiation. Impaired p27KIP1 expression and/or localization is often observedin tumor cells, further confirming its central role in regulating the cell cycle.
Recently, germline mutations in CDKN1B have been associated with the inheritedmultiple endocrine neoplasia syndrome type 4 (MEN4, MIM610755). MEN4 is arare autosomal dominant syndrome characterized by varying combinations oftumors that aﬀect at least two endocrine organs. Aim of present study was todetermine the possible causes of multiple endocrine tumors in 25 MEN1-likepatients by analyzing the entire CDKN1B gene for point mutations and large
rearrangements in germline DNA. A c.-456_-453delCCTT was identified in a
regulatory upstream ORF (uORF) in the 5’UTR, in a 62 year old acromegalic
43

patient with a pancreatic endocrine neoplasm. The 4-bp deletion causes the shiftof the uORF termination codon with the consequent lengthening of the uORF
encoded peptide and the drastic shortening of the intercistronic space. Ourfunctional studies clearly prove a negative influence of such deletion on thetranslation reinitiation at the CDKN1B starting site. LOH analysis from thepancreatic lesion revealed no loss of the second allele, confirming that p27KIP1
may act as haploinsuﬃcient tumor suppressor. Importantly, our in-silico analyses
showed a very high level of inter-species conservation of the uORF within the
CDKN1B gene (both at nucleotide and protein level), strongly supporting aphysiological role of the uORF-encoded peptide in modulating p27KIP1
translation. Although regulatory uORFs are very common in human and mousegenes, being observed in about half of cases, CDKN1B gene represents the fourthcase for which an uORF aﬀecting mutation have been clearly associated to humandiseases. In addition, our findings demonstrate for the first time that, besides thealready described degradation by the ubiquitin/proteasome pathway and noncovalent sequestration, p27KIP1 activity can also be modulated by an uORF, andthat mutations in this region may have deleterious consequences.

44

Oral Session 2
OR2.1
MEASUREMENT OF CALCA TRANSCRIPTS ARE USEFUL FOR THE
EVALUATION OF ASYMPTOMATIC RET-MUTATION CARRIERS AND IN THE
FOLLOW-UP OF PATIENTS WITH MEDULLARY THYROID CANCER AND MAY
REPLACE THE PENTAGASTRIN TEST. Cléber P. Camacho, Susan C. Lindsey,
Maria Clara C. Melo, Rosa Paula M. Biscolla, José Gilberto H. Vieira, Janete M.
Cerutti, Magnus R. Dias-da-Silva and Rui M. B. Maciel
Introduction: Calcitonin is the main tumor marker for medullary thyroid cancer(MTC), but it has certain limitations. In some clinical situations, the pentagastrin
stimulation test is desirable, such as in the screening for MTC in RET mutationcarrying relatives or in the postoperative follow-up of MTC patients.
Notwithstanding, the pentagastrin stimulation test is expensive, time-consuming
and uncomfortable for patients; besides, pentagastrin is not world wide available.
Objective: We aimed to 1) investigate the applicability of measuring CALCA genetranscripts (CT-CALCA and CGRP-CALCA) in patients with MTC and in relatives
diagnosed with a RET mutation and 2) suggest an alternative moleculardiagnostic tool for the pentagastrin stimulation test. Setting and Patients:
Twenty-six individuals consecutively evaluated for MTC at the Thyroid Clinic of
the Federal University of São Paulo were selected, including patients withsporadic or hereditary MTC (with or without evidence of the disease) and RET
mutation-carrying relatives. Results: We detected CT-CALCA mRNAs and CGRPCALCA mRNAs in the blood samples and observed a positive correlation
between them (r: 0.970 and p <0.0001). Both mRNAs also correlated with theserum CT (sCT) (CT-CALCA - r: 0.708 and p: <0.0001 / CGRP-CALCA - r: 0.702
and p: <0.0001). The relative expression (RE) of CT-CALCA and CGRP-CALCA
presented a higher sensitivity (85.71 and 100, respectively), specificity (83.33 and91.67, respectively), positive predictive value (85.71 and 93.33, respectively) anda higher negative predictive value (83.33 and 100, respectively), than did theisolated sCT (78.57, 75, 78.57 and 75, respectively). In addition, CGRP-CALCA
presented a higher sensitivity, specificity, PPV and NPV than did CT-CALCA. The

CALCA-transcript measurement mirrors the response to the pentagastrin
stimulation test. Conclusion: We demonstrated the measurement of CALCA genetranscripts in the bloodstream—refining the test in the follow-up of patients with
MTC and RET mutation-carrying relatives—and herein suggest the application ofthis molecular diagnostic tool as an alternative to the pentagastrin stimulation
test.

OR2.2
THE ROLE OF TYROSINE KINASE INHIBITORS IN A MEN2B PATIENT WITHMETASTATIC MEDULLARY THYROID CARCINOMAMartin-Hernandez Tomasa,
Tome-Garcia Monicab, Gonzalez-Rivera Natividada, Virizuela JAc, Beato Carmenc,
Gentil-Baldrich Alfonsoa, Sendon-Perez AngelaaDepartment of Endocrinology.
University Hospital Virgen Macarena. Seville. Spain.bService d´Endocrinologie.
Centre Hospitalier Universitaire de Liège. Belgium.cDepartment of Oncology.
University Hospital Virgen Macarena. Seville. Spain.
Medullary thyroid carcinoma (MTC) is present in up to 100% of patients withmultiple endocrine neoplasia syndrome type 2 (MEN2). Traditional chemotherapy
or external beam radiation have shown limited eﬀects. Development of tyrosine
kinase inhibitors open a new era in the management of the disease. A 23-yearold man with marfanoid phenotype was admitted to emergency room withpneumothorax. Surgery was performed and anatomopathologic diagnosis of lungsamples was metastatic MTC. The patient underwent total thyroidectomy andcervical lymphadenectomy. Genetic test was positive for protoncogene RET
Met918Tr mutation. The extension study included a whole body scan with 111Inoctreotide, PET-CT scan with 18F-FDG, whole body scincigraphy with 99mTc-DMSA
and cervical ultrasound. The results confirmed extension of local and distantmetastases in the right lung, the liver, mesenteric and retroperitoneal lymph
nodes and vertebral spine. Biochemical study presented an elevation in CEA
59ng/ml (NV <5ng/ml), calcitonin (CT) 2000pg/ml (N<18pg/ml), and an increase in45

urinary free catecholamines. Pheochromocytoma was excluded by imaging
methods and repeated catecholamines. Clinically the patient had malnutrition,
diarrhea, dyspnea and cervical nodules and calcitonin was increasing rapidly (CT10,128pg/ml). Dual treatment with octreotide LAR 20mg/28d and sorafenib
400mg/12h was started with clinical relief and a decrease in CT levels (2,000pg/
ml). Seven months later tumor progression was observed with an increase incalcitonin (26,753pg/ml) and everolimus was used instead of sorafenib. No
decrease in CEA or CT was observed with everolimus and moreover, the patient
experienced limited clinical tolerance. Some months later compassionate
treatment with sunitinib 37.5 mg/d was started in addition to the octreotide LAR
20mg/28d. Four months later after the 3rd sunitinib cycle, a reduction in CEA andCT levels was seen (CEA 72ng/ml, CT 19.249pg/ml). Again, four months later,
clinical and biochemical tumor progression prompted a change to vandetanib
200mg/24h with a significant reduction in CT (2000pg/ml). Seven months later,
vandetanib is still ongoing with maintained reduction in CEA and CT and an
improvement in clinical condition.:Tyrosine kinase inhibitors are promising drugs
for the treatment of metastatic MTC. A possible mechanism of tolerance causing
loss of eﬃcacy has led to sequential treatment being proposed. The eﬀective
chronic use of these drugs enhances the need for personalized treatment to weigh
the risk/benefit ratio.

Ct; b) Ct&#8804;40pg/mL; c) Ct>40pg/mL. Results: Forty two patients were
included in the study group: 28 individuals (68.3%) from a large familial MTC
harboring a germline RET Cys620Arg mutation, 10 patients (24.4%) with a C634Y/
Y791F double mutation; two patients (4.9%) with the V804M and one (2.4%) with
the C634Y mutation. Nineteen patients (46.3%) achieved cure (Group a).
According to RET mutation, there were 14 (50%) with C620R; 4 (40%) with
C634Y/Y791F and 1 (50%) with V804M. The only patient C634Y did not reachcure. Age at treatment was an important factor related to cure. Younger patients
had better prognosis (p=0.02). There was no statistical diﬀerence for preoperative
calcitonin and cure, although there was a trend to higher levels in patients not
cured. Calcitonin ranged from 4.5 to 1367pg/mL (average 124.5) in group “a”;
from 9 to 180149 (average 124.5) in group b and from 98 to 8358 (average 2587)
in group c. CEA levels ranged from 0.3 a18.4ng/mL (average 5.2) for group a; from
1.1 to 82.9 (average 12.4) for group b and from 2.6 a 641.7 (average 169.3) forgroup c. The extension of surgery was not related to cure. TT TT+CND TT+UND
TT+BND Group a 5 10 2 2 Group b 0 11 4 3 Group c 0 3 1 0 TT: Total
thyroidectomy CND: Central neck dissection (ND) UND: Unilateral ND BND:
Bilateral ND Fifteen patients (36.6%) presented postoperative hypoparathyroidism,
not related to cure. Conclusion: Genetic test is the most important exam to
perform in MTC patients, since age at treatment prevails as important prognostic
factor.

OR2.3
Profile of patients treated for Medullary Thyroid Carcinoma at São Paulo Medical
SchoolOR2.4

Marcos R Tavares, Sergio PA Toledo, Rodrigo A Toledo, Antonio Carlos Ferrete Jr,
Fernanda L D Ribeiro, Gabriel L Valente, Lenine G Brandão

Pheochromocytoma in Multiple Endocrine Neoplasia Type 2 in Japan: Analysis ofa Multicenter Database

Medullary thyroid carcinoma (MTC) behavior in MEN2 present variations, ranging
from indolent MTC, as frequently seem in cases harboring intra-cellular “weak”
mutations, to highly aggressive disease, with RET mutations in codons 634 and918. This retrospective chart review examines the profile and outcome of thepatients treated at our institution. Patients and methods: The charts of 67 MTC
patients, 26 sporadic (38.8%) and 41 carriers of RET mutations (61.2%) operated
at our institution from January 2002 to December 2011 were retrospectively
reviewed. Surgical and pathologic reports were accessed. Follow up ranged from
1 to 65 months (average 10.9 months). Patients were tested for RET hot spot
mutations, pre- and postoperative calcitonin (Ct), carcinoembryonic antigen (CEA),
parathyroid hormone (PTH) and calcium. Patients were stratified in 3 groups
according to Ct serum concentration in the last evaluation: a) cured: undetectable

Imai T, Kikumori T, Kosugi S, Okamoto T, Sakurai A, Suzuki S, Uchino S, and MEN
Consortium of Japan[Introduction] Approximately 50% of patients with multiple endocrine neoplasia
type 2 (MEN2) develop pheochromocytomas. While the clinical features andoptimal management of MEN2 are well characterized in Western countries, they
are less well recognized in Asian countries, including Japan. The aim of this study
was to clarify the clinical features and outcomes of the treatments ofpheochromocytoma in Japanese MEN2 patients. [Patients and Methods] We
established a MEN study group designated the “MEN Consortium of Japan” in
2008, and asked physicians and surgeons to provide clinical and genetic
information on patients they had treated. Of 493 registered MEN2 patients, 21246pheochromocytomas were analyzed. The questionnaire included the following
questions: 1) Was there a positive diagnosis of pheochromocytoma? If yes; age at
diagnosis. 2) Was surgical intervention performed? If yes; age at surgery. 3) Was
there unilateral or bilateral involvement? 4) Which particular surgical procedures
were performed? 5) Was there a malignant feature? 6) Were multiple surgeries
performed? 7) Was genetic testing performed? 8) Is the patient alive? [Results]
The median age at primary adrenalectomy for pheochromocytoma was 37. There
were 85 males and 126 females. Adrenal surgery was performed on 187 (88%) of
the 212 patients. Unilateral adrenalectomy was performed in 72 patients. Bilateraladrenalectomy was performed in 104 patients, 71 patients had one stage bilateraladrenalectomy and 33 patients had two stage bilateral adrenalectomy.
Laparoscopic surgery was performed in 48 patients. Clinical diagnosis including
follow-up analysis confirmed pheochromocytoma in all but one case of malignant
pheochromocytoma. Multiple operations were performed on 36 patients. The RET
mutation positive rate was 95.4% among 153 patients with pheochromocytoma.
There were 25 deaths among the 212 patients, of which six were due topheochromocytoma. The median age of death was 39 in pheochromocytoma
patients, which was younger than that in other causes of death. [Discussion] We
have established the first extensive database of pheochromocytoma in AsianMEN2 patients. Although malignant pheochromocytoma was very rare in MEN2,
complications arising from untreated pheochromocytoma or Addisonian crisis
after bilateral total adrenalectomy were critical in MEN2 patients.

OR2.5
A STUDY OF THE SPANISH NATIONAL REGISTER OF MULTIPLE ENDOCRINENEOPLASIA TYPE 2A
Nuria Valdés1, Paloma Portillo2, Javier Tébar2, Elena Navarro3, Lluis Forga4,
Anna Casterás5, José Angel Díaz6, Luis Castaño7, Sonia Gaztambide7, Cristina
Alvarez Escolá8, Victoria Alcázar,9 Francisco Pomares10, Jordi Mesa,5 Javier
Aller11, Margarita Boillos 12, , Elena Dios13, Lorena Suárez1, María Galiana
Rodriguez1, Cristina Lamas14 José Manuel Rodriguez15 Departments ofEndocrinology and Nutrition of: 1Hospital Central de Asturias, Oviedo. 2Hospital
Virgen de la Arrixaca, Murcia. 3Hospital Virgen del Rocío, Sevilla. 4Complejo
Hospitalario de Navarra, Pamplona. 5Hospital General Vall d’Hebron, Barcelona.
6Hospital Clínico San Carlos, Madrid. 7Hospital de Cruces, Bilbao. 8Hospital
Universitario la Paz, Madrid. 9Hospital Severo Ochoa, Madrid. 10Hospital Clínico
Universitario de San Juan, Alicante. 11Hospital Universitario Puerta de Hierro,

Madrid. 12Hospital Can Misses, Ibiza. 13Hospital Puerta de Europa, Madrid.
14Complejo Hospitalario de Albacete, Albacete.15Department of Endocrine
Surgery, Hospital Virgen de la Arrixaca, Murcia. Spain
Introduction: MUltiple endocrine neoplasia type 2 is a genetic rare disease due togermline RET mutations. MEN 2A is a syndrome of thyroid medullary carcinoma(MTC) in 90% of adult gene carriers, unilateral or bilateral pheochromocytoma(PHEO) in 50%, and multigland parathyroid tumors (HPT) in 20-30%. Objective:
The aim of this study was to analyse the clinical and genetic characteristics of
Spanish MEN 2A patients. Methods: The Spanish Group for the Study of Multiple
Endocrine Neoplasia designed an online national database, which was launched
in January 2009.Data was collected from January 2009 to December 2011.
Results: There were data on 233 genetic carriers from 84 unrelated families. The
mean age at diagnosis of any MEN 2 component was 27.74±18.19 years (6months-75 years). 198 (84.97%) patients had MTC: 28 index cases werediagnosed at 42.32±14.53 (15-71) years, 36 patients were diagnosed bybiochemical screening at 33.30±16.33 (8-68) years, and 134 patients werediagnosed by genetic screening at 27.55±16.11 (1-76) years. At the time ofdiagnosis 65 patients (32.82%) had metastases. 32 (13.73%) patients werediagnosed of thyroid C-cell hyperplasia by genetic screening at 9.93±7.4 (8months- 43 years) years. PHEO was detected in 104 (45.21%) patients: 19 index
cases were diagnosed at 43.21±16.63 (20-73) years, 20 patients were diagnosedby biochemical screening at 42.10±15.81 (19-68) years, and 65 patients weredetected by genetic screening at 34.56±13.14 (13-72) years. HPT was present in
12 (5.15%) patients at 32.75±17.50 (14-71) years. Only 2 patients had cutaneous
lichen amyloidosis. Three patients, at the ages of 2, 3 and 4 years, wereasymptomatic genetic carriers. Two (2.38%) families were negative for germline
RET mutations. 89% of RET gene mutations were located in codon 634 and themost common RET amino acid substitution was Cys634Tyr (75%). Conclusions:
The clinical characteristics of Spanish MEN 2A patients are similar to those ofEuropean patients but the prevalence of mutations in 634 codon is higher than inEuropean families, and specially the Cys634Tyr mutation, which suggests a“founder eﬀect”.
OR2.6
COULD THE LONG-ACTING SOMATOSTATIN ANALOGUES MODIFY THE
THERAPEUTIC STRATEGY IN PATIENTS WITH EARLY STAGE MEN1-RELATEDDUODENO-PANCREATIC NEUROENDOCRINE TUMORS (NET)S? A. Faggiano
1,5, V. Ramundo1, M. Del Prete1, V. Marotta1, F. Marciello1, L. Camera2, V.
Napolitano3, L. De Luca4, A. Carratù1, R. Esposito1, C. de Luca di Roseto1, A.
47

OR2.7

Context Periodic assessment of tumor manifestations and subsequent treatment
of MEN1 mutation carriers prevents complications and seems to lead to a morefavourable course of the disease. At present tumor markers are used in the
periodic screening for pancreatic neuroendocrine tumors (pNET) in Multiple
Endocrine Neoplasia type 1 (MEN1) patients, but have never been validated forthis purpose. Objective To assess the diagnostic accuracy of chromogranin A(CgA), pancreatic polypeptide (PP) and glucagon in the screening for pNET in
MEN1 patients. Design A diagnostic study as part of the Dutch national MEN1
database, which includes more than 90% of the total MEN1 population in the
Netherlands. Setting Patients >16 years with a confirmed MEN1 mutation under
the care of the Dutch University Medical Centers (2008-2010) (n=253) Patients andmethods Reference standard for pNET diagnosis was pathology and, if notavailable, detection on MRI, CT or EUS with confirmation at least once on further
imaging. For CgA patients with pulmonary, thymic, or stomach NET were
excluded and analysis were stratified for proton pump inhibitor (PPI) use. The
diagnostic accuracy for identifying metastatic disease in MEN1 patients was also
assessed. Main outcome measures Area under the curve (AUC), positive
predictive value (PPV), negative predictive value (NPV), sensitivity and specificity
were calculated for each marker. Results 155 patients were eligible for assessing
the reference standard, and measurement of the tumor markers were available incombination with the reference standard for PP in n=70 and for glucagon in n=91.
CgA measurement in combination with the reference standard was available in
n=78. The AUC of CgA without PPI was 0.58 (95% Confidence Interval (CI) 0.44 0.73), for glucagon 0.57 (95% CI 0.45 – 0.70) and for PP 0.61 (95% CI 0.47 –0.76). For diagnosing metastatic disease the AUC of CgA and PP was 0.69 (95%
CI 0.52 – 0.86) and 0.69 (95% CI 0.50-0.88) respectively, with significant NPVs of
90% or higher for all three tumor markers. Combined measurement of the three
individual tumor markers led to an AUC of 0.67 (95% CI 0.52 – 0.82) for identifying
pNET. Conclusion Tumor markers are not useful in the screening for pNET in
MEN1. Because of the high NPV, CgA and other markers seem to be more usefulfor excluding metastatic disease in MEN1 patients.

Diagnostic accuracy of chromogranin A, pancreas polypeptide and glucagon in
the screening for pancreatic neuroendocrine tumors in Multiple Endocrine
Neoplasia type 1 patients

OR2.8

Colao1 Departments of 1Molecular and Clinical Endocrinology and Oncology,
2Biomorphologic and Functional Sciences, Federico II University of Naples;
3Internal Medicine, Second University of Naples; 4Gastroenterology and Digestive
Endoscopy, Pellegrini Hospital ASL NA1, Napoli; 5Endocrinology, National Cancer
Institute, “Fondazione G. Pascale”, Naples, Italy
Background: Somatostatin analogues (SSA) represent one of the main therapeutic
option in patients aﬀected with functioning well-diﬀerentiated neuroendocrine
tumors (NET). There are no studies specifically focusing on NET associated toMultiple Endocrine Neoplasia type 1 (MEN1). Aim: To evaluate the eﬃcacy of longacting somatostatin analogues in MEN1 patients aﬀected with duodenopancreatic NET. Patients & Methods: All first-degree relatives of MEN1 subjects,
genetically diagnosed for MEN1 before the clinical diagnosis of NET and withevidence of one or more duodeno-pancreatic NET less than 15 mm in size wereenrolled. Twenty-two patients with MEN1-related duodeno-pancreatic NET (agerange 21-42 yrs) were treated with octreotide LAR (30 mg / 28 days). Treatment
duration ranged 1-7 yrs. At the radiological evaluation (performed bymultidetector-row computed tomography and endoscopic ultrasound), multiple
duodeno-pancreatic NET (range 1-8), sized 3–14 mm, were detected. Results: An
objective tumor response was observed in 18%, stable disease in 78% andprogression of disease in 4% of cases. In five patients with abnormally increased
chromogranin-A and/or gastrin serum concentrations, a significant hormonal
response occurred in 100% cases and was stable along the time. Conclusions:
Therapy with SSA is highly eﬀective in patients with early stage MEN1 duodenopancreatic NET, resulting in long-time suppression of tumor and hormonal activity
and 18% objective response. This suggest a change in therapeutic strategy inpatients with early stage MEN1.

Joanne M. de Laat, MD, Carolina R.C. Pieterman, MD, Maaike Weijmans, Ad R.
Hermus, MD PhD, Olaf M. Dekkers, MD PhD, Wouter W. de Herder, MD PhD,
Anouk N. A. van der Horst-Schrivers, MD PhD, Madeleine L. Drent, MD PhD, Peter
H. Bisschop, MD PhD, Bas Havekes, MD PhD, Menno R. Vriens, MD PhD, Gerlof
D. Valk, MD PhD

Analysis of penetrance and clinical impact resultant of the diagnosis of multiple
endocrine neoplasia type 1-related tumors during childhood and adolescence.
Tatiana Denck Gonçalves, Rodrigo Toledo, Tomoko Sekiya, Viviane C Longuini,
Michele Buscarilli, Flavia L Coutinho, Karine C Rodrigues, Sheila A C Siqueira,48

Andrea Glezer, Maria A A Pereira, Manoel S Rocha, Fauze Maluf Filho, Sergio E
Matuguma, Fabio L Montenegro, Ricardo Jureidini, Marcel C C Machado,
Telesforo Bacchella, Sergio P Toledo, Delmar M Lourenco Jr
Background: In order to reach an early diagnosis, the Consensus on MEN1
(2001/2012) established periodic hormonal/radiological exams in carriers of
MEN1germline mutation with beginning to each tumor type based on younger
case age reported. This recommendation is resultant of absence of consistent
data reported on penetrance, prevalence, phenotype and clinical impact of theMEN1-related tumors in adolescents. Aims: To recognize the penetrance/
prevalence of MEN1 tumors during 2nd decade reaching a more appropriate
screening. Patients/design: One hundred and fifteen MEN1 cases harboring
germline MEN1 mutations were studied. Two subgroups were selected: group 1,
27 cases approached during 2nd decade; group 2: 24 cases diagnosed with
MEN1 after 21 years but presenting suggestive clinical history of MEN1 during
2nd decade. Results: The penetrance and prevalence of HPT, PET and PIT in 27
cases of the group 1 were respectively 55.6 %, 44.4 %, 44% and 71.4 %, 57.1%,
55%. Indeed, the penetrance of prolactinoma, NF-PIT, NF-PET and insulinoma
were 34.6%, 8%, 44.4% and 7.4%, The overall penetrance during 2nd decade of
HPT, insulinoma, gastrinoma, non-functioning PET, PIT, prolactinoma and nonfunctioning PIT in 114 MEN1 cases were respectively 26.9, 2.6, 0, 44.4, 16.5, 15
and 8%. Half of young cases diagnosed were asymptomatic and predominant
symptoms were related to prolactinoma (82%), insulinoma (18.2%) and HPT (9%).
During follow-up, 26.4% of young cases with asymptomatic HPT presented
urolithiasis before 21 years. Prolactinoma was the more prevalent pituitary tumor(78%) and 44.5% were macroadenoma. Non-functioning PITs are less frequent(22%) presenting as incipient microadenomas. Non-functioning PETs are frequent
into 2nd decade (57%) and relevant clinically (55%, surgical indication). Clinical/
surgical treatment was conducted to one or more MEN1-related tumors in 44.4%(12/27) of the adolescents. Conclusions: Our data concerning penetrance/
prevalence/phenotype of MEN1 tumors reveal prolactinomas, insulinomas, HPT
and NF-PETs as significant clinically tumors in adolescents. We proposed an
intensive periodic clinical/hormonal screening to early diagnosis of these tumors.
In opposite, considering a very low penetrance of NF-PIT and an irrelevant clinicalimpact in adolescents, we recommend basal pituitary MRI 10 years later (15-20yold) than suggested for actual Consensus or before only if pituitary hormones willbe altered. Our screening approaching 27 patients reveal high penetrance of NFPET and surgical indication in 15% (4/27) of these young cases. In addition, aperiodic radiological approach including MRI (10-15 y-old) and endoscopic
ultrasonography and/or MRI (15-20 y-old) is recommended to active investigationof NF-PETs. We indicate basal radiological screening between 10-15 y-old andvalid the suggestion of the Consensus on MEN1 (2012) to begin this screening at
10 y-old based in case report of two adolescents presenting NF-PET.

OR2.9
Changing manifestations of MEN1 (Burin): increase in occurrence of PNETs
Green JS1,2, Myers TN3, Burry TN1, Hartery A3, Hibbs D3, Jeon P3, Fernandez
B1,2, Galway B2. Disciplines of 1Genetics and 2Medicine, Department of
3Radiology, Faculty of Medicine, Memorial University of Newfoundland, St.
John’s, NL, Canada
Introduction: Four families with Multiple Endocrine Neoplasia type 1 (MEN1) fromthe Burin Peninsula of Newfoundland (NL) were identified in the 1980s (N= 25
aﬀected). They were called the Prolactinoma variant of MEN1, or MEN1 (Burin),because the majority of patients presented with prolactinomas; pancreatictumours were very rare; and carcinoid tumours of the lung or thymus were morecommon than in typical MEN1. Objectives: i) to oﬀer clinical screening and genetic
testing to all aﬀected and at risk; ii) to prospectively document the natural historyof MEN1 (Burin) including age at diagnosis, order and frequency of manifestations,and treatment required; iii) to modify the screening protocol as necessary.
Methods: Clinical screening was introduced in 1987, and genetic testing has been
oﬀered since 1997 when a common mutation (R460X) was identified in menin. All
results of screening and testing were recorded in a database. Results: A common
ancestor of the four families has been identified through genealogical studies.
There are 139 individuals now known to be aﬀected with MEN1 (Burin). The
frequencies of hyperparathyroidism (95%), prolactinomas (38%), and carcinoid
tumours (13%) have remained constant but pancreatic tumours have increased(7% >35%). These are mainly pancreatic neuroendocrine tumours (PNETs);
gastrinomas and glucagonomas remain rare. Discussion: The PNETs are nonfunctioning so only detected with CT or MR imaging. They have been identified
since 2000 and have caused three deaths from metastatic disease. The increasein frequency of PNETs is not just increased recognition of previously present
tumours because abdominal CT and MRI have been used regularly for screening
since 1990. The screening protocol now includes blood work for biochemical
screening from age 10, MRI of the head from age 10, imaging of the abdomenfrom age 15, and MRI of the chest from age 20. The radiologists recommend
alternating triple phase CT and MRI of the abdomen to facilitate diagnosis of
PNETs while reducing radiation exposure. Interestingly the large VHL family in NL
49

has had a similar increase in PNETs (from 0-29%) in the same time period,
suggesting the possibility of an environmental component to the predisposition.

OR2.11
Association of Type-O Blood with Neuroendocrine Tumors in Multiple Endocrine
Neoplasia Type 1

OR2.10Functional characterization of mutations in the Multiple Endocrine Neoplasia type
1 (MEN1) gene suggest therapeutic strategies
Lucie Canaﬀ, Geoﬀrey N. Hendy. McGill University, Montreal, Quebec, Canada
Menin is the product of the multiple endocrine neoplasia type 1 (MEN1) genewhich when inactivated causes an autosomal dominant disorder characterized bytumors of the parathyroids, endocrine pancreas and anterior pituitary. We
identified an MEN1 splice-site mutation leading to a menin &#916;(184-218)
mutant having an in-frame deletion of 35 amino acids, but otherwise of wild-typesequence. The transfected mutant was well expressed, and like wild-type menin,
interacted directly with the transcriptional regulators JunD and NF-&#954;B andinhibited their activities. However, the mutant had lost the normal interaction with
Smad3 and was defective in mediating TGF-&#946;-stimulated Smad3transcriptional activity, stimulation of the cyclin dependent kinase inhibitors(CDKIs), p15 and p21, and cytostatic activity. Thus the mutant was stable, hadselective loss of TGF-&#946; signaling and growth inhibition and, importantly,
identified the menin/Smad3 interacting region on a homology model of the humanmenin structure. These studies suggest the menin/Smad3 interface as a potential
therapeutic target. We functionally characterized a panel of 16 menin missense
mutants, including W423R and S443Y identified in new MEN1 families and thatare poorly expressed. Proteasome inhibitors, MG132 and PS-341, and inhibitionof the chaperone, heat shock protein 70 (Hsp70), or the ubiquitin ligase, COOHterminus of Hsp70-interacting protein (CHIP), by specific siRNAs, restored thelevels of the mutants whereas that of wild-type menin was unaﬀected. Inhibition ofCHIP restored the ability of mutants to mediate normal functions of menin – TGF&#946; upregulation of p15 and p21, as well as TGF-&#946; inhibition of cellproliferation. Potentially, targeting specific components of the proteasome
chaperone pathway could be beneficial in treating a subset of MEN1 cases.

Allison B. Weisbrod, MD, Naris Nilubol, MD, Lee S. Weinstein, MD, William F.
Simonds, MD, Steven K. Libutti, MD, Robert T. Jensen, MD, Stephen J. Marx, MD,
Electron Kebebew, MD
Context: The ABO blood type system describes the expression of human bloodgroup antigens found on both erythrocytes and normal tissue throughout the
body. We recently reported an association between O blood type and the
manifestation of pancreatic neuroendocrine tumors in a cohort of patients with
Von Hippel-Lindau (VHL) syndrome. Objective: To determine if there is anassociation of ABO blood type with the development of neuroendocrine tumors inpatients with multiple endocrine neoplasia, type 1 (MEN-1). Design: A
retrospective analysis of 105 patients with MEN-1 was performed. Demographic,clinical and biochemical data were analyzed by ABO blood type. A Fisher Exact
test was used to determine association between ABO blood type andmanifestation of neuroendocrine tumor. Results: We found an association between
O blood type and the manifestation of a primary neuroendocrine tumor of thegastrointestinal tract, lung, pancreas and thymus in patients with MEN-1 (p=0.01).
Sixteen of 17 (94%) patients with metastatic neuroendocrine tumors had type-O
blood as compared to 11 of 32 (74%) who had a benign tumor with non-O blood
type. Demographic and clinical characteristics were similar amongst blood type
cohorts. Conclusions: Our findings suggest an association between O blood type
and the manifestation of a primary neuroendocrine tumor in patients with MEN-1.
Prospective clinical trials are warranted to see if patient blood type status may be
a useful addition to current screening and surveillance practices.

OR2.12
COMPARISON BETWEEN MANAGEMENTS OF MEN1 AND MEN2
Stephen J. Marx MD, Sunita K. Agarwal PhD, Kazuhiko Horiguchi MDPhD,
Thomas Gluick PhD, Craig S. Cochran RN, William F. Simonds MD, Metabolic
Disease Branch, NIH, Bethesda MD 20892 (MarxS@Mail.NIH.Gov)
BACKGROUND: There have been no direct comparisons of all of the major
management issues in MEN1 versus MEN2. METHODS: We assembled the50concepts about major managements of MEN1 and MEN2. Then, we subdivided
these into clinical-based and mutation-based managements. Next, we showed
our judgments about increasing and parallel ranking of importance of the
managements within the four groups. Clinical-based managements strong in
MEN1: *(a) surgery is improved by novel strategy (subtotal parathyroidectomy withthymectomy); *(b) excellent immunoassays (for carrier diagnosis or tumor
monitoring or tumor localization); *(c) surgery guided by (expression and stage oftumors). *(d) excellent medical treatments (for gastric hyperacidity). Clinical-based
managements strong in MEN2: *(a) surgery is improved by novel strategy (easyaccess and timing for thyroidectomy); *(b) excellent immunoassays (for carrier
diagnosis or tumor monitoring); *(c) surgery guided by (determination of the carrierstate). *(d) excellent medical treatments (for removed thyroid). Mutation-based
managements strong in MEN1: *(a) unusual expressions (pheochromocytma or
leydig cell tumor): *(b) non-hormonal expressions (angiofibomas or collagenomas);*(c) absence of identifiable MEN1 gene mutation in germ-line mimics of MEN1
(isolated parathyroid tumors, isolated pituitary tumor, isolated neuro-endocrine
tumor, or isolated and simultaneous sporadic tumor in both the parathyroids andpituitary); *(d) variant of MEN1 with identified MEN1 gene germline mutation(MEN1-Burin); *(e) variants of MEN1 without identified MEN1 gene germline
mutation: (~2% from identified genes [some CDKIs]), ~40% from germline
mutations of MEN1 and/or unidentified genes), Mutation-based managements
strong in MEN2: *(a) unusual expressions (Hirschsprung); *(b) non-hormonal
expressions (neurofibromas); *(c) absence of identifiable RET gene germiline
mutation in germ-line mimics of MEN2 (isolated C-cell cancer or isolated
pheochromocytoma); *(d) variants of MEN2 with identified RET gene
germlinemutation (MEN2a, MEN2b, FMTC); *(e) variants of MEN2 without
identified RET gene germlinemutation: (these are rare). CONCLUSIONS: Clinicalbased managements in MEN1 and MEN2 diﬀer but have changed little. Thesebenefit from immunoassays; they have excellent surgical and medical
managements. Mutation-based tests assist managements (early and accurate
diagnosis of carriers; help to identify variants of syndromes). Overall, the clinicalbased or mutation-based managements diﬀer strikingly.

FRANCE 2 Institut Curie, Centre de Recherche, Orsay F-91405 France and CNRS,
UMR 146 ; 3The E-Institute of Shanghai, Sino-French Life Science and Genomic
Center, Ruijin Hospital, Shanghai, China. 4 Shanghai Clinical Center for Endocrineand Metabolic Diseases, Ruijin Hospital, Shanghai Jiao-Tong University, Shanghai,
200025 China;
Multiple Endocrine Neoplasia Type1 is a hereditary tumor disorder aﬀecting mainly
endocrine organs. MEN1 patients are, in general, carriers of a germinal mutation of
the predisposing gene, MEN1, a tumor-suppressor that is completely inactivatedin tumors by loss-of heterozygosity. In MEN1 patients, pancreatic endocrine
tumors are the major cause of death due to malignancy. To better study themechanisms underlying the tumorigenesis of endocrine cells related to MEN1
inactivation, our group had previously generated &#946;-cell specific Men1-KO
mice that develop insulinomas at 6 months of age, several months after Men1
ablation. This suggests that Men1-disruption itself is not suﬃcient to trigger tumor
development. It is, therefore, crucial to uncover the subsequent molecularalterations following Men1 inactivation that may contribute specifically to
endocrine tumorigenesis. The transcription factor MafB is essential for embryonicand terminal diﬀerentiation of pancreatic &#945; and &#946;-cells. Considering its
oncogenic potential in several other tissues, we investigated the possible
alteration of its expression in our &#946;-cell specific Men1-KO mouse model. We
found that MafB, normally silenced in mouse &#946;-cells, was reactivated in theearly mouse Men1 &#946;-cell lesions and insulinomas that developed in thesemutant mice. Importantly, our data further demonstrated that MafB expression
could be induced following Men1 knockdown by siRNA in cultured INS-1E cells.
Moreover, MafB overexpression in cultured &#946;TC3 cells enhanced cell fociformation both in culture medium and on soft-agar, accompanied with theincreased expression of Cyclin B1 and D2. Conversely, MafB down-regulation by
siRNA transfection reduced BrdU incorporation in INS-1E cells. Taken together,our data reveal that Men1 inactivation leads to MafB re-expression in mouse&#946;-cells in vivo, and provides evidence that deregulated ectopic MafB
expression may play a hitherto unknown role in adult &#946;-cell proliferation and
Men1-related tumorigenesis in the mouse.

OR2.13
Oncoprotein MafB is switched on in early mouse Men1 &#946-cell neoplastic
lesions. R Bonnavion1 Z Hamze1, J Lu1,3,4, , N Herath2, C Pouponnot2, F
Assade1, S Fontanière1, P Bertolino1, M Cordier-Bussat1, and CX Zhang1,3, 1
Team4, Cancer Research Center of Lyon, INSERM U1052, CNRS UMR5286, Lyon
51

OR2.14
Quinazoline sensitive binding sites are promising new targets for chemotherapy ofneuroendocrine tumors

against the toxic eﬀects of prazosin. The identification of the still unknown
quinazoline binding sites which seem to be associated with the cytoskeleton,
might open the possibility to design new cancer drugs for the treatment ofneuroendocrine tumors.

Robert Fuchs (1), Gert Schwach (1), Beate Rinner (2), Tatjana Kueznik (2), Markus
Absenger (2), Eleonore Froehlich (2), Anika Stracke (1), Ruth Birner-Gruenberger(2), Anton Sadjak (1) and Roswitha Pfragner (1) (1) Institute of Pathophysiology
and Immunology, Center of Molecular Medicine, Medical University of Graz,
Heinrichstrasse 31A, 8010 Graz, Austria. (2) Center for Medical Research, Medical
University of Graz, Stiftingtalstraße 24, 8010 Graz, Austria.
Background: Recently we demonstrated that the quinazoline-based alpha1adrenergic blocker prazosin inhibits the growth and induces apoptosis in the
medullary thyroid cancer (MTC) cell lines MTC-SK and TT. Similar to other cell
types, the pro-apoptotic eﬀect of prazosin on MTC-cells is independent of alpha1adrenoceptors. In addition to apoptosis, prazosin treated MTC-cells showprominent alterations of cell morphology, including needle like protrusions and adramatic increase of cell size. Aims: To further characterize the eﬀects of prazosin
on MTC-cells, we analyzed the DNA-content of cells using flow cytometry andperformed live cell imaging to observe the formation of protrusions. For
identification of the target-organelle of prazosin, we used the fluorescent prazosin
derivate QAPB and organelle specific dyes. Furthermore, we tested, whether
prazosin also induces apoptosis in the SI-NET cell line KRJ-I in order to extend
the field of application of quinazoline based drugs to other neuroendocrine
tumors. Results: We discovered that prazosin treated MTC-SK cells exhibit asignificantly higher content of tetraploid cells. Furthermore, an accumulation ofcells arrested in the G2/M phase of the cell cycle was evident. Analysis of TT cells
by Live Cell Imaging showed that the needle like protrusions formed in response
to prazosin treatment are involved in cell fusion which seems to be a frequently
happening process in the TT cell line. Microscopic analysis of TT cells expressing
GFP-actin revealed that the formed protrusions are positive for GFP-actin. Using
QAPB and confocal microscopy, we observed colocalization of QAPB and thelysosomal specific dye LysoTracker®Red. Pretreatment of cells with chloroquine,
which aﬀects the mass and pH of lysosomes, protected MTC-SK cells against thetoxity of prazosin. Assays testing proliferation and apoptosis showed that prazosin
also induces cell death in the SI-NET cell line KRJ-I. Conclusion: We demonstratethat treatment of MTC-cells with prazosin induces apoptosis as well as polyploidy.
The induction of polyploidy seems to be closely associated with alterations of theactin-cytoskeleton of the cells which may result in a defect of cytokinesis and/or
enhanced cell fusion. The lysosomes may act as a buﬀer which protects cells
52

Oral Session 3
OR3.1
Radiofrequency ablation of pulmonary metastases in parathyroid carcinoma: analternative therapy for severe refractory hypercalcemia.
Delmar M Lourenço Jr, Ana Oliveira Hoﬀ, Ana Elisa Evangelista Alcantara, Carlos
H Teixeira, Regina Matsunaga Martin, Pedro Henrique Silveira Corrêa, Publio
Viana, Marcos Menezes
Background: Parathyroid carcinoma (PCA) is a rare disease accounting for0.005% of all malignances and less than 2% of primary hyperparathyroidism(HPT) cases. HRPT2 gene mutations play a central role in the pathogenesis ofparathyroid carcinoma and are observed not only in sporadic but also in familial
cases. Parathyroid carcinoma is an aggressive disease associated with significant
morbidity and mortality. Patients present with severe hypercalcemia, renal
insuﬃciency and debilitating bone manifestations including fractures and browntumors. Surgery is the main treatment but unfortunately recurrent disease isextremely common. With the goal of disease control and improvement ofhypercalcemia, the treatment of metastatic PCA includes surgery of metastatic
lesions, bisphosphonates, radiotherapy, chemotherapy and calcimimetics.
Despite a multidisciplinary approach, death from uncontrolled hypercalcemia iscommon. Recently, radiofrequency ablation of metastatic PCA has been
proposed as an alternative approach to control disease. In this report, we
describe 3 patients with metastatic parathyroid carcinoma that failed
conventional therapy and underwent radiofrequency ablation of pulmonary
lesions. All patients had severe hypercalcemia resistant to hydration, calcitoninand zoledronic acid. One patient was treated with cinacalcet but failed to tolerate
it. All patients had multiple bilateral pulmonary metastases not amenable forsurgery. Severe bone disease (fractures, brown tumors) was observed in twocases and the last presented recurrent pancreatitis. Pre-procedure serum calcium
ranged from 14.8 mg/dL to 19.3 mg/dL and serum PTH ranged from 1519 pg/mL
to 6118 pg/mL. Radiofrequency ablation was performed in at least two steps totreat lesions from both lungs. Normalization of serum calcium and significant

reduction of PTH was observed in all 3 patients. Information on long-term control
is available in 1 patient who remained stable for 7 months when a repeat ablation
was performed and resulted in calcium normalization and disease control for
another 8 months. The other 2 patients were recently treated. Conclusion:
Radiofrequency ablation of metastatic parathyroid carcinoma to lungs is analternative approach to control refractory hypercalcemia.
OR3.2
Clinical features of primary hyperparathyroidism (PHPT) in patients withparathyroid carcinoma.
Mokrysheva N.G., RozhinskayaL.Ya.
Objective: To determine pre-operative predictors of parathyroid carcinoma (PC).
Materials and methods: The pre-operative diagnosis of malignancy is very diﬃcult
to obtain, and, thus, intra-operative recognition of PC is mandatory. A
retrospective review was performed based on the medical records of 358 patientswith primary hyperparathyroidism who underwent surgical treatment between
2000 and 2009. Data of serum levels of calcium and phosphorus, urinary
excretion of calcium, serum levels of CTx, osteocalcin and alkaline phosphatase,creatinine, urea, serum and urine osmolality and GFR (MDRD) were available forall patients. Body composition was determined by X-ray and DEXA. The
ultrasonograms of kidneys, ECG and EGD of all patients were studied for theevaluation of possible complications. Ultrasonography and isotope scanningwere used for regional exclusion. Recurrence rates were evaluated for 214
patients 5 years after surgery. Results: Parathyroid adenoma occurred in 76%(275/358) patients, parathyroid hyperplasia – in 19% (66/258) patients and PC –in 4.7% (17/358) patients. Male/female ratio was significantly smaller in patientswith PC (1:2.5) in comparison with patients with parathyroid adenoma (1:4) andhyperplasia (1:10). No significant diﬀerences were found between the two groups
with regards to age. The median serum levels of PTH (590[252;1650] vs243[150;462], &#1088;=0,03) and ionized calcium (1,6±0,2 vs 1,4 ±0,24 mmol/l)53

were significantly greater in patients with PC. Prevalence of severe complications
was also significantly greater in patients with PC (88%) in comparison withpatients with parathyroid adenoma (52%) and hyperplasia (37%), &#1088;1=0,04,&#1088;2=0,03. Overall recurrence rate 5 years after surgery was 5% (20% forPC, 7.5% for hyperplasia and 3% for adenoma). PC are larger than otherparathyroid lesions (hyperplasia, adenoma) (p=0.005). The risk of malignancy is 3
times more in patients with parathyroid lesion bigger than 6 sm3. Conclusions:
The pre-operative predictors of PC are extremely high serum levels of calcium,
severe complications of PHPT and size of parathyroid lesion more than 6 sm3.

54

Posters
P1
ASYNCHRONUS DEBUT OF THE ADRENAL CUSHING´S SYNDROME BY
BILATERAL MACRONODULAR ADRENAL HYPERPLASIA
Gentil Baldrich Alfonso C 1, Tomé Garcia Mónica 2, Perez Rodriguez José 1,
Martin Hernandez Tomás 1, Sendón Perez Angel 1. 1 Department ofEndocriniology. University Hospital Virgen Macarena. Seville. Spain 2 Service d´endocrinologie. Centre Hospitalier Universitaire de Liege. Belgique.
INTRODUCTION: ACTH-independent macronodular adrenal hyperplasia (AIMAH)
is a rare cause of Cushing's syndrome. Bilateral adrenalectomy is considered thetreatment of choice, with subsequent lifetime steroid replacement, but unilateraladrenalectomy has been recently proposed to reduce the secreting tissue. We
presented two patients witch AIMAH to evaluate the 5-10 years results of
unilateral adrenalectomy concerning the main laboratory, MRI and clinicalabnormalities. METHODS: The patients with confirmed AIMAH underwent
unilateral adrenalectomy of the largest gland. ACTH and cortisol levels, arterial
blood pressure (BP), glycometabolic parameters and MRI, were measured
preoperatively and annually during your evolution. RESULTS: Six months after
unilateral adrenalectomy, clinical improvement was evident. Free urinary cortisol
was normalized as well the morning ACTH and cortisol and low/highdexamethasone suppression, in the beginning and after a follow-up (5 and10
years). The size of the contralateral adrenal appeared quite stable.
CONCLUSIONS: Unilateral adrenalectomy of the largest gland can be an eﬀective
and safe treatment for AIMAH in case of asymmetric involvement. It may achieve
long-term remission of Cushing's syndrome.
P2
Surprising clinical presentation of a family with germline SDHD mutation.
Anja De Rycke 1, Vincent Vander Poorten 2, Esther Hauben 3, Marleen Thijs 4,
Brigitte Decallonne 1 University Hospitals Leuven, Leuven, Belgium 1 dpt ofEndocrinology 2 dpt of ENT/head&neck surgery 3 dpt of Pathology 4 dpt ofRadiology
Introduction: Germline SDHD mutations have been associated with the presenceof multifocal head&neck paragangliomas. Most cases are hormonally inactive andbenign. Papillary thyroid cancer, renal cell cancer and GIST are reported as otherassociated tumors. SDH mutations are transmitted in an autosomal dominantmanner (with paternal transmission of tumor susceptibility). Therefore, genetic
testing should be oﬀered to all first degree relatives. Case description: A 32-year
old Caucasian female was diagnosed with a thyroid nodule. By co-incidence, atneck ultrasound bilateral neck paragangliomas were detected. Thyroid nodule
cytology was inconclusive (follicular neoplasia). After negative functional
screening for catecholamine excess the patient underwent total thyroidectomy toobtain definitive histological diagnosis and resection of one paraganglioma
because of local disturbance. Histological analysis revealed an invasive follicularthyroid cancer (insular subtype) and a paraganglioma. Postoperatively,
radioactive iodine ablation was given. No metastases were observed on posttherapeutic whole-body 131I-scintigraphy. Molecular genetic testing revealed aframeshift mutation in the SDHD gene (c.4.5delC,p.Phe136LeufsX32). CT imagingof thorax and abdomen did not show other paraganglial or extraparaganglial
tumors. At genetic testing, both the 63-year old father and unique 40-year-old
brother were detected as carriers and further clinically screened. In contrast to
the father who was free of clinical disease (suggesting maternal transmission of
the mutation), the asymptomatic brother was diagnosed with multifocal small
head&neck non-secreting paragangliomas and diﬀuse lung metastases (FDG-PETand Ga-68-Dotatoc-PET positive) without evidence for another primary tumor,
apart from a very small (5 mm) nodule in the thyroid with inconclusive fine needle
cytology. Diagnostic resection of a lung metastatic lesion showed typical featuresof metastatic paraganglioma. Because of the diﬀuse lung lesions, the absence ofevidence for hormonal hypersecretrion, the absence of symptoms and the
expected slow tumor growth, a watchful waiting approach was proposed with
control CT imaging after three months. SDHx immunohistochemistry on the55

diﬀerent tumor tissues available is scheduled. Especially in case of the thyroid
cancer this would allow to support the association between SDHD inactivationand follicular thyroid carcinogenesis. Conclusion: We describe a remarkable
kindred with germline SDHD mutation: besides the presence of multifocal nonfunctional bilateral head&neck paragangliomas, one case presented with aconcurrent thyroid cancer of the follicular subtype and one case presented withlung metastases without evidence for another primary tumor. In the near future theclinical spectrum of individuals harboring a pathogenic germline SDHD mutation
will be probably further broadened.

P3
Clinical profile of 25 patients with bilateral pheochromocytoma (PCC) presented toa single tertiary care center in India
Rajeev kasaliwal,Sweta budyal, Harshal kakade Reshma Pandit,Anurag lila, Tushar
Bangar,Nalini Shah
Title: Clinical profile of 25 patients with bilateral pheochromocytoma (PCC)presented to a single tertiary care center in India Objective: To study clinical profile
of patient presented with bilateral PCC presented to a single tertiary care center inIndia Patients and methods: Medical record of 25 patients diagnosed with bilateral
PCC from 1995 to 2012 were reviewed and analysed. Results: Of 25 patients, 12
were male and 13 were female. Mean age of onset of symptom was 23.0±11.7
years (6-50 yrs), and the mean age of diagnosis is 24.0 ± 11.2 (7-53 yrs). The
mean interval between age of onset and diagnosis was 16 ± 5.5 months (1-72
months). Typical history of paroxysmal symptoms was present in 17 patients while
it was incidentally diagnosed in 6 patients, In 2 patients; PCC was diagnosed
during screening due to positive family history. Family history of PCC was present
in 9 patients while 16 patients were apparently sporadic. Plasma freemetanephrines were available in 18 patients. 14 patients had normetanephrine
secreting biochemical phenotype while 4 patients had metanephrine secreting
phenotype. Conclusion: Average age of presentation for bilateral PCC wasyounger. 24% patients with bilateral PCC were diagnosed incidentally. Thoughfamily history was present in only 36% of our patient, all patients with bilateral
PCC should be subjected to genetic analysis as they have high likelihood of
having genetic abnormality.

P4
Malignant abdominal paraganglioma treated by 131I-MIBG (a case report)
Lamia Kedad, Djamila Meskine, Nadira Fafa. Endocrine unit, E.P.H Ibn Ziri
Bologhine, Algiers, Algeria.
Introduction: paragangliomas are rare neuroendocrine tumors that arised fromextra-adrenal sympathetic and parasympathetic paraganglia that derived from theembryonic neural crest. 30% of paragangliomas are genetically determined. They
are often multiple, malignant, recidivant in familial cases. The first line treatment issurgical sometimes combined with therapeutic 131I-MIBG. Case presentation: A
77-year-old women with a familial history of carotid body tumor andRecklinghausen disease in whom a left para-aortic paraganglioma was diagnosed
in 2000 based on clinical, biological and radiological data. Clinical signs were:paroxystic hypertension, palpitations, headaches, excess sweating and abdominal
pain. Urinary methanephrines were high up to 6 fold the normal range. The
abdominal scan revealed a solid left para-aortic mass measuring 60mm indiameter, the MIBG scintigraphy showed a unique left abdominal uptake. In thesame year of diagnosis, the patient underwent a laparotomy with resection of amass measuring 60 mm in diameter. Histologic examination confirmed the
diagnosis of paraganglioma. Post-operatively, hypertension improved and urinary
metanephrines fall into normal range. 8 years later, the patient presented withspinal pain. A spinal MRI discovered a vertebral metastasis in D11. The patientunderwent in 2009 a laminectomy with vertebral arthrodesis. Histologic
examination diagnosed a vertebral metastasis of the paraganglioma. An
angioscann revealed a paravertebral solid mass of 35 mm in diameter with
vascular invasion and high suspicion of malignancy. This mass demonstrated an
intense MIBG uptake. Plasmatic chromogranin was increased. The mass wasunresectable because the tumor showed an important vascular invasion andtissue adhesions. In an attempt to palliate the metastatic disease, a therapeutic
complement with MIBG was given. The patient received 59 mci of Iode131-MIBG
by slow IV infusion. Toxicity was limited to an abdominal pain in day 2 after MIBG
therapy. The control octreoscan revealed many uptakes in the abdomino-pelvic
region however the MIBG scintigraphy didn’t show any uptake. Conclusion:
metastasis of malignant paraganglioma can arise many years after the diagnosis
was made. Familial cases are often malignant, bilateral and recurrent. The followup should last all the life. Genetic testing could be of great interest for this patient
and their relatives in order to make an early diagnosis and an early management.

56

P5
Paraganglioma syndrome: a SDHD mutation family, with a wide spectrum ofpenetrance
Uberta Verga, Marcello Filopanti, Francesca Schiavi, Giuseppe Opocher, MarcelloRodari, Arturo Chiti, Anna Spada1, and Paolo Beck-Peccoz Endocrinology andDiabetology Unit(U.V, M.F. P.B. A.S.), Fondazione IRCCS Ca' Granda Ospedale
Maggiore Policlinico, Milan, Italy Familial Cancer Clinic (F.S., G.O.), Venetian
Institute of Oncology, Padua, Italy Department of Nuclear Medicine (A.C., M.R.),
IRCCS Humanitas, Rozzano, Italy Department of Clinical Sciences andCommunity Health (A.S., P.B.), University of Milan, Italy
Familial paraganglioma (PGL) syndrome is an autosomal dominant disorder due tomutations in genes encoding for subunits of respiratory chain complexes or theirassembly factors. We recently characterized a family aﬀected with PGL syndrome
type 1 due to a new succinate dehydrogenase complex subunit D (SDHD) genemutation c.437A>T p.Asp146Val. The in silico analysis through Pathogenic Or Not– Pipeline attributes a probability of pathogenicity of 98% (standard error:
2.0e-02). The pathogenicity of this mutation is sustained by the negative SDHB
immunohistochemistry of the proband tumor. The proband, male 43 yo, had asurgical intervention for a basicranial right jugulotimpanic PGL at age 24, andrecent surgical operations for bilateral carotid bodies. A post-surgery F-PET-DOPA
scan depicted a 20 mm hepatic mass, suspected to be a malignant PGL liver
metastasis, which is waiting to be removed by DaVinci robotic surgery. His father,82 yo has been operated for right carotid body 40 years ago, while the left has
been recently localized, simultaneously he was found to be carrier of the same
SDH mutation. Genetic analysis has been extended to all relatives with no priorevidence of PGL, showing the mutation in one out of three siblings (male, 50 yo)
and in two out of three children (male 4 yo; female 11 yo). The proband’s brother is
now undergoing radiological imaging and radioreceptorial scan, whereas the son,due to young age, is not yet under investigation. To date, the daughter underwent
to an initial PGL screening by neck and abdomen ultrasound scan that was
negative. Clinically, she was aﬀected with congenital psychomotor retardation,and during childhood she manifested severe visus impairment, ataxia, dystonia,
hearing loss, language and mental retardation, although a definitive diagnosis has
not yet been made. Interestingly, most of these findings were described also in
Leigh syndrome, a clinically heterogeneous mitochondrial disorder due todysfunctions of the respiratory chain complexes, including succinate
dehydrogenase, coenzyme Q, and pyruvate dehydrogenase complex. The
molecular analysis has been extended to SDHA, B, C, D, and AF2 genes. No

mutations has been detected in the coding regions. The mRNA of SDH genes isunder evaluation.Further studies on mitochondrial DNA mutations are ongoing toclarify a genotype-phenotype correlation.

P6
IDENTIFICATION OF SDHA MUTATION IN A PATIENT WITH HEAD AND NECKPARAGANGLIOMA
Elisa Taschin1, Uberta Verga2, Sara Bobisse1, Marcello Filopanti2, Antonio
Bozzani3, Vittorio Arici3, Michele Piazza4, Andrea Olivotto5, Paolo Beck-Peccoz2,
Ettore Seregni6, Ambrogio Fassina5, Franco Grego4, Attilio Odero3, Giuseppe
Opocher1, Francesca Schiavi1 1 Familial Cancer Clinic and Oncoendocrinology IRCCS Veneto Institute of Oncology - Padova, Italy 2 Endocrinology andDiabetology, Fondazione IRCCS Ca' Granda Ospedale Maggiore 3 Division of
Vascular Surgery, Fondazione IRCCS Policlinico San Matteo, Pavia 4 Departmentof Cardiac, Thoracic and Vascular Sciences - University of Padova Padova, Italy 5
Surgical Pathology and Cytopathology Unit, Department of Medicine - Universityof Padova Padova, Italy 6 Nuclear Medicine - IRCCS Foundation-Istituto
Nazionale dei Tumori - Milano Italy
SDHA gene is located on chromosome 5p15 and encodes the flavoprotein subunitof succinate dehydrogenase. In 2010, the first heterozygous germ-line mutation
associated with a catecholamine-secreting extra-adrenal PGL was identified, andshowed that tumor associated with SDHA mutation displays negative staining for
SDHA as well as SDHB. More recently, using an immunohistochemical procedure,other two diﬀerent SDHA mutations in five non-related patients were identified:
one with pheochromocytoma, two with sympathetic PGL and two with head andneck PGL. It has been demonstrated that SDHA is a tumor suppressor geneassociated to Paraganglioma syndrome type 5. Case report In 2009, a 28-yearsold man presented with an evident mass on the neck; there was no known historyof familial syndromes associated to head and neck paraganglioma. The patientunderwent computed tomography examination which demonstrated a 2,5 cm rightcarotid body solid mass. In 2009 a non secreting paraganglioma (2,5x1,2x1,1) wasremoved. There was evidence of malignancy in the lymphonodes. In 2010 and2011 the patient underwent additional surgeries for local recurrences. In order todetect alterations related to a heritable disorder, complete genetic testing for the
known genetic loci associated with paraganglioma, SDHB, SDHC, SDHD and
SDHAF2 genes, has been performed. Large genomic deletion or duplication
57

analysis was analyzed by multiplex ligation-dependent probe amplification(MLPA). No pathogenic sequence variant has been identified. Recently,
immunohistochemistry was carried out for SDHB and SDHA and both resulted
negative for protein expression. Sequence analysis of SDHA was performed on
germ-line DNA, identifying a point mutation aﬀecting the splice acceptor site ofexon 14 (c.1795-1G>T). Sequence splicing variation was analyzed using Human
Splicing Finder and Splice Site Prediction by Neural Network, software thatcompares normal with variant sequences for diﬀerences in potential regulatory
signals, including donor and acceptor sites. In silico analysis indicated that the
SDHA splicing mutation was predicted to disrupt the acceptor splice site. The
eﬀects of the mutation on RNA splicing and the study of the loss of heterozygosity
in the tumor are ongoing. In case of a patient without familial or clinical indications
for a particular type of PGL syndrome, it’s possible to combine molecular analysis
strategy with SDHA-SDHB staining on paraﬃn-embedded tumors to identify
patients carrying germ-line SDHA mutations. This case report describes theseventh patient aﬀected by PGL5, the fourth SDHA mutation and the first casewith evidence of malignancy associated to PGL5.

performed direct sequencing on CDKN1B exons and exon/intron boundaries in 69
samples comprising parathyroid carcinoma (CA, n=6), atypical adenoma (AA, n=9)
and typical adenoma (TA, n=54) in an Italian cohort of primary hyperparathyroid
patients having no mutations in the MEN1 gene. LOH analysis for the CDKN1B
locus (chr 12p13.1) was performed in a subset of samples, and promoter
hypermethylation was also assessed. In a CDC73 mutation-negative CA and in
two TAs, we identified 3 heterozygous coding variants – S100I, c.50delAinsGG,
F62V, respectively. Clearly the c.50delAinsGG mutation involving a frameshift(p.D17del/ins/fsX124) would be deleterious. Moreover, an intronic variant(IVS1+30G>A) was observed in a CA case. The germline CDKN1B sequence of alltested samples was normal. None of the variant CDKN1B sequences was found in2000 previously reported alleles from normal individuals (1000 Genomes
Database). LOH was detected in 6 of 33 cases (18,2%) but promoter
hypermethylation was not observed. Flag-tagged p27Kip1 mutant F62V and S100I
constructs transfected into HEK293 cells were as well expressed as wild-type andwere unaﬀected by the proteasome inhibitor MG132. Our data suggest that the
CDKN1B gene can be involved, albeit rarely, in the pathogenesis of sporadic
parathyroid tumours. Additional functional analyses are ongoing.

P7
P8
Identification and functional analysis of novel variants of CDKN1B (encoding
p27Kip1) in sporadic parathyroid tumors from an Italian cohort

CDKN1B V109G POLYMORPHISM AS A NEW PUTATIVE PROGNOSTIC FACTORIN MULTIPLE ENDOCRINE NEOPLASIA TYPE 1 (MEN 1) PATIENTS

Vito Guarnieri1, Filomena Baorda1, Sabrina Corbetta2, Claudia Battista3, Anna
Spada2, Leonardo D’Agruma1, David E C Cole4, Geoﬀrey N Hendy5, Alfredo
Scillitani3 1: Medical Genetics and 3: Endocrinology, IRCCS “Casa Sollievo dellaSoﬀerenza”, San Giovanni Rotondo (FG), Italy; 2: Endocrinology and Diabetology
Unit, Department of Medical Sciences, University of Milan and IRCCS Policlinico
San Donato, San Donato Milanese, Milan, Italy; 4: Departments of Laboratory
Medicine and Pathobiology, Medicine and Genetics, University of Toronto, Toronto
ON, Canada; 5: Calcium Research Laboratory and Hormones and Cancer
Research Unit, Royal Victoria Hospital, Montreal, QC, Canada

L. Circelli1, V. Ramundo2, F. Marciello2, M. Del Prete2, V. Marotta2, A. C. Carratù2,
R. Esposito2, C. de Luca di Roseto2, D. Pasquali3, A. Colao2, A. Faggiano2,4, V.
Colantuoni5 1CEINGE SCARL, Advanced Biotechnologies, Naples; 2Departmentof Clinical and Molecular Endocrinology and Oncology, “Federico II” University of
Naples; 3Department of Cardiothoracic and Respiratory Sciences, Second
University of Naples; 4Endocrinology, National Cancer Institute, “Fondazione G.
Pascale” Naples; 5Department of Biological, Geological and Environmental
Sciences, University of Sannio, Benevento, Italy

Mutations in the MEN1 gene not only cause the MEN1 syndrome but are also
found in sporadic hyperparathyroid tumors. Recently, a novel MEN-like syndrome,MEN4, was described, caused by heterozygous germline inactivating mutations of
the CDKN1B gene, encoding the cyclin-dependent kinase inhibitor, p27kip1. In
addition, somatic CDKN1B mutations have been reported in sporadic parathyroid
adenomas. To further investigate the contribution of such abnormalities, we

Background: CDKN1B encodes the cyclin-dependent kinase (Cdk) inhibitor p27(Kip1), an important cell-cycle regulatory protein that inhibits the progression from
G1 to the S phase. Loss of p27 function may contribute to tumorigenesis. A totalof 21 single nucleotide polymorphisms in CDKN1B have been described. Of
these, only one single nucleotide polymorphism (T/G) causes a glycine for a valine
substitution at codon 109. This V109G polymorphism aﬀects p27 degradation in58

vivo and appears to be associated with several cancers, suggesting that it may
play a role in tumor progression. Furthermore, expanded pedigree analysis
showed that p27 mutations are associated with the development of a MEN-likephenotype in multiple generations. In a previous study, we demonstrated that the
V109G polymorphism is associated with a better prognosis in patients withsporadic medullary thyroid cancer. Multiple endocrine neoplasia type 1 (MEN1) isa rare autosomal dominant syndrome, with inter- and intra-familial variability,
without a known genotype-phenotype correlation. This emphasizes the need for
new prognostic markers to better understand the outcome. Aim: To evaluate thefrequency of the CDKN1B V109G polymorphism in patients with MEN1 andcorrelate its presence with disease progression and outcome. Patients & Methods:
31 consecutive MEN 1 patients followed at the Neuroendocrine Tumors Unit of theFederico II University of Naples, were enrolled. The V109G polymorphism was
examined in all cases on the germline DNA, using PCR amplification of exon 1,
followed by direct sequencing of the amplicon. Tumor type, severity and follow-up
data were collected and related to the genetic data. Results: Out of 31 MEN1
patients, 10 were positive for the V109G polymorphism. Among them, 2 required
surgery because of a G2-type proliferating tumor (1 pancreatic neuroendocrine
tumor, 1 atypical thymic carcinoid) and 1 had a pancreatic neuroendocrine tumor
which progressed under therapy. Out of the remaining 7 patients, 6 had stablepancreatic neuroendocrine tumors and 1 had no pancreatic neuroendocrine
tumor. Twenty-one patients tested negative for the polymorphism, 13 of whichshowed stable pancreatic neuroendocrine tumors, without progressive disease ormetastasis, and 8 had no pancreatic or thymic neuroendocrine tumors.
Conclusions: The present data suggest that CDKN1B V109G polymorphism may
play a critical role in the outcome of MEN1 patients not addressed so far. Further
studies are needed to better elucidate the mechanisms underlying the interplay ofthis polymorphism with the MEN1-gene pathway.

P9
Potential Benefits of PET-CT Imaging in the Management of MEN1 Syndrome
Maria Dunca, Moreno Rodrigo, Bernard Corvilain, France Devuyst
Introduction The management of MEN 1 syndrome requires screening for thepresence of multiple tumours both through biochemicals evaluations and the useof diﬀerent imaging techniques. The role of the PET-CT imaging in evaluating thissyndrome is still to be determined. Clinical case study A 49-year old man, suspectof MEN1, was referred to our department, for persistent primary
hyperparathyroidism, already operated twice, unsuccessfully. A 99mTc MIBI
scintigraphy suggested the presence of pathologic parathyroid tissue in the areaof the thyroid isthmus and the anterior mediastinum. A 11C-methionine PET-CT
was performed and revealed two hypermetabolic lesions, one in the right
retrotracheal area, the other in the thymic region. A 18F- FDG PET-CT revealed
that the thymic lesion was highly hypermetabolic while the retrotracheal masscaptured only slightly FDG. Surgery was performed: a benign parathyroid
adenoma was removed. The final pathology examination of the thymic mass
revealed a B3-type thymoma. The MEN1 syndrome was confirmed by genetic
testing (c.1328delC mutation) Conclusion Thymic carcinoids occur in 2 to 5 % of
MEN 1 patients, but the occurrence of a thymoma as in our patient is much rarer.
In our case, thymoma and parathyroid adenoma had the same avidity formethionine, but the avidity of the thymoma for FDG was higher. This permitted us
to speculate not only on the nature but also on the degree of malignity of thesetwo diﬀerent tumours.

P10
Primary hyperparathyroidism confirmed by histology: sensitivity and predictors of
99mTc-Sestamibi / CT scan.
Dr Hernan VALDES SOCIN, Dr Carmen BISOGNIb Dr Daniela BETEA, Dr Henri
LILLET, Dr Irene SCAGNOL, Pr Roland HUSTINX, Dr Etienne HAMOIR, Pr Michel
MEURISSE, Pr Albert BECKERS. University of Liège. BELGIUMOBJECTIVE: The purpose of this study is to evaluate the sensitivity, the positive
predictive value (PPV) and predictors of 99mTc-Sestamibi / CT scan dual phase inpatients with primary hyperparathyroidism (PPH) with histologic confirmation.
PATIENTS AND METHODS: Since 2011 to 2012, we have investigated 35
consecutive patients with (PPH). They underwent biological studies, cervicalultrasonography and a neck-chest CTscan/99mTc-MIBI scintigraphy. A total of
19/35 patients had an histological confirmation after cervical exploration.
Sensitivity and positive predictive value (probability that the disease is present
when the test is positive) of this method were calculated. RESULTS: At diagnosis,
the average age of the patients (15F / 4 H) was 54±14 years. 99MTc-MIBI CT scan
was positive in 14/19 cases: sensitivity = 74% and (VPP) = 100%. The left/rightlateralization predicted by the scan (and found by the surgeon) was concordant in
14/19 cases and discordant in 3/13 cases. In 5 cases with negative scan, cervical59

exploration found in 4 cases an adenoma and in another case, three hyperplastic
glands. The probability of a positive scan is not associated with age, gender orweight of parathyroid (p > 0.1). CONCLUSIONS: 99mTc-Sestamibi / CT scan has ahigh VPP for identification of pathological parathyroid glands. However, a negative
scan does not exclude a parathyroid adenoma. A frequent growth pattern ofsuperior polar adenomas through the inferior thyroid pole is a potential misleading
diagnosis.

P11
Neuroendocrine tumors: additional value of new molecular imaging tracers in thedetection of recurrent/residual disease
Uberta Verga, Marcello Filopanti, Laura Fugazzola, Marcello Rodari, , Egesta
Lopci, Arturo Chiti, Francesca Schiavi, Giuseppe Opocher, Vittorio Achilli, Anna
Spada and Paolo Beck-Peccoz Endocrinology and Diabetology Unit,(UV,MF,LF,AS,PB) Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico,Milan, Italy Department of Clinical Sciences and Communiyi Health,(LF,AS,PB)
University of Milan, Italy Department of Nuclear Medicine, (AC,MR,EL)Humanitas
Cancer Center, Rozzano, Italy Familial Cancer Clinic,(FS,OP) Venetian Institute of
Oncology, Padua, Italy Unit of Otorhinolaryngology and Cervicofacial Surgery,Unitof Otorhinolaryngology and Cervicofacial Surgery, (VA) Ospedale Maggiore di Lodi,
Lodi, Italy Ospedale Maggiore di Lodi, Lodi, Italy
Context: Recent studies have proposed the use of new molecular imaging tracers,
such as 18F-DOPA and 68Ga-DOTANOC, in studying neuroendocrine tumors(NET) and in particular for the detection of recurrent or residual disease in case ofnegative conventional imaging modalities. Objective: to evaluate sensitivity of 18FDOPA PET/CT and 68Ga- DOTANOC PET/CT in the detection of residual/recurrent
NET. Patients: 15 patients (M:F=7:8; median age 51, range 27-79), withhistologically proven NET were prospectively enrolled. In all cases, there was abiochemical evidence of recurrent/residual disease, not evident with conventional
imaging techniques (¹¹¹In-DTPA-octreotide scan, MRI and/or TC). Six patients had
medullary thyroid carcinoma (MTC) with post-surgical persistence of increased
calcitonin (3 MEN2A, 1 FMTC, 2 sporadic), 2 patients had a suspect ofpheocromocytoma with increased urinary metanephrines/normetanephrines(MEN2A), 5 were aﬀected with head-and-neck non-secreting paraganglioma(PGL), SDHB and SDHD mutation gene carriers underlying multiple/malignant PGL
syndrome, and two patients had MEN1 (Hyperparathyroidism, one pancreatic

GHRH-secreting, and the other with bronchopulmonary NET). Intervention: Allpatients underwent investigation with 18F-DOPA PET/CT (13 cases) or 68GaDOTANOC PET/CT (2 cases). Results: Among patients undergone to 18F-DOPA
PET/CT, the presence of disease was identified in 9/13 cases (69%), whereas thetwo MEN 1 patients investigated with 68Ga-DOTANOC PET/CT resulted negative
for residual disease, in contrast with the presurgical imaging that localized multiple
pancreatic GHRH secreting lesions. In particular, in 4/6 cases with MTC (66.7%),
18F-DOPA PET/CT detected loco-regional recurrence in the thyroid bed, upper
mediastinum, laterocervical region. Two patients with suspect ofpheocromocytoma (MEN2A) showed a positive uptake in the adrenal gland.
Whereas 4 patients out of the 5 cases with PGL (80%) had a documented
recurrent/residual disease at 18F-DOPA PET/CT in the head-and-neck district(cervical, pharyngeal) and one showed a liver metastasis. Discussion: The
identification of limited residual/recurrent disease in NET is crucial for patientmanagement and therapeutic optimization. In the present study, residual/recurrent
disease was documented in 69% of the overall NET population and in 80% of
patients aﬀected with PGL, strongly suggesting that the introduction of newmolecular imaging tracers, such as 18F-DOPA and 68Ga-DOTANOC permits anearly diagnosis of minimal disease even in case of negative conventional imaging
modalities.

P12
Multiple endocrine neoplasia type 1: initial experience and management
Audrius Šileikis, Edvinas Kildušis, Virgilijus Beiša, K&#281;stutis Strupas
Multiple endocrine neoplasia syndrome, type 1 (MEN1) is an underdiagnosed
autosomal dominant inherited cancer syndrome. Disease is caused by mutationsin the MEN1 gene on chromosome 11. Patients with MEN1 have a shorter life
expectancy than the general population. Recognition of the syndrome is important
both for treatment and for evaluation of family members. Aim We present ourexperience of management of genetically confirmed MEN1 family members from
Lithuania. This is the first set of well characterized MEN1 mutation carriers
presented from Lithuania. Materials and Methods Retrospective case study ofMEN1 patient and his family was performed. Data collected from medical records
included anamnesis of illness, clinical characteristics and findings, treatment,
surgical procedures and genealogy. Results The 22-year-old man was operated
for adhesive intestinal obstruction and metastases of neuroendocrine carcinoma
60

in the lymph nodes at the stomach were found. During
esophagogastroduodenoscopy the primary tumor in the gastric body was found.
Gastric resection by Billroth I was performed and the diagnosis of welldiﬀerentiated neuroendocrine tumor secreting gastrin was established. Following acomputer tomography scan of the abdomen multiple foci in the pancreas were
found. Hyperparathyroidism and hypercalcaemia remained. We clinicallysuspected and oncogeneticist confirmed diagnosis of MEN1. Well-diﬀerentiatedpancreatic neuroendocrine tumors (somatostatinoma, gastrinoma) wereenucleated from caput, corpus and tale of pancreas. Recently subtotal
parathyroidectomy for hyperparathyroidism was performed. In total 8 additional
clinically asymptomatic family members were found to be mutation carriers. Fourof them were found to have characteristic biochemical abnormalities afterlaboratory investigations. They are followed-up and treated. Discussion At present
the diagnosis must be established by direct mutation testing. MEN1 patients, theirrelatives and patients suspected of MEN1 are eligible for mutation testing. MEN1
patients and mutation carriers should be subjected to periodic screening in orderto detect manifestations in an early stage. Early genetic diagnosis and subsequent
periodic screening is associated with less morbidity and mortality at follow-up.

P13
Laboratory management of Multiple Endocrine Neoplasia Type 1 genetic test:
results and considerations of two decades of activity

no MEN1 germline mutation is identified, genetic ascertainment can be performedby 11q13 haplotype analysis in at least two diﬀerent generations of aﬀected
members. We performed 11q13 microsatellite haplotype analysis in 8 living and 1
deceased members of a MEN1 Italian family without any MEN1 mutation. The
application of ancient DNA forensic techniques, in association with modern
molecular biology approaches, allowed to identify the familial disease-associatedhaplotype and to identify two young asymptomatic subjects as non-carriers of thedisease haplotype and thus not at risk of develop MEN1 syndrome. The multiplex
ligation-dependent probe amplification (MPLA) allows to identify large deletions
within the gene using at least two generations of clinically aﬀect subjects and nonaﬀected relatives. Using this technique we identified a large deletion within MEN1
gene in a MEN1 family, identifying two mutated members, confirming the clinicaldiagnosis and enabling the early genetic test for the young, still unaﬀected,
generations of this pedigree. A negative genetic test can also be due to aphenocopy, such as MEN4, caused by mutations in CDKI gene. Genetic screeningof CDKI gene is strongly recommended in MEN1 negative subjects. We analyzed 7
suspected MEN4 patients for mutations of the CDKI gene, failing to find any
mutation in all of them. In conclusion, MEN1 genetic test is strongly recommended
for all the members (symptomatic and asymptomatic) of a family in which agermline MEN1 mutation has been previously identified, since it allows to identify
asymptomatic mutant gene carriers leading to perform earlier and more frequentbiochemical and imaging screenings for MEN1 tumors and helping to reducemorbidity and mortality. 1. Lemos MC, Thakker RV. Hum Mutat 29(1):22-32, 2008

Francesca Marini, Francesca Giusti, Ettore Luzi, Debora Strigoli, Francesco
Franceschelli, Sergio Fabbri, Simone Ciuﬃ, Francesco Tonelli and Maria Luisa
Brandi. Regional Center on Endocrine Hereditary Tumors of the “Regione
Toscana”, Department of Internal Medicine, University of Florence, Florence, Italy

P14

Since the identification of MEN1 gene, our Laboratory has set up and performed
mutation analysis, by PCR-based sequencing of coding region (exon 2-10) andintron-exon junctions. We identified 73 diﬀerent mutations: 31 frameshift (42.5%),
20 missense (27.4%), 12 nonsense (16.4%) and 10 splicing site (13.7%),
confirming percentage data from literature [1]. 57 mutations was found only in one
family or one single case. We identified a family with two diﬀerent mutations (inexon 4 and in exon 8), both inherited by the same parental lineage. No correlation
between genotype and phenotype has been found, in our series, for any mutation.
In about 30% of clinically aﬀected individuals we failed to find any mutation incoding region and intron-exon junctions of MEN1 gene. When in a MEN1 pedigree

Budyal SR, Kasliwal R, Lila AR, Bandagar TR, Shah NS

A Case series of three patients with multiple endocrine neoplasia type 1:
molecular diagnosis, treatment and follow up.

Introduction: We present the clinical profile, treatment, follow up and moleculardiagnosis of 3 patients with MEN 1. Clinical Profile: All the patients were females
and the age at the development of first symptom were 5years (patient 1), 20 years(patient 2) and 33 years (patient 3) respectively. The components at thepresentation were insulinoma and prolactinoma respectively in patient 1 and 2,
whereas patient 3 presented with both prolactinoma and insulinoma. Patient 1
subsequently developed prolactinoma (22 yrs) and hyperparathyroidism (HPT) (27yrs); patient 2 developed gastrinoma (25 yrs) and HPT (30 yrs) and patient 3
61

developed HPT (35 yrs). All the patients had microprolactinoma. None of thepatients had positive family history. Treatment: Microprolactinoma is containedwith cabergoline in all patients (0.25-0.5 mg/week). Patient 1 and 3 underwent 3.5
parathyroidectomy, whereas patient 2 underwent total parathyroidectomy withimplantation of the gland in sternocleidomastoid. For insulinoma, patient 1 hasundergone Whipples Procedure and distal Panareactosplenctomy (due topresence of multiple PNETS in heads and tail) and patient 3 underwent distal
Pancreatectomy and splenectomy. In patient 2, gastrinoma is symptomaticallytreated with PPIs. Follow up: Patient 1 and 2 have developed hypoparathyroidism
whereas patient 3 developed recurrence of HPT after 3 years of surgery. Molecularstudies: PCR based DNA sequencing was done for menin gene (exon 2-10). MEN
1 mutation is positive in all the patients (reported mutation in patients 1 and 2,
novel mutation in patient 3). Patient 1 has point mutation in exon 4 [codon 220
TGG(Trp) > TAG(Stop)]. Patient 2 has point mutation in exon 2 [codon 42 GGC(Gly)> GAC(Asp)]. Patient 3 has deletion exon 3 [codon 156 c.506delG].

P15
Incidental Sarcomatoid Carcinoma of the Kidney in a Young MEN1 Patient. Case
report and genetic profile.
Cavalli Tiziana, Giudici Francesco, Nesi Gabriella, Giusti Francesca, Marini
Francesca, Cavalli Loredana, Brandi Maria Luisa, Tonelli Francesco
Herein we report a case, unique to our knowledge, of renal sarcomatoid
carcinoma with concomitant omolateral non-secreting adrenal adenoma occurringin a young male MEN1 patient, previously operated on for hyperparathyroidism
and multiple pancreatic neuroendocrine neoplasms with suspected liver
metastasis: three duodenal gastrinomas, 25 non-secreting pancreating NETs with5 metastatic pancreatic-duodenal lymph nodes. The hepatic lesion resulted Focal
Nodular Hyperplasia. The following year he had undergone total
parathyroidectomy and tymectomy with parathyroid graft in the right forearm. The
patient is also aﬀected by pituitary prolactinoma, recently increased in size, andmicrocytic anemia. MEN1 genetic analysis had evidenced the presence of thegerminal missense Leu413Pro mutation in the exon 9 of the gene. In July 2010 thepatient underwent surgical intervention. A lumbar incision was performed withremoval of left twelfth rib, isolation of the kidney with the adipose capsule andidentification of the tumor, which had a diameter of 3 cm; it appeared at the centerof the kidney and deep, reaching to the pelvis. Above it there was an adrenal

nodule about 1,5 cm in diameter. A nephro-adrenalectomy was chosen. Double
ligation of the renal vessels, section of ureter, spermatic and phrenic vessels. An
intraoperative ultrasonography showed no nodules in the distal pancreas.
Macroscopic examination described a macroscopic renal lesion of 2.8 x 3 cm;
adrenal gland of 7 x 3 x 1 cm with a lesion of 1.5 x 1.2 cm. After a proper request
for consent to the patient, multiple biopsies were made on fresh surgical
specimen, and immediately sent to our laboratory for genetic study. The somatic
alterations found on biopsies were then compared with germline mutations
detected in a blood sample. The histopathological diagnosis was as follows:
malignant biphasic cortico-medullary renal neoplasm with tubulo-papillaryepithelial component and mesenchymal components osteo-sarcomatous andgiant-cell, 3 cm in greatest dimension. Morphological picture referring to carcinosarcoma with heterologous diﬀerentiation. In the sections examined, no evidenceof tumor in perirenal adipose tissue and in renal vessels. Capsulated corticoadrenal tumor, maximum diameter 1.5 cm. No evidence of capsular and vascularinvasion. Absence of necrosis and atypical mitotic figures. Proliferative fraction
with Ki-67 below 1%. Histological and immunohistochemical findings suggestive
for an adrenocortical adenoma. Molecular analysis in the MEN1 locus at 11q13
showed loss of eterozigosity (LOH) in the adrenal lesion, while the kidney tumor
resulted unrelated to MEN1 syndrome. No chemotherapy was performed. The
patient is disease-free after 2 years of follow up.

P16
Diﬀerent phenotypes of multiple endocrine neoplasia type 1 (MEN1) : a casereport of an Italian family.
Sciortino G, Vitale G, Manfredi G , Guizzardi F, Persani L
INTRODUCTION: MEN1 is a rare autosomal dominant familial cancer syndrome
characterized by involvement of parathyroid glands, enteropancreatic endocrine
tissues and anterior pituitary gland. This disease is linked to germline mutations in
the MEN1 gene (more than 460 described), whose identification allows the familial
genetic counselling. We describe here the clinical correlates of a germinal
mutation in exon 10 of the MEN1 gene identified in an Italian family CASEREPORT: A 61-year-old woman was admitted to our Unit of Endocrinology
because of recurrent kidney stones, osteoporosis, upper abdominal pain. She
reported previous surgical removal of multiple lipomas, hysterectomy for uterine
leyomiomas, hyperprolactinemia since the age of 30. Multiple cases of endocrine
62and non endocrine tumors occurred in both maternal and paternal side of thefamily. Interestingly, one cousin and her four oﬀspring were aﬀected by familial
isolated primary hyperparathyroidism. Proband’s laboratory examinations showed
PHPT, mild hypergastrinemia, high CgA and hyperprolactinemia. Neck US showed
multinodular goiter and a voluminous parathyroid enlargement, while bonedensitometry disclosed severe osteoporosis. Therefore, she underwent subtotal
parathyroidectomy; histological diagnosis was diﬀuse cells hyperplasia. Abdomen
MRI showed pancreatic cyst, undetermined pelvic lesions and left adrenal lesion.
MRI with gadolinium disclosed a pituitary microadenoma. The proband’s son (40yr-old), reported a history of recurrent kidney stones already treated with laser
lithotripsy, sexual dysfunction, pseudo-gynecomastia and multiple lipomas.
Laboratory data revealed PHPT, severe hyperprolactinemia, hypogonadotropic
hypogonadism. Neck US exploration disclosed multinodular goiter; (99m)Tcsestamibi parathyroid scintigraphy was negative. The MRI showed a pituitary
macroadenoma invading the right cavernous sinus. In all members with clinicaldiagnosis of MEN1 or FIHP the genetic testing identified a MEN1 germline
heterozygous deletion of 1bp in exon 10, p.K564RfsX3 (c.1691delA), referencesequence: ENST00000377313, resulting in a frameshift generating a prematuretermination codon. CONCLUSION: It has been well established that thepenetrance for all clinical features of MEN1 syndrome is age-related and PHPT is
the earliest (above 95% by age 40). In our family there is a diﬀerent phenotypic
expression of the same mutation in MEN1 gene: classical MEN1 and FIHP. We
cannot exclude that other unknown molecular events may have influenced thisdiﬀerent clinical expression. Further studies will be needed to confirm thishypothesis.

P17
Rare disease associated with multiple endocrine neoplasia type1 ?
Kiyomi Horiuchi, Akihiro Sakurai, Shinichi Suzuki, Shinji Kosugi, Takahiro
Okamoto, Shinya Uchino,Akihiro Miya, Tsuneo Imai, Hiroshi Kaji, Izumi Komoto,
Daishu Miura, MasanobuYamada, Shohei Hirakawa, Makoto Kanmori, Shigeki
Koizumi, Takehito Igarashi,Iwao Sugitani, Rika Miyabe, Takuyuki Kabatami, Hiroshi
Takeyama, Takashi Uruno,Masanori Yamazaki, Sanae Midorikawa, Toshihiko
Fukushima, Kazuyo Kiribayashi, Miyuki Katai, Toyone Kikumori, Atsuo Iwatani,
Atsushi Ozawa,Akira Miyauchi, Masayuki Imamura, MEN Consortium of Japan.
We investigated rare disease associated multiple endocrine neoplasia type1.
There were 582 patients registered as MEN1from the data of MEN Consortium ofJapan. 76 patients (13%) had complications without thymic tumor, adrenal tumor,
facial angiofibroma, and lipoma. The average age was 48 years old (11~79) whichis rather older than average age (47 years old) of all 582 patients of MEN1. Of 76
patients, 21 were male and 54 were female and 1 was unknown. Forty-one
patients (53.9%) had malignant disease and 31(40.8%) had benign disease and 4
were unknown. The average age of complications was 49.9 years old for
malignant disease and 43.3 for benign disease. Of malignant complication, 13(17.1%) had thyroid neoplasia (1: medullary thyroid carcinoma & 12: papillary
thyroid carcinoma) and 2 had colon cancer and another 2 patients had lungcancer. For benign complication, 13 (17.1%) had myoma uteri and 9 (11.8%) had
thyroid adenoma or denomatous goiter of the thyroid. It is interesting thatfrequency of papillary thyroid cancer in MEN1 patients is rather high.

P18
CLINICAL CASE OF MULTIPLE ENDOCRINE NEOPLASIA (MEN) TYPE 1: L. Rozhinskaya1, L. Dzeranova1, A. Lipatenkova1, A. Kochatkov2, E. Pigarova1,
L. Rostomyan1,3 1 Department of Neuroendocrinology and Bone diseases,
Federal state research centre for endocrinology, Moscow, Russia 2 Department of
abdominal surgery, A. V. Vishnevsky Institute of Surgery, Moscow, Russia. 3
Department of Endocrinology CHU de Liège, Liege, Belgium
The age-related penetrance for all features of MEN type 1 rises above 50% by age
20 years and above 95% by age 40 years. Aim: to describe the clinical course of apatient with MEN type 1 developing sequentially endocrine tumors. Case report: A
32 y.o. woman presented with three main components of MEN type 1 and tumors
in both adrenals. Disease had manifested at the age of 16 years with headaches
and oligomenorrhea then progressed to amenorrhea. The CT scan and hormonal
tests revealed a prolactin-secreting macroadenom&#1072; and absence ofmacroprolactinaemia. Long-term medical treatment with high doses of dopamineagonists didn’t result in normalization of prolactin levels. At age of 22 years sheunderwent a transnasal adenomectomy without remission. Cabergoline wascontinued in escalating doses from 2.5 to 10 mg/week without positive eﬀect on
prolactin levels, which were normalized only after second transnasal
adenomectomy at the age of 30 years. Primary hyperparathyroidism wasdiagnosed at age 28 years caused by 1.4cm adenoma of the right inferior
parathyroid gland, hyperplasia of right inferior and left superior parathyroid glands
and successfully cured by total parathyroidectomy with autotransplantation of the63least changed gland in the left forearm. Genetic tests were performed at age of 29
years and revealed R415X mutation in MEN1. Nonfunctioning adenomas in bothadrenals were found at age of 30 years. One year later the symptoms ofhypoglycemia appeared (anxiety, behavior changes, weight gain, headache,dizziness, hunger, tremor blood sugar levels 1.8-2.8 mmol/l). The 72-hour fasting
test was positive stopped at 9 hours due to hypoglycemia with normal levels of
insulin and C-peptide, extremely increased levels of proinsulin. On endoscopic
ultrasound, CT with contrast and MRI two lesions were visualized in the head andthe tail of the pancreas. Celiac arteriography, mesenterial arteriography,
angiography of hepatic vein - showed an increase in insulin and C-peptide levels
only in distal parts of the pancreas and allowed to perform a successful organ
saving operation - resection of the pancreas tail, lymphadenectomy. At the last
follow-up (2 years later) the patient has normal levels of prolactin, PTH, calcium,
glucose, insulin, C-peptide, marginally increased proinsulin. Conclusion: This casedemonstrates multiple formations of endocrine organs step-by-step appearing
during 17 years. Starting with macroprolactonoma resistant to dopamine agonists
therapy other endocrine disorders developed gradually eventually leading to life
threatening extreme hypoglycemia caused by multiple pancreas lesions, one ofwhich produced proinsulin in high levels.

evaluated. To eﬀectively select patients at high risk of having MEN and perform
appropriate work-up procedure, we here propose diagnostic flow charts for MEN1
and MEN2. They consist of 6 and 2 flow charts for MEN1 and MEN2, respectively.
Each flow chart starts from a single endocrine disorder (hyperparathyroidism,
gastrinoma, insulinoma, other functioning pancreas NET, nonfunctioning pancreas
NET and pituitary tumor for MEN1, and thyroid tumor and pheochromocytoma forMEN2). Although consistency with the previously published guidelines ismaintained, we reflected some data obtained from analysis of the multicenter
database established by MEN Consortium of Japan. This database includes 560
MEN1 cases and 505 MEN2 cases. For example, we unconditionally categorized
patients with insulinoma diagnosed before 20 years as “suspected as MEN1” andrecommended to oﬀer them MEN1 genetic testing. These charts are now underpeer-review by committee members of Japan Endocrine Society, and will be
released after public hearing and subsequent revision. Although sensitivity andspecificity of these flow charts need to be validated in future, they are expected tolead to early diagnosis and appropriate intervention for patients with MEN and to
improve prognosis of those patients.

P20
P19
Proposal of diagnostic flow charts for MEN1 and MEN2
Akihiro Sakurai, Tsuneo Imai, Shinji Kosugi, Shinichi Suzuki, Shinya Uchino,
Masayuki Imamura, Akira Miyauchi, MEN Consortium of JapanThe early diagnosis of MEN and disease-related endocrine disorders is expected
to reduce morbidity and mortality of aﬀected patients. However, many patientswith MEN likely remain undiagnosed or are diagnosed only after a significant time
has elapsed. For example, previous studies reported that in average, 10-17 years
elapse from the appearance of first manifestation to the diagnosis of MEN1. There
are some possible reasons for this delay. Most of clinical symptoms in MEN
patients are nonspecific (such as urolithiasis, peptic ulcer, amenorrhea,
hypertension etc.), and are commonly seen by other causes. Also, due toinsuﬃcient awareness of MEN in clinicians, diagnosis of one endocrine tumor
does not always proceed to a work-up of other MEN-related tumors. For general
physicians or specialists other than experienced endocrinologists, it may not beclear which patients are at higher risk of having MEN and should be further

A STUDY OF THE SPANISH NATIONAL REGISTER OF MULTIPLE ENDOCRINENEOPLASIA TYPE 1
Nuria Valdés1, Paloma Portillo2, Javier Tébar2, Elena Navarro3, Lluis Forga4,
Anna Casterás5, José Angel Díaz6, Luis Castaño7, Sonia Gaztambide7, Cristina
Alvarez Escolá8, Victoria Alcázar,9 Francisco Pomares10, Jordi Mesa,5 Javier
Aller11, Margarita Boillos 12, , Elena Dios13, Lorena Suárez1, María Galiana
Rodriguez1, Cristina Lamas14 José Manuel Rodriguez15 Departments ofEndocrinology and Nutrition of: 1Hospital Central de Asturias, Oviedo. 2Hospital
Virgen de la Arrixaca, Murcia. 3Hospital Virgen del Rocío, Sevilla. 4Complejo
Hospitalario de Navarra, Pamplona. 5Hospital General Vall d’Hebron, Barcelona.
6Hospital Clínico San Carlos, Madrid. 7Hospital de Cruces, Bilbao. 8Hospital
Universitario la Paz, Madrid. 9Hospital Severo Ochoa, Madrid. 10Hospital Clínico
Universitario de San Juan, Alicante. 11Hospital Universitario Puerta de Hierro,
Madrid. 12Hospital Can Misses, Ibiza. 13Hospital Puerta de Europa, Madrid.
14Complejo Hospitalario de Albacete, Albacete.15Department of Endocrine
Surgery, Hospital Virgen de la Arrixaca, Murcia. Spain64

Introduction: multiple endocrine neoplasia type 1 (MEN 1) is an autosomal
dominant disorder that is due to mutations in the tumor suppressor gene MEN 1.
MEN 1 syndrome is characterized by the occurrence of parathyroid (HPT)(82-100%), gastroenteropancreatic (GEP) (60-80%) and anterior pituitary tumors(PIT) (30-50%). Some patients may also develop carcinoid tumors, adrenocorticaltumors, meningiomas, facial angiofibromas, collagenomas, and lipomas.
Objective: the aim of this study was to analyse the clinical and genetic
characteristics of Spanish MEN 1 patients. Methods: The Spanish Group for the
Study of Multiple Endocrine Neoplasia designed an online national database,which was launched on January 2009. Data were collected from January 2009 to
December 2011. Results: there were data on 70 genetic carriers from 26 unrelatedfamilies. 65 patients were diagnosed with any MEN 1 component at a mean age of
38.47±14.82 (14.62-71.8) years, and 5 subjects were asymptomatic genetic
carriers at 13.6 ±4.03 years. HPT was diagnosed in 64 patients (91.42%) at 39.73± 13.61 (17-75) years. 34 GEPs were detected in 32 (45.71%) patients at
49.00±15.47 (30-75) years. As a whole, 17 (5%) patients developed gastrinomas,
9 (26.47%) non-functioning tumors, 3 (8.8%) PPomas, 2 (5.88%) insulinomas, 1(2.9%) glucagonoma, 1 (2.9%) somastostatinoma, and 1 (2.9%) gastric carcinoid.
At the time of diagnosis 6 patients had distant metastases. 26 (37.14%) patientsdeveloped a PIT at 36.84±11.71 (16-60) years. 15 (57.69%) patients had aprolactinoma, 9 (34.26%) non-functioning adenomas, 1 (3.84%)
somatolactotrophinoma, and 1 (3.84%) corticotropinoma. Only 5 (19.23%) of out
26 were macroadenomas. 6 patients had adrenal tumors, 3 patients had lipomas,
2 patients were diagnosed of bronchopulmonary carcinoids, and 2 patients had
angiofibromas. We have identified 13 diﬀerent mutations in the coding region of
the MEN1 gene, and in the splicing sites in 22 (84.61%) families. Of theseidentified mutations, 4 were in exon 10 (30.76%), 4 in exon 2 (30.76%), 3 in exon 3(23.07%) and 1 in exon 7, and 1 in intron 3. One mutation has been found in 7
unrelated families. Most of the mutations are nonsense, or frameshift deletions or
insertions that are likely to result in a functional loss of the menin protein.
Conclusions: compared to the literature the clinical and genetic characteristics of
Spanish MEN 1 patients are similar to those previously published, although theprevalence of pituitary macroadenomas is surprisingly lower than those reported
in the literature.

Endocrine Hereditary Tumors of the “Regione Toscana”, Department of Internal
Medicine, University of Florence, Florence, Italy
Multiple endocrine neoplasia type 1 (MEN1) syndrome is a rare hereditary cancer
disorder caused by mutation of MEN1 gene, a tumor suppressor gene, encodes
menin protein. Loss of heterozygosity at 11q13 is typical of MEN1 tumors, inagreement with the Knudson's two-hit hypothesis. In silico analysis with Target
Scan, Miranda and Pictar-Vert softwares for the prediction of miRNA targets
indicated miR-24-1 as capable to bind to the 3'UTR of MEN1 mRNA. We
investigated the relationship between MEN1 mRNA, miR-24-1 and menin protein,by analysis of miR-24-1 expression profiles in parathyroid adenomatous tissues 1)
from patients bearing a MEN1 gene mutation, in which the main diﬀerence was
the MEN1 LOH or the maintenance of the wild type MEN1 allele, 2) fromparathyroid sporadic non-MEN1 adenomas, and 3) from normal parathyroid
tissue. While parathyroid adenomas from patients that lost both MEN1 alleles
showed no expression of MEN1 mRNA, of menin, or of miR-24-1, MEN1
parathyroid adenomas from patients that maintain one wild type copy of theMEN1 gene showed, as expected, a reduced expression of MEN1 mRNA, but noexpression of menin, while miR-24-1 was expressed. Conversely, non-MEN1
adenomas and normal parathyroid showed the expression of MEN1 mRNA andmenin but not of miR-24-1. Thus, the induction of miR-24-1 seems to depend on
transcriptional expression of MEN1 mRNA and miR-24-1 expression contributes
to the inhibition of menin expression. The ChIP study demonstrated theassociation of menin with the miR-24-1 promoter, suggesting that the primiR-24-1 transcription was regulated by menin. Therefore, the MEN1
tumorigenesis seems to be under the control of a "negative feedback loop"
between miR-24-1 and menin protein, that mimics the second hit of Knudson's
hypothesis and that could buﬀer the eﬀect of the stochastic factors that contributeto the onset and progression of this disease. Our data show an alternative way to
MEN1 tumorigenesis and, probably, to the “two-hit dogma”. The functionalsignificance of this regulatory mechanism in MEN1 tumorigenesis is also the basis
for opening future developments of RNA antagomir(s)-based strategies in the invivo control of tumorigenesis in MEN1 carriers.

P21
The Negative Feedback-Loop Between the Oncomir Mir-24-1 and Menin
Modulates the MEN1 Tumorigenesis. Ettore Luzi, Francesca Marini, Francesca
Giusti, Gianna Galli, Loredana Cavalli and Maria Luisa Brandi Regional Center on

65

P22

and mutations in the p53 gene probably do not have a pivotal role in MEN 1
parathyroid tumorogenesis.

IMMUNOEXPRESSION OF CELL CYCLE-ASSOCIATED PROTEINS IN MULTIPLE
ENDOCRINE NEOPLASIA TYPE 1 PARATHYROID GLANDS
1Nuria Valdés, 1Lorena Suárez, 1María Galiana Rodriguez, 2Eliecer Coto,
1Edelmiro Menéndez, 3Manuel Fresno, 3Aurora Astudillo 1Department ofEndocrinology and Nutrition. 2Department of Molecular Genetics. 3Department of
Pathology. Hospital Universitario Central de Asturias, Oviedo, Spain.

P23

Introduction: the genetic basis for Multiple Endocrine Neoplasia type 1 ( MEN 1 ) is
the homozygous inactivation of MEN 1 gene. However, clinical and molecularfindings suggest the involvement of other genetic changes. Objective: there areseveral reports about the role of p27kip1, PRAD1/ cyclin D1 and p53 inparathyroid adenomas. However, to our knowledge, there were no reports
studying the expression of these proteins in a large panel of MEN 1 parathyroid
glands, thus we undertook this study in order to contribute to the understandingof the molecular Materials and methods: we examined the immunoexpression of
PRAD1/cyclin D1, p27, and Ki-67 in paraﬃn-embedded specific tumor samples ofbiopsies of 30 parathyroid glands from 8 genetic confirmed MEN 1 patients from aunique family, all of them carry a nonsense mutation in the exon 10 of the MEN 1
gen, W471X. In order to compare we studied 11 parathyroid adenomas and 7
associated glands obtained from patients with sporadic primary
hyperparathyroidism. Results: Nuclear staining of Ki-67 protein was identified with
the MIB-1 antibody in 13 of 30 (43.33%) MEN 1 parathyroid glands, in 9 of 11(81.81%) parathyroid adenomas. No positive cells were identified in theassociated glands. Ki-67 labelling index (LI) was higher in sporadic parathyroid
adenomas (5.40 ± 4.57) than in MEN 1 parathyroid hyperplasias (2.07 ± 4.54) (p =0.01). We identified p27kip1 positive cells in 3 out of 7 ( 42.85 %) associatedparathyroid glands, with a p27kip1 LI: 1, 1 and 3. In MEN 1 parathyroid glands andparathyroid adenomas we identified positive cells in all of them. MEN 1
parathyroid hyperplasias had similar p27kip1 expression (LI: 33.66 ± 28.75, range
1.0 to 90) than parathyroid adenomas (LI: 38.72 ± 40.88, range 1.0 to 100 ).
Statistically significant correlation between the immunoexpression of p27kip1 andthat of Ki-67 was observed in both parathyroid adenomas (p =0.006) and MEN 1
parathyroid hyperplasias (p= 0.029). PRAD1/Cyclin D1 was overexpressed in 2 outof 11 (18%) adenomas, but in none of the MEN 1 hyperplasias. p53
immunostaining was negative in MEN 1 parathyroid glands, in parathyroid
adenomas and in associated glands. Conclusions: these findings suggest thatMEN 1 parathyroid glands have a low growth fraction; p27 protein would have arole in controlling parathyroid cell proliferation, PRAD1/cyclin D1 rearrangement

G. Schwach1, C. Horvath1, R. Pfragner1, W. Schoefberger2, S. Wilfert3, O.
Brüggemann3, I. Teasdale3 1Institute of Pathophysiology and Immunology, Centerof Molecular Medicine, Medical University of Graz, Graz, Austria; 2 Institute ofInorganic Chemistry, Johannes Kepler University Linz, Linz, Austria; 3 Institute ofPolymer Chemistry (ICP), Johannes Kepler Universität Linz, Leonding, Austria

Activity of novel water soluble epirubicin substituted polymer against small
intestinal neuroendocrine tumor and medullary thyroid carcinoma cell lines

Background: Small intestinal neuroendocrine tumors (SI-NETs) represent a groupof rare neoplasms derived from neuroendocrine cells, mainly enterochromaﬃne
cells. Medullary thyroid carcinoma (MTC) is a calcitonin-producing neuroendocrine
tumor arising from the parafollicular C-Cells of the thyroid gland. It is noteworthy
that SI-NETs as well as MTCs are known for their poor response to standard
chemotherapy and radiotherapy and surgical intervention remains the only
curative treatment. Therefore, there is a substantial need to establish newtherapeutic options in the clinical treatment of these tumors. Aim: Earlier studies
have demonstrated antiproliferative and tumoristic eﬀects of epirubicin inneuroendocrine cells. Here we report on the eﬀects of a novel water soluble
epirubicin substituted polymer in small intestinal neuroendocrine tumors andmedullary thyroid carcinomas. Therefore, the SI-NET cell lines, KRJ-I, P-STS, LSTS, H-STS and the MTC cell line MTC-SK were incubated for 24, 48 and 72
hours at diﬀerent concentrations of epirubicin substituted polymer and the nonsubstituted polymer, and cells were analysed using cell counting, WST-1
cytotoxicity assay, DAPI staining and caspase assays. Normal human fibroblats
HF-SAR served as control cells. Results: Treatment with the epirubicin substituted
polymer resulted in antiproliferative eﬀects in SI-NET cell lines, KRJ-I, P-STS, LSTS, H-STS and the MTC cell line MTC-SK. An inhibition of cell proliferation, as
well as a decrease in cell viability was noted, while human fibroblasts HF-SAR
treated in the same way showed no significant alterations. Treatment of cells with
non- substituted polymer did not show antiproliferative eﬀects. Conclusions:
Novel epirubicin substituted polymers could be a new option in the treatment ofchemoresistant and radioresistant neuroendocrine tumors.

66

P24
Multiple microvascular alterations in the pancreatic neuroendocrine tumors of theMEN1 mouse model

Conclusion: The PNETs developed in the MEN1 mouse model were characterized
by disturbed morphology, vascular reactivity and diﬀerential activation of several
angiogenic molecular mechanisms. Upon validation in humans these findings may
be exploited to improve cancer treatment.

Xia Chu, Xiang Gao, Leif Jansson, Britt Skogseid and Andreea Barbu

P25

Background: Vascularization in each tumor type operates its distinct mechanismthat involves a signaling network of angiogenic factors. Pancreatic neuroendocrine
tumors (PNETs), the second most prevalent type of tumors in the multiple
endocrine neoplasia 1 (MEN1) syndrome, have a highly developed vasculature.
This study aimed to characterize the structural and functional features ofvasculature in PNETs, and to investigate the underlying molecular mechanisms ofangiogenesis. Methods: In this study a conventional MEN1 knock-out mousemodel (4 months and >12 months) was used. We analyzed the vessel density (byCD31 immunoreactivity) and pericyte distribution (by NG2 immunoreactivity) within
the endocrine pancreas. mRNA expression of angiogenic factors in VEGF, FGF,
PDGF and angiopoietins signaling pathways was quantified by qPCR, using
isolated islets and adenomas cultured in normoxic and hypoxic conditions. The
vascular reactivity of arterioles supporting isolated islets and tumors, in response
to D-glucose and L-nitro-arginine methyl ester (L-NAME), was documented by asingle-islet/tumor perfusion technique as an indication of a functional vesseladaptation. Results: A significant increase of microvascular density was observed
within PNETs and Men1+/- islets (>12 months) compared to age-matched Men1+/+ islets. The distribution of the pericytes was considerably altered in the endocrine
pancreas of Men1+/- mice as compared to their controls. Following hypoxic
challenge, islets and adenomas isolated from mice older than12 months revealed
elevated VEGF-A mRNA levels. In adenomas VEGFR2 mRNA expression was
significantly higher than in islets. Hypoxia promoted increased mRNA levels of
PlGF, FGF2 and FGFR1 in islets isolated from 4 month-old Men1+/- mice as wellas in adenomas isolated from 12 month-old Men1+/- mice. In young mice, PDGFBB and PDGFR-&#946; mRNA expression levels were significantly higher in
Men1+/- islets than in Men1+/+ islets. We also found a dramatic induction of theirexpressions in adenomas compared to islets (12 months) potentiated by hypoxia.
A significant increase of mRNA expression of Ang2 and Tie2 was shown inadenomas compared to the age-matched islets. Perfusion with 17 mmol/l Dglucose caused vasodilation of arterioles supporting Men1+/+ and Men1+/- islets
and tumors, while 0.1 mmol/l L-NAME caused their constriction. PNET’s arterioles
exhibited the slightest vasodilation (2%) and the maximal constriction (17%).

Pancreatic NETs with aggressive behaviour as the only manifestation of Multiple
Endocrine Neoplasia Syndrome type 1 associated with a novel mutation of MEN1
gene in a large Italian family.
Davi’ MV*, Amodio A**, Benini L**, Corbo V***, Scarpa A***, Toaiari M*, Francia G*
Multiple Endocrine Neoplasia type 1 (MEN1) is an autosomal dominant syndromecaused by germline mutation of MEN1 gene, located at chromosome 11q13. The
classic features of this syndrome are related to parathyroid, pituitary tumor/
hyperplasia and pancreatic neuroendocrine tumors (P-NETs). Our case reportdeals with a large Italian family aﬀected by MEN1 caused by a novel germline
mutation of the MEN1 gene. The proband, a 39-yr old female, was referred to our
Department after incidental finding of a 2 cm non-functioning NET in the tail of thepancreas at abdomen MR. Surprisingly, during surgical exploration multiple pNETs in the pancreatic head and tail were found. She subsequently underwent
total pancreasectomy with splenectomy and lymph node dissection. The
histological picture was consistent with multiple NETs G1, Ki67: 2% (WHO 2010)
with perineural invasion and 18/30 lymph node metastases. Although parathyroid
and pituitary involvement had been excluded by endocrinological evaluation andpituitary MR, the molecular test for MEN1 mutations was performed on a blood
specimen, given the young age of the patient and the multifocality of neoplastic
lesions. The sequencing analysis of the coding regions of MEN1 identified a nonsynonymous mutation (P390R) aﬀecting the exon 8 of the gene. This heterozygous
mutation has not been described up to now and it is predicted to impact proteinfunction because it aﬀects a conserved aminoacidic domain that is involved indiverse protein functional interactions. At 1 yr follow up an abdomen MR showed
retroperitoneal lymph node metastases whereas Ga-PET-DOTANOC and FDG-PET
were negative. Genetic testing was extended to the other components of thefamily and gave positive results in 8 members (mother, 2 sisters, 2 brothers, 3nephews). One asymptomatic 33 yr-old brother was diagnosed with multiple pNETs with one peripancreatic lymph node metastases at MR and Ga-PETDOTATOC, whereas pituitary MR and parathyroid function were negative. The
67

other brother and 2 sisters had normal parathyroid and pituitary function andnegative abdomen MR but slightly elevated gastrin and Chromogranin A level in 2
out of 3. The other positive members are still under investigation. Two recent casereports (Raef H Clin Endocrinol 2011; 1365-2265; Hasani-Ranjbar S Fam Cancer.
2011; 343–8), described families with a high penetrance of malignant p-NETs, butwith other classic features. Both these families carried germline mutations thatcompletely abolish menin function. The only manifestation of this new mutation
here described seems to be a predominant and aggressive involvement of thepancreas.

P26
SURGERY FOR MULTIPLE ENDOCRINE NEOPLASIA TYPE 1-INSULINOMAcm). In two cases insulinoma had a diameter &#8804; 4 mm The IOUS proved asensitivity of 87.6% for detecting the insulin positive neuroendocrine tumors. The
I/G ratio decreased over 40% from higher pre-excision value at 30 minutes fromresection and over 50% at 60 minutes. At a mean follow-up of 90 months, allpatients were normoglycemic with no evidence of disease recurrence. Conclusion.
MEN-1 insulinomas should be considered a surgically curable diseases. Choosing
the type of pancreatic resection should depend on the localization of thepancreatic endocrine neoplasias, their relationship with Wirsung duct and thepresence of other duodenal lesions. Because of the possibility of having multiple
insulinomas or lesions less than 0.5 cm in diameter and the acceptable morbidityof the procedure a pancreatic resection associated to enucleation of endocrine
tumors of the residual pancreas is preferable to a less radical surgical approach toensure higher cure rates. Intraoperative insulin and glycemia assay withcalculation of I/G ratio is of value in assessing the outcome of surgery.

Giudici Francesco, Nesi Gabriella, Cavalli Tiziana, Maria Luisa Brandi, Tonelli
Francesco
Background. Insulinoma is after gastrinoma the most frequent functioning
pancreatic endocrine tumours in MEN-1, occurring in about 15-20% of aﬀectedpatients. Since the usual presence of concomitant multiple pancreatic
neuroendocrine lesions, the surgical management of these patients istroublesome. Objective. Aim of our study has been to evaluate the diagnostic andsurgical approaches in MEN-1 insulinoma. Patients and Methods. Ten geneticallyconfirmed MEN-1 patients were referred to our Surgical Unit (1992–2012) andwere operated on for hypoglycemic crisis, associated with nonfunctioning
pancreatic endocrine neoplasias in all patients and Zollinger-Ellison syndrome intwo cases. Resection of the most aﬀected pancreatic regions and enucleation of
the nodules eventually found in least aﬀected ones were performed. An accurate
histopathological analysis of the specimen and the immunohistochemistry forneuroendocrine hormones antibodies were performed. The intraoperative insulin/
glycemia ratio was evaluated in all patients. Results. Three pylorus-preserving
pancreatoduodenectomies and seven distal pancreatectomies were performed.
Enucleation of nodules in least aﬀected pancreas was necessary in 8 pts. Spleenand splenic vessels were preserved in all but 2 cases. There was no postoperative
mortality; three patients developed complications (1 pancreatic fistula and 2 acutepancreatitis). Pathological analysis showed a mean of 6.5 macrotumours (range
1-14) and of 19.8 microlesions (range 1-60). Immunohistochemistry confirmed thepresence of insulinoma in all patients: four patients had 2 insulinomas for a total of
14 insulin positive lesions with a mean diameter of 1.26 centimeter (range 0.3-2.4

P27
Case report: MEN1 patient with malignant pancreatic neuroendcrine tumor andmultiple liver metastases surviving for 8 years.
Miyuki Katai, Yutaka Nishi,Keishi Yamauagi, Hiroshi Ofusa, Shikou Matsuda,
Akihiro Sakurai
59 year-old man visited our hospital with right low back pain 8 years ago.
Ultrasonography and MRI revealed pancreatic tumor and metastatic tumors inliver.

P28
Malignant Vipoma (a case report).
Nadira Fafa , Djamila Meskine, Lamia Kedad Endocrine unit, E.P.H Ibn Ziri
Bologhine, Algiers, Algeria.
Introduction: Vasoactive intestinal peptide producing tumour (VIPoma) or VernerMorrison syndrome is a very rare neuroendocine tumour. VIPoma aﬀect the68pancreas in 90% of the cases. Vasoactive intestinal peptide stimulates cAMP
production by the intestinal tract resulting in profuse diarrhea manifesting as waterand electrolyte loss especially potassium, this syndrome is also known as WDHA:
Watery Diarrhea Hypokalemia Achlorhydria syndrome. In 5 to 15% of the cases
Vipoma is associated with a multiple endocrine neoplasia type 1 (NEM 1). Case
presentation: A 49-year old women admitted in an intensive-care unit for
diarrhea, dehydration with electrolyte loss, septic shock after suppurative
thrombophlebitis. The diagnosis of vipoma was based on a large volume diarrhea
up to 7 at 8 l per day, a severe Hypokalemia under 1,40 mmol/l and a weightloss of 25 Kg, high Level of VIP up to 200pg/ml (normal<60pg/ml), otherinvestigation including : serotonin, carcinoembryonic antigen (CEA), CA 19-9,
alpha-foetoprotein (AFP), neuron specific enolase (NSE), and the 24 hour urinehydroxyindoleacetic acid (5 HIAA) were at the normal range. Clinical features andbiochemical tests for multiple endocrine neoplasia type 1 were negative.
Endoscopic-ultrasonography revealed a 2 cm mass arising from the body and tailof the pancreas. Abdominal scan and MRI showed a suspicious lesion measuring
5cm in the segment 7 of the liver, the biopsy and immunochemistry stained forchromogranin and synaptophysin were positive, the results implied the presenceof a neuroendocrine tumour, the proliferation index cell Ki67 was at 3%.The
somatostatin receptor scintigraphy with octreotide scan showed an intense
uptake in both pancreas and liver mass. Preoperatively somatostatin analogue
treatment was administrated to the patient with improvement of dehydration anddiarrhea. The patient underwent a left splenectomy, a right liver resection with
dissection of lymph nodes in the celiac and liver region. Histopathology
diagnosed a liver metastasis of the pancreatic tumour, and the immunochemistry
confirmed that the tumour cell expressed VIP, chromogranin and synaptophysin,
proliferation index cell (Ki67) was about 4%. Postoperatively sandostatine
treatment was stopped and there was no evidence of disease
recurrence.Conclusion: despite malignancy in 50 à 60 % of the cases with liver or
lymph nodes metastasis at diagnosis, vipoma can be treated successfully withsurgery if the resection of both vipoma and metastasis is realized, somatostatin
analogue before surgery, or when the tumour is unresectable improved symptoms
and quality of life.
P29
Metastatic digestive neuroendocrine tumors Interest of serum choromogranin A
Himeur M A(1), Berkane A W(2), Aït Abdesselam K(2), Chikouche A(1), Sai(3),Bouzid K(3), Griene L(1). 1-Laboratoire d’Hormonologie, CPMC- Alger. 2-Facultédes Sciences Biologiques, USTHB-Alger. 3-Service d’Oncologie Médicale, CPMCAlger.
Chromogranin A (CgA), is a member of the chromogranin family that comprises
several proteins, is a hydrophilic acidic one-chain peptide containing 439 aminoacids (49KDa). Chromogranin A occurs in chromaﬃn granules of neuroendocrine
cells. Interest of serum CgA, initially demonstrated in pheochromocytoma, wasquickly extended to other endocrine cancers. Serum levels of CgA are particularlyhigh in the intestinal carcinoid and pancreatic endocrine tumors. Objective•Assess the value of serum CgA in the diagnosis and monitoring of metastatic
gastrointestinal neuroendocrine tumors. •Comparison of CgA level between our
population and control group (patients in advanced stage for other tumors)
Materials and Methods This is a prospective study of 18 patients with digestive
neuroendocrine tumor stage liver metastasis or peritoneal carcinomatosis, referredto the service of Medical Oncology at CPMC-Algiers for therapeutic management.
The determination of CgA was carried out with the reagent CGA-RIACT (CIS bio).
This type assay IRMA uses as tracer a monoclonal anti-CgA labeled with iodine
125. Detection limit: 1.5ng/ml Serum CgA in considered pathological values 100
ng/ml Results: Our work shows that: CgA serum is a very specific parameter ofneuroendocrine tumors, which justifies its indication in the staging ofgastrointestinal neoplasm in advanced, especially before the negativity of
conventional tumor markers . Changes in CgA serum is parallel to the evolution of
the tumor mass, hence the interest of its assay in monitoring therapeutic The
sensitivity of the CgA serum depends on the volume of the tumor mass and thedegree of diﬀerentiation and secretion of tumor. Significant diﬀerence in rates of
CgA between our group of patients and the control group. Conclusion: View its
specificity, serum CGA is a relevant parameter in the diagnostic workup andmonitoring of neuroendocrine tumors in advanced stages, although its clinicalsensitivity depends on the volume and character-secreting tumor.

P30
The thyrogastric syndrome: an under diagnosed etiology for acquired gastricneuroendocrine tumors. A Case Report
Hernan Valdes Socin, Jean Loly, Pierette Gast, Laurence Lutteri, Laura Vranken,
Etienne Cavalier and Albert Beckers. Service of Endocrinology. Service of
Gastroenterology. Service of Biology Service. University of Liège. BELGIUM

69

Background: The thyrogastric syndrome is the autoimmune association ofHashimoto thyroiditis and atrophic gastritis. In man, atrophic gastritis leads tomicronutriments malabsorption, chronic hypergastrinemia, subsequent
enterochromaﬃn cells hyperplasia and eventually the development of a gastricneuroendocrine tumor. Case Report: Among a series of 410 patients with
autoimmune disorders (AITD), we have identified 56 patients (14%) with
autoimmune gastritis (1). The aim of this case report is to describe the first of suchpatients in which high levels of gastrine and chromogranine lead to the suspicionof a de novo neuroendocrine gastric tumor. In 2009 a 61 years old woman with
Hashimoto Thyroiditis complains about bilateral tunnel carpal syndrome. Vitamin
B12 is 58 pg/ml (>200), Hb=11.7 ng/L, mean corpuscular volume: 78 µ3 (84-94),
ferritin 7 ng/ml (22-112), gastrin is 1705 ng/ml. Gastric auto antibodies andintrinsic factor antibodies are positive, whereas serology for Helicobacter Pylori is
negative. A carpal tunnel electromyogram confirms bilateral low sensitive andmotor conductance. Gastroscopy and biopsies show chronic atrophic gastritis
with signs of intestinal metaplasia. Cyanocobalamin treatment ameliorates carpal
tunnel syndrome and gastric follow-up is recommended. In 2010, an endoscopy
with biopsies is performed again, showing enterochomaﬃn cells hyperplasia. In
2012, gastrin levels are increased at 2800 pg/ml and chromogranin is 212 ng/ml.
Another gastroscopy is performed: a neuroendocrine tumor grade II, pT1 is foundat the lesser gastric curvature and successfully resected. Discussion: The
thyrogastric syndrome is prevalent but under diagnosed. Pernicious anemia,
gastric carcinoid and stomach cancer are the primary complications, justifying agastric screening. If unrecognized, pernicious anemia led to neurological andhematological potentially reversible complications. Early gastroscopy ameliorates
the prognosis of gastric neoplasias. In some series (2) gastric carcinoids develop
in up to 10% of patients with pernicious anemia, after a mean follow-up of 8
years. Nearly 76% of our patients with autoimmune gastritis have signs ofmetaplasia and enterochromaﬃn cells hyperplasia. The present case is our firstgastric carcinoid prospectively diagnosed, which represent less than 3% (1/33) ofpatients with thyrogastric syndrome. References 1-H. Valdes Socin & al. Autoimmune gastritis characteristics in a large series of patients with auto-immune
thyroiditis. XXIVth. Belgian Week of Gastroenterology 2012. 2-Kokkola & al. The
risk of gastric carcinoma and carcinoid tumours in patients with pernicious
anaemia. A prospective follow-up study Scand J Gastroenterol. 1998.

P31
VITAMIN D PATHWAY IN SPORADIC AND MEN1-RELATED NEUROENDOCRINETUMORS
V. Ramundo1, L. Vuolo1, A. Negri1, M. Sarnataro1, C. Pivonello1, C. Di Somma1,
F. Marciello1, M. Del Prete1, V. Marotta1, R. Esposito1, A.C. Carratù1, C. de Lucadi Roseto1, A. Colao1, A. Faggiano1,2 1Department of Clinical and Molecular
Endocrinology and Oncology, “Federico II” University of Naples, Italy;
2Endocrinology, National Cancer Institute, “Fondazione G. Pascale” Naples, Italy
Background & Aim: Vitamin D exerts anti-proliferative eﬀects by binding to thevitamin D receptor (VDR), an intracellular nuclear receptor. There is evidence on
the association between cancer and specific polymorphisms of VDR. Whit regard
to neuroendocrine tumors (NETs), in murine and human insulinoma cell lines the1-25(OH)2D has been shown to inhibit cell proliferation, induce apoptosis, inhibit
insulin secretion, down-regulate the expression of insulin gene and up-regulate
the expression of VDR. The aim of this study was to investigate expression andprognostic role of the vitamin D pathway in patients with NETs. Patients &Methods: 33 patients with NETs (15 sporadic and 18 hereditary MEN1-associated;
14 with recurrent/progressive disease and 19 with remission/stable disease) were
evaluated and compared to 33 age- and sex-matched controls. Serum 25(OH)Dlevels were measured by chemiluminescence (CLIA) with dosing limits in the range
4-150 ng/ml. VDR polymorphisms evaluated included Fok-1 and Taq-1. Results:
Mean serum 25(OH)D levels were significantly lower in patients with NETs
(19.9+/-2.0 ng/ml) than in controls (30.4+/-1.9 ng/ml). Allelic variants of the VDRpolymorphisms, Fok-1 and Taq-1, were similarly distributed in patients andcontrols (p=NS). Serum 25(OH)D levels were significantly lower in patients withrecurrent/progressive disease than in those with remission/stable disease(16.2+/-2.0 vs 23.3+/-2.8 ng/ml). No significant diﬀerences were observed in the
distribution of allelic variants of the VDR polymorphisms between sporadic andhereditary MEN1-associated NETs and between patients with recurrent/
progressive disease and those with remission/stable disease. Conclusions: VDRpolymorphisms, Fox-1 and Taq-1, do not diﬀer between sporadic and hereditaryNETs and do non influence the prognosis of these tumors. Serum 25(OH)D levels
are significantly lower in patients with poor prognosis NETs, suggesting a potential
therapeutic use of vitamin D in these patients.

70

P32

P33

PREOPERATIVE DIAGNOSTICS: THE NEUROENDOCRINE TUMORS OFPANCREAS

Multiple Neuroendocrinopathy type 2 (NEM 2)

N.A. Maystrenko, P.N. Romashchenko, M.V. Lysanyuk. The chair of faculty surgery
MMA, S.M. Kirov, Saint-Petersburg
The purpose of research: to optimize modern possibilities of early diagnostics
neuroendocrine tumors of pancreas (NETP) for substantiation choice of surgicaltreatment variant.The results of examination and treatment of 124 patients with
NETP are analysed. Organic hyperinsulinism (OGI) diagnosed in 63 patients,
gastrinoma – in 43, rare forms of tumors (carcinoid, glucagonoma, vipoma) – in 13
cases. The multiple tumors in patients with insulinoma diagnosed in 5,8%, withgastrinoma – in 26,9% cases. MEN-I syndrome recognized in 8,1% NETP
patients. Checkup are realized with using hormone containing (immune reactive
insulin, C-peptide, gastrin, chromogranin A), functional (hunger – probe, gastricsecretion estimation), instrumental ( US, CT, MRI, PET, angiography) andmorphological researchs (light- and electronic microscopy,
immunohistochemistry). The right diagnosis among OGI patients was establishedduring first year in 42,5% cases only. Patients with gastrinoma repeatedly
operated by complicated ulcerous. Hypoglycemia in OGI patients by complete
rest observed in 50%, by hunger – probe in 89%. Complex using of laboratory
research methods allowed to verify OGI in 93% cases. Hypersecretion in
gastrinoma patients diagnosed in 67%, gastrin blood level research increased
eﬀectiveness preoperative diagnostics of disease till 96%. Ultrasonography
sensibility in NETP diagnostics was 66%, CT – 64%, MRI – 62%. The most selfdescriptiveness in topical diagnostics established by CT and PET with sensibility
75% and 80% accordingly. Intraoperative US allowed to localize tumor inpancreas with sensibility 93%. Tumor enucleation performed in 37% cases, distal
pancreas resection with tumor – in 39%, marginal excision of pancreas – in 21%,
pancreaticoduodenal resection – in 3%. So, modern methods of laboratory andinstrumental diagnostics allow diagnosing NETP in proper time and determining
selection of rational variants of operations for improvement patients surgicaltreatment results and quality of life.

M. Boudissa, A. Chikouche, M. Ait Abdallah, Y. Oukaci, L. Griene, M. Semrouni
Center of Pierre and Marie Curie. Algiers, Algéria
Introduction: the family CMT is characterized by the mutation of RET protooncogene. The objective of work is to distinguish between sporadic and familial
forms of a particular support early surgical cases related Material and Methods:
From 2003 to 2010, 70 index cases of CMT have been identified whose10 casesof MEN2 (MEN2A and 01 NEM2b 09) including 8 women and 2 men, the mean
age was34 years. All have benefited from an ultrasound confirming the cervical or
thyroid nodules. The biological euthyroidism was in all our patients, the TCT
measured in 7 patients was pathological income. Cytoponction performed in 8
patients, was malignant in 4 cases, suspicious in 2 cases and mild in two others. T
he metanephrines are high among 5cas/10 income. Abdominal CT scan showed
an adrenal bilateral mass in 4 cases and unilateral in another, as to the adrenal
MIBG scintigraphy performed only in 2 patients showed a bilateral setting. One
patient had in addition to the CMT and pheochromocytoma, parathyroid nodule(P3) which established the biological and MIBI. Pheochromocytoma was operated
initially in 3 cases and second time in two others. All patients underwent total
thyroidectomy them with central neck dissection, lateral and bilateral ablation of aparathyroid nodule (P3) in a patient. Results: The histological andimmunohistochemical studies confirmed the CMT and the parathyroid adenoma inthe single case of pheochromocytoma in 5 cases showing two EOD. The genetic
study done systematically in Algeria since 2003 found 10 mutations in 70 index
cases (7%): eight in codon 634, one at codon 918 and a variant C515D
Conclusion: Since 2003 The management of NEM 2 and it has evolved
considerably through molecular analysis of the RET gene, genetic marker became
available in Algeria.

P34
Two Brazilian kindreds with the rare p.Ser891Arg RET mutationJi H Yang, Susan C Lindsey, Cléber P Camacho, Flávia O F Valente, Fausto
Germano-Neto, Alberto L Machado, Magnus R Dias-da-Silva, Rui M B Maciel

71

The clinical behavior of some rare RET mutations causing MTC is not completely
documented, and description of such kindreds may help to establish clinicalprotocols. The mutation p.Ser891Arg accounts for less than 5 % of the RET
mutations and it is considered level A in the risk stratification of the American
Thyroid Association guidelines. From the first description of two cases in 1989, up
to 80 reports are found in the literature. Here we report two Brazilian kindreds withthe p.Ser891Arg mutation. Kindred 1 - The index case is a 54-year-old woman
who had been evaluated for a 2.5 cm thyroid nodule. FNA biopsy was suggestiveof follicular neoplasm and she underwent total thyroidectomy and centralcompartment neck dissection. Histopathological analysis was consistent with
MTC. Three months later, a bilateral neck dissection was performed and bilaterallymph node metastases were confirmed. Then she was referred to our center. Her
family history was positive for cancer - her father had died at the age of 33 years
with bone metastases from an unknown cancer. Post-operative serum calcitonin(sCT) levels were elevated and a neck ultrasound (US) revealed recurrent lesions in
the thyroid bed. Screening for primary hyperparathyroidism was negative and thepatient is under investigation for pheochromocytoma. RET genetic testing
revealed a p.Ser891Arg mutation and analysis of 9 family members revealed themutation in one son, one daughter and two nieces, all with ages between 20-27
years. sCT in all aﬀected relatives was elevated (29-250 pg/mL) and they are now
under scheduling to prophylactic thyroidectomy. Kindred 2 - A 47 year woman
presented to another clinic with a history of thyroid enlargement over the past 5
years. Although such 3.5 cm thyroid nodule was classified as benign in thecytologic study, she underwent surgery due to compressive symptoms.
Histopathology revealed a 3.5 cm MTC. She was later submitted to two ipsilateralcervical lymph node dissections, but still has persistent cervical disease andelevated levels of sCT. Her family history was unremarkable. RET sequencing
revealed a p.Ser891Arg mutation. Family investigation uncovered the mutation inher 55-year old brother, who has no evidence of disease so far, and prophylactic
thyroidectomy was recommended. Conclusion: Patients with the p.Ser891Arg RET
mutation seem to have higher rate of biochemical cure when early thyroidectomy
is performed.
P35
MEN 2A AND OTHER ENDOCRINE NEOPLASIAS: BEYOND MEN 2A?
Paula Sánchez Sobrino, Concepción Páramo Fernández, Federico Mallo Ferrer. 1
Endocrinology Department, Hospital Complex of Pontevedra 2 Endocrinology
Department, Hospital Complex of Vigo, 3 Endocrinology Department, University ofVigo (Spain)

Multiple Endocrine Neoplasia Syndrome type 2A (MEN 2A) is a genetic, hereditarycomplex disorder characterized by the presence of medullary thyroid cancer(MTC), pheochromocytoma and primary hyperparathyroidism. MEN 2A has tworare variants, one associated to Hirschprung’s disease and another to cutaneous
lichen planus amyloidosis. MEN 2A is caused by missense germline mutations on
RET protooncogen (10q11.2) which encodes the RET tyrosine kinase receptor,
present on neuroendocrine cells of neural crest origin. RET is a developmentally
important gene, playing a significant role on growth and cell diﬀerentiation.
Exceptionally MEN 2 coexists with other syndromes resulting in combined
phenotypes, like MEN 1 and 2. There are few reports where MEN 2A shows an
unexpected phenotype, for example, V804M mutation with papillary thyroid
carcinoma, medullary thyroid cancer and hyperparathyroidism. We report a familywith MEN 2A by C634Y mutation. Their members developed expected neoplasias
but also additional endocrine tumors and showed cutaneous stigmata typical ofother multiple endocrine neoplasia syndromes. Two of the eight members with
C634Y mutation had multiple café-au-lait spots, another one a liver carcinoid. Oneof the subjects who refused performing a genetic test had a pinealoma (SeeFigure 1). Association with other endocrine neoplasias and cutaneous stigmata
characteristic of other MEN syndromes (Carney Complex, McCune-AlbrightSyndrome) makes us thinking about “amplified” forms of MEN2A in which RET
mutation is expressed in other ectodermal tissues like skin and some endocrine
cells, which derive from the neural crest too.

P36
Discrepant genotype-phenotype correlation in MEN 2 patients: meticulous
screening for double RET germline mutation and discovery the largest kindreds
with p.C634Y/p.Y791 RET double mutations
Valente,FOF; Silva,MRD; Camacho,CP; Kunii,IS; Simião,HPC; Tamanaha,R;
Maciel,RMD and Cerutti,JM.
BACKGROUND. Although a strong genotype-phenotype correlation is observed in
MEN 2 syndrome, lack of correlation has been observed in few families. We havepreviously identified a four-generation kindred with p.Y791F RET mutation andmore aggressive clinical phenotype. Due to the fact that double germline RET
mutation may occur in patients with uncommon clinical manifestation and that it
may have a certain impact on the prognosis and treatment of the patients, we here
re-examined whether an additional mutation within the RET gene could be in72

linkage disequilibrium with the p.Y791F variant. METHODS. We re-screened theentire coding region of the RET gene from the index-case using diﬀerent sets ofprimers. In addition, in silico analysis was performed to investigate the probableeﬀect of substitutions in codon 791. RESULTS. A p.C634Y substitution was foundin cis with p.Y791F substitution. We additionally identified 4 families harbouring
the p.C634Y/p.Y791F double mutation, comprising the largest case series withsuch genotype in the literature. Most patients have clinical and/or biochemical
evidence of MTC. Hyperparathyroidism was found in three carriers of the samefamily. Interestingly, cutaneous lichen amyloidosis was reported in two families.
Finally, we here report a family with p.Y791N substitution alone. Using the Protein
Data Bank and the RET 3D resolved structure, we investigated in silico the eﬀectof residue Asparagine substitution at codon 791, suggesting that this aminoacidchange could be less pathogenic than the substitution for Phenilalanine.
CONCLUSIONS. Double-mutation in RET gene may contribute to elucidating
divergent genotype-phenotype correlation, what calls out for careful screening andre-screening when necessary in those patients. More studies are necessary toestablish the potential pathogenic of the aminoacid changes in codon 791 otherthan phenylalanine and, thus, clarify the genetic couselling to the aﬀected families,
avoiding overtreatment.

cancer patients and 18 control endometrium. high methylation percentages were
demonstrated in grade 1 and 2 EEC whereas grade 3 had lower values. The
distribution of OX2R was next evaluated thorough the normal menstrual cycle andin the EEC samples tested for the methylation status. Our data provide for the firsttime the evidence of the expression of the OX2R protein in normal endometrial
epithelia and its frequent loss in EEC. In order to establish correlation between
OX2R methylation and the protein expression MFE280, ECC1 and Ishikawa celllines were used. In ECC1 and Ishikawa, methylation correlated with weak or
absent transcription. Interestingly for the MFE280 cells, completely unmethylated
and methylated alleles were present concomitantly leading to a hemizygous locus
permissive for OX2R expression. Additionally, in vitro treatment of the three EEC
cell lines with orexin did not result in proliferation change. The exact role of OX2R
in the endometrial cancer progression remains to be elucidated. Altogether ourdata provide evidence for the hypermethylation of OX2R first exon in EEC leading
to complete or partial loss of the protein in tumoral tissues.

P38
The case of severe congenital hyperinsulinism and undermasculinization in a boy

P37

I.L. Nikitina, I.Y.Artemeva, A.A.Kostareva, L.B. Mitrophanova, E. N.Grineva.

Frequent methylation of the first exon of orexin receptor type 2 in endometrial
cancerBackground. Congenital hyperinsulinism (HI) represents a heterogeneous group of
insulin regulation disorders. Genetic defects in four common genes have been
identified: SUR1, KIR6.2, GK and GDH HI. The causes of both HI and disorders ofsex development (DSD) are presented by mutations in specific genes, however,the combination of DSD and HI was not found by authors. We report patient C.
was born from the 3rd pregnancy and the second delivery (1 abortion in theanamnesis) at 40 weeks of gestation. The birth weight was 4500g, length. In 5
months weight was 10500g, length - 66 cm, BMI>95 percentile. Heart and liver
were increased. The features of undermasculinization included micropenis, mild
hypospadias, hypoplasia of scrotum and bilateral abdominal criptorchidism.
Karyotype was 46XY. Persistent hypoglycemia in the newborn was revealed during
the first five hours of life: the lowest glucose level was 0,7 mmol/L, the highest
insulin level was 2512,0 pmol/L. Hypoglycemia was accompanied by trembling,
irritability, hypodynamia, diﬀuse cyanosis, seizures. No disease causing mutationin KCNJ11 and the ABCC8 genes was observed. Glucose blood level 2,0±0,5mmol/l was maintained by intravenous infusion of 20% glucose solution with therate of infusion 15-20 mg/kg/h. At the age of 1,5 months treatment with octreotide

Dehan P.1, Canon C.1, Trooskens G.2, Rehli M.3, Munaut C.4, Van Criekinge W.2,
Delvenne P1. 1 Department of Experimental Pathology University of Liège, Tour dePathologie (B23), Groupe Interdisciplinaire de Génoprotéomique AppliquéeCancer (GIGA Cancer), Liege, Belgium 2 MDx Health-SA Liege Belgium 3
Department of Hematology & Oncology, University Hospital Regensburg,
Regensburg, Germany 4 Laboratory of Tumour and Development Biology,
University of Liège, GIGA Cancer, Liège, Belgium
Several DNA methylation epigenetic biomarkers have already been reported inendometrioid endometrial carcinoma (EEC) which is the most frequent
gynecological cancer. A new genome-wide microarray analysis led to theidentification of the frequent methylation of the first exon of the orexin receptor
type 2 gene (OX2R) in EEC. The bisulfite sequencing method after bacterial
cloning allowed mapping of the local DNA methylation changes in a cohort of 3473

by dose 23 mkg/kg/d by 4 times a day was started. However, severe
hypoglycemia was repeated with the risk of developmental delay and neurologicaldamage. At the age of 4 months open near-total pancreatectomy was made. In
histologic examination the diﬀuse subtype of congenital HI was confirmed.
Conclusions. The undermasculinization in the boy with congenital HI can be
related by increase of aromatase activity in the HI-binding too much fatty tissue,
and, therefore, by decrease of level and activity of testosterone in fetus. A raretype of Beckwith-Viedemann syndrome be dscussed. The GLP-1 receptor may be
a useful therapeutic target for the management of patients with hyperinsulinemic
hypoglycemia.

metastasis at diagnosis (4.5% vs 14.5%, p=0.045) and at follow-up (11.8% vs34.9%, p=0.005). No significant diﬀerences in lymph node invasion,
microcarcinoma prevalence and stage at diagnosis were found between groups.
Significantly worse clinical features (outcome of disease, stage at diagnosis) werenoted in the sporadic cases only in the first period of observation, while no such
diﬀerences were observed during the more recent period. No significant
diﬀerences in pre- and postoperative calcitonin levels were found between
sporadic and familial cases. Conclusions: Currently diagnosed sporadic andfamilial MTC cases do not diﬀer significantly concerning clinical features as
opposed to worse characteristics observed in sporadic cases during the previous
decades. Women may have increased awareness for genetic screening in familial
disease.

P39
CLINICAL CHARACTERISTICS OF FAMILIAL AND SPORADIC MTC’S DURING
RECENT YEARS IN A SINGLE CENTRE IN GREECE

P40Interest of genetics in the management of familial medullary thyroid cancer

1Alevizaki M, 1Saltiki K, 1Rentziou G, 1Athanasiadou A, 1Kyratzoglou E,
2Anastasiou E, 2Sarika HL 1Endocrine Unit, Dept Medical Therapeutics and 21st
Endocrine Section Alexandra Hospital, Athens University School of Medicine,
Athens, Greece
Background: MTC has varying clinical course. Sporadic disease is believed tohave more aggressive course as familial cases are usually diagnosed earlier. The
purpose of this study was to assess the diﬀerences in the clinical features
between familial and sporadic cases in a single centre in Greece. Methods: 179
MTC patients (36.9% males) were followed up for 0.9-34 years (mean 6.16±6.1
yrs, median 4.0 yrs). Total thyroidectomy was performed in all patients. 48.1% had
familial disease. 57 patients (31.8%) were diagnosed between 1977-2000 and 122
patients between 2001-2011 (recent period). Extent of disease at diagnosis andduring follow-up, and pre- and postoperative calcitonin levels were recorded.
Results: Median age at diagnosis for familial MTC was 33.11±15.41 (range 5-72
years) and for sporadic: 53.53±12.58 (range 32-78, p < 0.001). The prevalence offamilial disease was significantly higher in women than in men (72% vs 51.8%, p=0.014, linear by linear association). When the whole period of observation wasconsidered, patients with familial MTC had more frequently remission of disease(64.7% vs 47.5%) and less frequently progressive disease (8.8% vs 31.3%, p=0.003) at follow-up. They also had more frequently multifocality and c-cell
hyperplasia (p < 0.001), smaller tumour size (1.24±0.8 vs 1.94±1.59 cm, p=0.001),
less frequently capsular invasion (33.3% vs 50.7%, p=0.042) and distant

BOUDISSA.M*, CHIKOUCHE.A**,S.A.BENSAFAR, AIT ABDELLAH.M***,GRIENE.L**, OUKACI.Y***, SEMROUNI.M*. Endocrinology CPMC Algiers.
Laboratory ** hormonology CPMC Algiers. Molecular Biology Unit *** CPMC
Algiers. Algeria.
Introduction: The CMT is a tumor of parafollicular cells of the thyroid. It represents
3.95 to 6.35% of thyroid cancers in Algeria. The gene responsible for familial MTC
is the RET proto-oncogene, specific genetic marker. Purpose of the work:
Research familial forms, to allow early management of genetically related cases atrisk. Materials and methods: CMT 70 (index case) had a genetic study which has
found 13 familial forms, with the following mutations: nine at codon 634, one incodon 918, one in codon 804, one at codon 768 and one at codon 891. 42 cases
related to these 13 families had a genetic screening and finding 16 cases (RET +)carrying the same mutation as their parents. Among these 16 cases, 9 underwent
total thyroidectomy, which immunohistochemical examination had found: 4 casesof micro cancers and 3 cases of C-cell hyperplasia and 2 cases were histologically
healthy thyroid. Recovery was in 9 cases, confirmed by a postoperative
pentagastrin test normal. . Conclusion: Through molecular analysis of the RET
gene, genetic marker became available in Algeria Since 2003 we have moved fromcurative surgery to prophylactic surgery.

74

P41

the diﬀerences between the sporadic and inherited groups. Surgery was the main
treatment option; experience with new treatments is still limited.

Medullary thyroid cancer: last 5-year experience of the Portuguese Oncology
Institute of Oporto
MJ Matos1, RG Martins1,2, J Couto1, AP Santos1, C Sanches3, I Azevedo4, I
Torres1 1Endocrinology, 3Oncologic Surgery and 4Medical Oncology
Departments, Portuguese Institute of Oncology of Oporto; 2Medical Psychology
Unit, Clinic Neurosciences and Mental Health Department, Medical School,
University of Oporto
Introduction: Medullary thyroid cancer (MTC) can be challenging as it usuallypresents as advanced disease and has a poor response to conventional
treatments. Additionally, its low incidence makes it diﬃcult to obtain extensive
experience in treatment and follow-up. This study aims to review our experience
with MTC during the last 5 years. Methods: Retrospective study of all MTC
patients (n= 52) followed in the Portuguese Institute of Oncology of Oporto
between 2006 and 2011. Information on demographics, genetics, disease staging
and progression was obtained. Data were analyzed in SPSS. Results: Mean age at
diagnosis was 52.3±15.5 years; 61.5% were female patients. The majority ofpatients presented with stage IV disease (63.8%), 4.3% in stage III, 8.5% in stage
II and 23.4% in stage I. Mutation analysis of RET gene was done in 75.0% of thepatients. Among index cases, a RET mutation was found in 12.9%. Three patientswere diagnosed after genetic testing because of an aﬀected relative. The groupwith hereditary disease had a higher proportion of female patients (71.4% vs64.0%), stage IV disease (75.0% vs 52.0%) and lower mean age at diagnosis(34.3±7.8 vs 52.3±15.7 years), but diﬀerences were not statistically significant. The
initial therapy was thyroidectomy and lateral neck dissection in 59.6% (and alsoradiotherapy in 5.8%); total thyroidectomy in 21.2%; hemithyroidectomy in 7.7%
(42.9% of the patients were initially treated in another hospital). After this, 45.2%
were submitted to other treatments: 38.1% reoperation; 4.8% radiotherapy; 4.8%
chemotherapy; 2.4% 131I-MIBG; 2.4% tyrosine kinase inhibitor and 2.4%
somatostatin analogue. Biochemical evidence of persistent/recurrent disease wasfound in 53.2%, but recidive or metastases were identified only in 42.6% (lymph
nodes 14.9%; lung 12.8%; bone 12.8%; liver 10.6%). Overall survival was 80.8%;2-year survival 91.8% and 5-year survival 81.7% (all dead patients presented
stage IV disease at diagnosis; overall survival of this stage was 70.0%).
Conclusions: Most MTC cases were diagnosed in advanced stages, which areassociated with lower survival. We found a lower proportion of inherited MTC thanis described in the literature (20-25%). The small sample size limited analysis of

P42
MIXED MEDULLARY AND PAPILLARY CARCINOMA OF THE THYROIDPRESENTED WITH THYROTOXICOSIS
Silvia Filipponi(1,2), Liliya Rostomyan(2), Antonella Franchi(1), Valentina
Congedo(1), Giuseppe Fiore(1), Bruno Raggiunti(1) 1 Department of Endocrinology
P.O. S. Liberatore, Atri (TE), Italy 2 Department of Endocrinology CHU de Liège,
Liege, Belgium
The coexistence of a papillary and medullary carcinoma in the thyroid gland has
been reported extremely rarely. For now in the literature there are 35 reports for a
total of 46 cases. Most of these reports described the simultaneous occurrence ofa papillary and medullary carcinoma as two distinct tumors, and only 15 cases oftrue mixed tumors (both components in the same lesion) were found. The
malignancy may be rarely found in hyperfunctioning “hot” nodules. Aim: todescribe a rare case of mixed thyroid carcinoma with thyrotoxicosis. Case report:
A 61-year old woman presented to our department with increasing breathing
distress syndrome and dysphagia. The patient has been treated succesfully withantithyroid drugs for hyperthyroidism (TSH=0,27 mcg/mL and fT3-fT4 within thenormal range) during the last two years. A large swelling of the left side of the neck
was revealed by physical examination. An ultrasound confirmed a 30x35x45 mm
hypoechoic nodule of the left lobe, with multiple nodules in the right lobe andanother nodule (around 1 cm) in the isthmus. Thyroid scintigraphy with I-131
showed a cold area corresponding to the nodule in the left lobe and a hot area in
the isthmus. Serum level of calcitonin was within the normal range (1 pg/mL). A
fine needle aspiration showed the benign behaviour of the left nodule. Because ofmultinodular structure and thyrotoxicosis the patient underwent a total
thyroidectomy. The histology demonstrated a mixed medullary and papillary cell
carcinoma in the nodule of the isthmus with coexistent multinodular goiter in both
lobes of thyroid. Conclusion: while mixed medullary and papillary carcinomas are
extremely rare, especially in hyperfunctioning nodules, these cases are clinicallychallenging because it's components apart require diﬀerent approaches ontreatment and follow up.

75

P43
FMTC and prolactinoma: a casual association or a new genetic syndrome?
F. Lugli1, E. Leone1, D. Iacovazzo1, A. Fusco1, D. Milardi1, S. Piacentini1, E.
Lucci-Cordisco2, A. Minucci3, E. Capoluongo3, G. Neri2, L. De Marinis1 1
Division of Endocrinology, 2 Institute of Medical Genetics, 3 Institute of
Biochemistry and Clinical Biochemistry, Catholic University, Policlinico “A.
Gemelli” Rome
Medullary thyroid carcinoma (MTC) is a rare thyroid malignancy of C-cellderivation representing approximately 5% to 10% of all thyroid cancers. Twentyfive to 30% of MTC are inheritable, associated with multiple endocrine neoplasia(MEN) 2A, MEN 2B or with the familiar medullary thyroid carcinoma syndrome(FMTC), due to autosomal dominant mutations of the RET proto-oncogene. In
MEN 2A and 2B MTC can be associated to other endocrine neoplasia(pheochromocytoma, hyperparathyroidism) but the association with pituitaryadenomas has been rarely described. We report the association of MTC andprolactinoma in two FMTC families. Family 1. A 49-years-old male patientunderwent thyroidectomy at the age of 31 for MTC with cervical lymphnode andliver metastases. He was followed up for the succeeding 15 years when, forsexual dysfunction, a prolactin-secreting pituitary adenoma was diagnosed andsurgically resected. The RET gene was analyzed by direct DNA sequencing. The
proband was found to have the c.2711C>T exon 15 mutation leading to a
substitution of serine 904 with either a phenylalanine or a leucine (p.S904F/L). Thisis a rare mutation, first described in 2007 in a case of FMTC. The only first degree
alive relative, his 53 years-old sister, underwent clinical and biochemicalevaluation with evidence of MTC. Total thyroidectomy was performed. The same
mutation in the RET gene was found. Prolactin was normal. Family 2. FMTC familywith three aﬀected members: a 55 years-old female diagnosed with MTC in 2011,
her 54 years-old sister with an history of PRL-secreting pituitary microadenoma
treated with cabergoline diagnosed with MTC in 2011 and their 52 years-old
brother with recently diagnosed mild hypercalcitoninemia waiting forthyroidectomy. The RET gene was analyzed by direct DNA sequencing and the c.
2410G>A exon 14 mutation (p.V804M) was found in all aﬀected members. Thismutation, first described in 1996, is associated with FMTC and MEN 2A. Moreoverthe second proband was found to have a pancreatic (body-tail junction) 6 mmlesion with high levels of gastrin and chromogranin A waiting for diagnostic
evaluation. Conclusions: we report the association between FMTC andprolactinoma in two families with diﬀerent RET mutations. Reviewing the literature
only one case of MEN 2A and prolactinoma has been described (Bertrand JH et

al, Clin Endocrinol 1987). It’d be interesting to understand the possible role of RET
mutations in the pathogenesis of prolactinomas so as prolactinemia could
become a screening assay in patients aﬀected by inheritable MTC.

P44
Aggressive medullary thyroid cancer and follicular thyroid cancer in a patient withthe rare germline RET variant p.Val648Ile
Susan C. Lindsey, Flávia O. F. Valente, Cléber P. Camacho, Danielle M. Andreoni,
Fabiano M. Callegari, Magnus R. Dias-da-Silva, Rui M. B. Maciel
A 65 year-old woman was evaluated for medullary thyroid cancer (MTC) andfollicular thyroid cancer (FTC). She had undergone total thyroidectomy in anothermedical center at the age of 46 years due to a thyroid nodule. Pathological study
revealed a 2.0-cm MTC in the left lobe and a 1.3-cm moderately diﬀerentiatedfollicular carcinoma in the right lobe, invading surrounding soft tissue. She denied
having received radioactive iodine therapy and, apparently, she was never under
suppressive therapy with levothyroxine.
Her initial evaluation at our center revealed elevated serum thyroglobulin levels
under rhTSH stimulation (Tg 52.8 ng/mL), low calcitonin levels (<2 pg/mL), and left
cervical lymphadenopathy. Whole body scan with I131 was positive in the anteriorneck area. A neck computed tomography revealed a 3.5cm-solid lesion from thelevel of the sternal notch to the hyoid bone, in close contact with the trachea andthe esophagus, possibly infiltrating their wall, and infiltrating the adjacent muscle
and the cricoid and thyroid cartilages. FNA biopsy of such lesion and the left
lymph nodes was suggestive of MTC metastasis, and FNA biopsy of a 2.5cm
lymph node in the central compartment was suggestive of neoplasia from follicularorigin. RET genetic testing was positive for the variant p.Val648Ile. Her family isunder investigation and, so far, her 3 children who tested positive for the same
RET variant do not show evidence of disease. In conclusion, we report a case ofa patient with a rare germline RET variant – p.Val648Ile – with an aggressive MTC
and an FTC, and whose relatives known to carry the variant are not aﬀected so far.
Whether this variant has a pathogenic role is unclear and the relatives carrying thisvariant must be closely followed-up.

76

P45
Expression pattern of matrix metalloproteases in human medullary thyroid
carcinoma cell lines
Ghaﬀari Tabrizi-Wizsy N1, Haas HS1, Fuchs R1, Schwach G1, 2, Allard N1,Webersinke G3, Sadjak A1, Pfragner R1 1Institute of Pathophysiology and
Immunology, Medical University of Graz, Austria; 2Department of Surgery, Yale
School of Surgery, New Haven, Connecticut 06520-8062, USA, 3Clinics of BHS,
Linz, Austria
Objectives: Medullary carcinoma of the thyroid (MTC) is a rare carcinoma thatoriginates in the parafollicular C cells of the thyroid gland having a high metastasis
potential. Over the last decade, several findings indicate that matrix
metalloproteases (MMPs) are involved in tumourigenesis and metastasis. Their
expression is related to the progression of several types of cancer. However the
impact of MMPs in the formation and metastasis of MTC is not investigated.
Materials and Methods: In this study we verified the expression pattern of the 23
MMPs, presently known in humans, in well characterized human medullarycarcinoma cell lines. In total, 9 MTC-cell lines (BOJO, GRS-IV, GRS-V, MTC-SK,
RARE, SHER-I, SINJ, OEE-III and TT) were examined. The expression of matrix
metalloproteases was analysed by RT-PCR. Western blot analyses were
performed on selected MMPs. Results and conclusion: All MTC cell lines
constitutively express a wide variety of MMPs at mRNA and protein levels. In ourstudy MMP-12, -20, -25, -26 and -27 have not been detected at mRNA levels inany of the 9 cell lines analysed, but MMP-2, -9 and -14 in most of them. Some of
MMPs had a rather diverse expression pattern. We conclude that MTC cell lines
can serve as promising candidates for future investigation of the role of MMPs intumourigenesis and metastasis of medullary thyroid carcinoma.

P46
Establishment and Characterization of the Cell Line OEE-III derived from Sporadic
Medullary Thyroid Carcinoma with RET mutation
Roswitha Pfragner1, Gert Schwach1, Nassim Ghaﬀari Tabrizi-Wizsy1, Robert
Fuchs1, Helga S Haas1, Carmen Tam-Amersdorfer1, Nathalie Allard1, Harald
Hoeger2, Elisabeth Ingolic3, Annemarie Behmel4, Karin Flicker4, Michael
Speicher4, Petra Zeitlhofer5, Oskar A Haas5, Bruno Niederle6 1Institute of
Pathophysiology and Immunology, Medical University Graz, Graz, Austria; 2Unit of

Biomedical Resarch, Division of Laboratory Animal Science and Genetics,
University of Vienna, Himberg, Austria; 3Research Institute for Electron
Microscopy and Fine Structure Research, Technical University of Graz, Graz,
Austria; 4Institute of Human Genetics, Medical University of Graz, Austria;
5medgen.at GmbH, Vienna, Austria; 6Section of Endocrine Surgery, Division ofGeneral Surgery, Department of Surgery, Medical University of Vienna, Austria
Background: Medullary thyroid carcinomas (MTC) are associated with mutations in
the RET proto-oncogene located on chromosome 10q11.2. RET-Mutations aremainly found in hereditary MTC forms but also in about 50% of sporadic cases.
Representative MTC cell lines are rare due to technical diﬃculty. Aims: Our
objective is the establishment of MTC cell lines and their biologic and genetic
characterization. Here we present the novel cell line OEE-III which was derived
from a lymph node metastasis of a 50 year-old female; tumor stage at time ofsurgery pT2aN1bM1. Results: The cell line grows adherently and forms clusters of
triangular or spindle shaped cells. The cells maintained neuroendocrine markers,
such as calcitonin and contain a large amount of neuroendocrine granules.
Distinctive chromosomal abnormalities were found by conventional chromosome
analyses, multiplex FISH and array-CGH. Sequence analysis revealed a M918
mutation (ATG>ACG) in the RET proto-oncogene. In early passages (p18), themutation was detected in both allels, later passages (P43) were heterozygous.
Several molecular markers for NETs could be identified by RT PCR. OEE-III cells
express mRNA for the neuroendocrine markers achaete-scute complex homolog(ASCL1), Homo sapiens cut-like homeobox 1 (CUX1), chromogranin A (CHGA),
secretogranin II (SCG2), secretogranin III (SCG3), secretogranin V (SCG5),
chromogranin B (CHGB), synaptophysin (SYP), highly similar to Galectin-3-binding
protein (M2BP), Enolase 1 (ENO1) and Enolase 2 (ENO2). Tumorigenicity wasevaluated by subcutaneous transplantation of OEE-III cells in severe combined
immunodeficiency (SCID)–mice. Resulting nodules had comparable cytogenetic
and molecular properties as cultured cells. Conclusion: As MTC is resistant tochemo- and radiation therapy, the OEE-III cellline may serve as a promising modelfor novel therapies.
P47
Prevalence and clinical significance of macroprolactinemia in patients withprolactinomas
Atanaska Elenkova, Nikolai Genov, Zdravka Abadzhieva, Georgi Kirilov, Vladimir
Vasilev, Krasimir Kalinov, Marin Marinov, Sabina Zacharieva

77

Background: Presence of high-molecular prolactin isoform is generally suspectedin cases of mild hyperprolactinemia presenting with no typical hyperprolactinemiarelated symptoms and negative pituitary imaging. Objective: The aim of thisobservational case-control study was to assess the prevalence and clinicalsignificance of macroprolactinemia among patients with prolactinomas. Subjects
with non tumoral hyperprolactinemia were not recruited. Methods: The study
population consisted of 239 subjects: 131 patients and 108 sex-, age- andethnicity– matched healthy controls. Macroprolactinemia was defined by a PRL
recovery after PEG precipitation of < 40%. Results: Macroprolactinemia wasequally prevalent in newly diagnosed prolactinoma patients and healthy controls(3.5 vs. 3.7%; p=1.000). Significant association between serum levels of themonomeric form and macroprolactin and disruptions of ovarian function was
found not only in subjects with true hyperprolactinemia but also inmacroprolactinemic patients. Conclusions: In few cases, the presence of typical
hyperprolactinemia-related clinical symptoms and their disappearance after
treatment with DA suggests biological activity of macroprolactin comparable withthat of monomeric prolactin isoform. Decrease of macroprolactin levels after
dopamine agonist (DA) treatment suggests tumoral origin of the high-molecularisoform in these rare cases. An individualized approach to the management ofpatients with macroprolactinemia should be applied. Pituitary imaging, DA
treatment, and prolonged follow-up may be necessary in certain cases.

P48
THE COEXISTENCE OF A PITUITARY ADENOMA AND PHEOCHROMOCYTOMA(a case report)
Silvia Filipponi, Liliya Rostomyan, Laurent Vroonen, Adrian F. Daly, Albert Beckers
For now 29 cases of the coexistence of a pituitary adenoma andpheochromocytoma have been reported in the literature. Most of these cases
presented with GH-secreting pituitary tumors and rarely prolactinomas. On our
knowledge pituitary adenoma with mixed secretion has not been described so far
in association with pheochromocytoma. Aim: to describe a rare association ofpheochromocytoma with a prolactinoma with probably GH cosecretion. Case
report: A 49-year old man, who had been operated for a pheochromocytoma 15
years ago with complete normalization of blood pressure and levels ofcathecolamines, presented to our department with gynecomastia andhyperprolactinemia (PRL=1.372 mUI/L). The biological tests confirmed theabsence of macroprolactinaemia and the IRM showed a invasive into the rightcavernous sinus pituitary adenoma (7,5x4,7x6,3 mm). He was succesfully treatedwith dopamine agonist (PRL=120 mUI/L) without pituitary tumor growth during thewhole follow-up. Three years after the patient developed again episodic
headache, elevated blood pressure and flushing face. The urinary test revealed theelevated levels of normetanephrine (521 mcg/24h) and normal level ofmetanephrine (155 mcg/24h) that could be evident for the recurrence ofpheochromocytoma. Moreover in the hormonal tests the elevated level of IGF1
was noticed (244 ng/mL, normal range till 221 ng/mL) with normal basal GH (0,19ng/mL) but without the suppression during the OGTT, in the meantime the levels of
PRL were within the normal range (60mUI/L) on the treatment with cabergoline(0.25 mg/week). According to the clinical examination the patient didn’t present
any signs of acromegaly. The size of pituitary adenoma was stable (5mm) withextension into right cavernous sinus. No mutations in pituitary adenoma andadrenal tumors predisposing genes were found neither in direct sequencing nor in
MLPA. Conclusion: the associations of pheochromocythoma and pituitaryadenoma could represent a new syndrome and might be caused by other than
known predisposing to these tumors genes.

P49
Successful Temozolomide treatment in a MEN1-related aggressive resistantprolactinoma
Jaﬀrain-Rea ML1,2, Recchia F3, Arcella A1, Innocenzi G1, Minniti G4, Filipponi
S1,2, Persani L5, Cappabianca P6, Giangaspero F1, Cantore G1 1Neuromed
Institute, IRCCS, Pozzilli, 2Department of Clinical Sciences and Biotechnology,
University of L’Aquila 3Oncology, Civilian Hospital, Avezzano 4Radiotherapy, Sant’Andrea Hospital, Rome, 5 Istituto Auxologico Italiano, IRCCS, Milan & Universityof Milan, 6Neurosurgery, University Federico II, Naples. Italy.
Prolactinomas (PA) in Multiple Endocrine Neoplasia type 1 (MEN1) tend to be moreaggressive and resistant to dopamine-agonist drugs (DA) than sporadic cases.
Temozolomide (TMZ), an alkylating agent, has become the drug of choice forhighly aggressive PA and carcinomas, but experience in MEN1 patients is limited.
Case-report. In 1983, an apparently sporadic non-invasive macroprolactinoma
was diagnosed in a 23 yrs-old woman and successfully removed bytransphenoidal surgery (TS). Fifteen years later, a recurrence developed, with anincreasing resistance to DA (bromocriptine up to 30 mg/d, cabergoline up to 8.0
78mg/w y) requiring repeated TS surgery (1998,2004,2008) and conformational
radiotherapy (2004), followed by a transient reduction in PRL secretion (from 2000
ng/ml to 130 ng/ml) and tumor volume (~30%). In 2004 she also developed
primary hyperparathyroidism (2004) and a germline heterozygous truncating
MEN1 gene mutation was found. Since 2007, progressive tumour regrowth wasobserved, and in 2009, the patient developed a severe right cavernous sinus
syndrome (ophtamoplegia, palpebral ptosis, invalidating headache and facial pain)with increasing plasma PRL levels (2500 ng/ml), aggressive local tumour growth,no evidence of cranio-spinal or distant metastasis. TMZ was started in February2010 (200 mg/m2/d, 5 days every 28 days) and continued for 24 months with arapid clinical improvement, progressive PRL normalization and marked tumour
reduction with large cystic areas in the residual mass. Two months after TMZ
withdrawal plasma PRL remains &lt5 ng/ml on a 1.0 mg weekly CAB dose.
Noteworthy, methylation-specific PCR study of the MGMT promoter on tumor
DNA showed no evidence of methylation, and diﬀuse MGMT expression was
found by immunohistochemistry. Conclusion. TMZ appears as a suitable option inaggressive prolactinomas regardless of MEN1 mutation. In our patient, a rapid
therapeutic response was observed despite unfavourable MGMT status andcorrelated with the long-term response, supporting the view that MGMT
expression should not be considered as an exclusion criteria for TMZ treatment.

The protein product of the GCM2 gene is a key participant in the organogenesis of
the parathyroid glands. Inactivating mutations, either recessive or dominantnegative, are a known cause of congenital isolated hypoparathyroidism. The
continued expression of GCM2 in the adult parathyroid raises the possibility that
overactive forms could play a role in the evolution of parathyroid hyperactivity or
tumorigenesis. One single nucleotide polymorphism (SNP) – a c.844T>Gtransversion encoding a Y282D missense variant – has been identified by several
investigators, but its association with primary hyperparathyroidism has not beentested. We undertook a genotyping study of a large southern Italian cohort (San
Giovanni Rotondo, SGR) and then included smaller cohorts from Pisa and Milan,
subjecting the three independent results to a meta-analysis. For all samples,genotyping was performed by PCR amplification and enzymatic digestion with
Hph1. In the SGR cohort, the variant allele frequency (f) was significantly higher in
310 primary hyperparathyroid subjects (PHPT, f=0.066) than in 433 controls (C,f=0.029) by Fisher exact test (p=.0008). The Y282D SNP was also more frequent in
PHPT cases from Pisa and Milan, compared to their controls, but the diﬀerenceswere not significant. Meta-analysis (PHPT=510; C=665), yielded a likelihood ratioof 2.27 (95% CI 1.50 – 3.42) for the presence of PHPT in subjects carrying at least
one copy of the Y282D mutation

P51
P50
Increased prevalence of the GCM2 polymorphism, Y282D, in three Italian primary
hyperparathyroidism cohorts: results of a meta-analysis
Vito Guarnieri1, Michelina Coco1, Claudia Battista2, Sabrina Corbetta3, Anna
Spada3, Filomena Cetani4, Claudio Marcocci4, Lucie Canaﬀ5, Leonardo
D'Agruma1, Alfredo Scillitani2, Geoﬀrey N Hendy5, David EC Cole6 1: Medical
Genetics and 2: Endocrinology, IRCCS “Casa Sollievo della Soﬀerenza”, San
Giovanni Rotondo (FG), Italy; 3: Endocrinology and Diabetology Unit, Departmentof Medical Sciences, University of Milan and IRCCS Policlinico San Donato, San
Donato Milanese, Milan, Italy; 4: Department of Endocrinology and Metabolism,
University of Pisa, Pisa, Italy; 5: Calcium Research Laboratory and Hormones andCancer Research Unit, Royal Victoria Hospital, Montreal, QC, Canada; 6:
Departments of Laboratory Medicine and Pathobiology, Medicine and Genetics,
University of Toronto, Toronto ON, Canada;

THE CLINICAL CHARACTERISTICS OF PRIMARY HYPERPARATHYROIDISM(PHPT) IN PATIENTS WITH MULTIPLE ENDOCRINE NEOPLASIA (MEN) TYPE 1.
Liliya Rostomyan1,2, Nataliya Mokrysheva1, Anatoly Tiulpakov1, Alla Artemova1,
Nataliya Kirdyankina1, Liudmila Rozhinskaya1 1 Federal state research centre for
endocrinology, Moscow, Russia 2 Department of Endocrinology CHU de Liège,
Liege, Belgium
Rare cases of PHPT could be a component of some genetic syndromes, mostfrequently in patients with MEN 1 (2-4.5%). Little is known about clinicaldiﬀerences between MEN1 related and sporadic PHPT. Aim: to compare theclinical features of PHPT in MEN type 1 cases and sporadic PHPT. Materials andmethods: Data were obtained in 442 patients: 62 sharing MEN1 phenotype
presented with PHPT in association with pituitary adenomas and/or
gastroenteropancreatic neuroendocrine tumors (Group-I) and 380 with apparently
sporadic PHPT (Group-II). Serum Ca, intact PTH, urine Ca, 25-OH-VitD,
osteocalcin, &#946;-CTx) and BMD Z-scores measurments, renal ultrasonography,
79

visualization of parathyroid glands were performed in both groups. The additional
diagnostic tests (prolactin levels, ultrasound of pancreas and adrenals) were
performed in patients to exclude or evaluate other than PHPT endocrine
disorders. Results: The age at diagnosis was younger in Group I (39.5yr. [28;51])
than in Group II (57yr. [48;64]), p&lt0.001. In 50% of Group I PHPT debuted before
age of 40 years, whereas in Group II in 70% of patients the diagnosis was madeafter age of 50yr. The distribution of males/females was 1:2,6 in Group I and 2:10
in Group II. In 93% of Group II PHPT was caused by a single parathyroid
adenoma, in Group I in 59,6 % an enlargement of multiple parathyroid glands wasobserved. In 64% of iPTH was higher than upper normal range less than 2,5times, whereas in Group II 54% was more than 3 times higher than normal limits.
In the meantime the levels of &#1057;&#1072; in both groups weren’t significantly
diﬀerent (p=0.28). The mild PHPT was observed in Group I more frequently than inGroup II (33,8% vs 19%). PHPT presented with osteoporosis with the same
prevalence in both groups, but with more frequent renal manifestations in Group II.
In Group I the decrease in BMD at all sites and nephrolithiasis developed
independently of the degree of PTH elevation, as opposed to Group II.
Multifactorial analysis revealed the combination of moderately elevated PTH andthe age at diagnosis younger than 40 years to increase the risk of MEN1-related
PHPT in these patients independently of their gender and the mild course of
PHPT. Conclusion: The patients with MEN1-related PHPT are younger at thediagnosis of PHPT, have more frequently multiple enlarged parathyroid glands andshow mostly mild course of disease (especially in young age) and less increased
PTH compared with those with sporadic PHPT.

pheochromocytoma and primary hyperparathyroidism. PHTP occurs in 15-30% ofcases and is related to certain mutations in protooncogen RET. Surveillance for
PHPT should include annual corrected or ionized calcium with or without PTH. In
carriers of RET mutations in codons 630 and 634 it should begin by 8 years oldand continue throughout life. Patients and Methods: We present eight members
from the same family with MEN2A by C634Y mutation and absence of PHTP.
Results: None of our patients showed PHTP at diagnosis neither during follow-up,
which lasted between 10 and 23 years. Case 5 was submitted to excision of someenlarged parathyroid glands during thyroid surgery. This conditioned a permanenthypoparathyroidism with high requirements of calcium and vitamin D. Comments:
PHTP in MEN 2A is infrequent and often asymptomatic, being the last componentof the syndrome to develop, with a median age at diagnosis of 38. In 75%-80% of
patients the diagnosis of PHPT occurs synchronously with the diagnosis of
medullary thyroid cancer or pheochromocytoma, in the remainder ones PHPT is
detected years after thyroidectomy. Initial lesion appears to be an asymmetric
hyperplasia of parathyroid glands, which does not cause hypercalcemia. It
explains that some patients show normal PTH values although pathologic
parathyroid glands are found at surgery. In spite of surgery indications are thesame of sporadic PHTP is common to remove macroscopically enlarged
parathyroid glands, generating permanent hypoparathyroidism in 30% of cases.
Conclusions: PHPT in MEN 2A has some peculiarities that make us to reconsider
the suitability of an exhaustive and aggressive management. The removal ofmacroscopically enlarged parathyroid glands in normocalcemic patients carries
significant morbidity without any clinical benefit.

P52

P53

ABSENCE OF PRIMARY HYPERPARATHYROIDISM IN MEN 2A

Clinical and genetic studies in patients with Pituitary/ Parathyroid variant of MEN1
without MEN1 gene mutation: the french GENEM collaborative study.

Paula Sánchez Sobrino (1), Concepción Páramo Fernández (2), Federico Mallo
Ferrer (3). (1) Endocrinology Department, Hospital Complex of Pontevedra; (2)Endocrinology Department, Hospital Complex of Vigo, (3) Endocrinology
Department, University of Vigo (Spain).
Background: Hyperparathyroidism is defined by an inappropriately high PTH
secretion for the degree of calcemia. Primary hyperparathyroidism (PHTP) iscaused by autonomization of one or more parathyroid glands. PHPT is the least
common component of Multiple Endocrine Neoplasia Syndrome type 2A (MEN2A), that is characterized by the presence of medullary thyroid cancer,

H Valdes Socin (1), C Burlacu (1), B Delemer (2) , L Rostomyan (1), M Tichomirowa(1) , WW de Herder (3) , A Tabarin (4) , P Goudet (5) and A Beckers (1) for the
GENEM. (1) University of Liège. (2) University of Reims. (3) University ofRotterdam. (4) University of Bordeaux.(5) University of Dijon.
Background : We have previously identified some patients harboring only apituitary and a parathyroid(s) adenoma(s) without MEN1 or CDKN1 genemutations (1,2). Most of these were sporadic patients with a predominant female
sex ratio. A pituitary GH adenoma was the most frequent phenotype whereas a80

pituitary adenoma was usually diagnosed before the parathyroid tumor. Noneother typical MEN1 associated features were observed after long term follow-up.
Aim: To enlarge our study in collaboration with the French GENEM database andto compare clinical characteristics of these patients (group I) to those with
germline MEN1 confirmed mutations (group II). Results : We identified 35 patients(sex ratio 29F/6M ) presenting the double association of pituitary and primary
hyperparathyroidism without germline MEN1 mutations. There were 30 sporadic
and 5 familial cases. Pituitary adenoma was diagnosed at a mean age of 57 years
whereas parathyroid adenoma was found later, at 60 years (p>0.05). Among thepituitary phenotypes there were 23 somatotrophynomas (2 micro/21 macro), 3
mixed GH/PRL (all macro), 7 prolactinomas (all micro) and 2 non secreting
adenomas (both macro). Cervicotomy identified one parathyroid adenoma in 10
cases and multiple parathyroid adenomas/hyperplasia in 10 cases. Long term
follow- up did not showed other MEN1 features in Group I. Clinical characteristics
of group I will be compared to 30 patients of group II. Patients will be matched byage and pituitary phenotype adenoma. Conclusions: Pituitary-parathyroid
adenoma MEN1 variant seems, from clinical grounds, diﬀerent from MEN1
syndrome. The pituitary and parathyroid adenoma tumorigenesis might involveother mechanisms than either MEN1 or CDKN1B mutations. 1-H Valdes-Socin &al. for the GENEM. Association acromégaly –primary hyperparathyroïdism : MEN 1
or a diﬀerent entity ?. Abstract. In Annales d’Endocrinologie 2006. 2-L Rostomyan& al. The Pilot Study on clinical presentation of pituitary adenoma in patients withmultiple endocrine neoplasia type 1 phenotype with and without MEN1 mutation.
Abstract ICE/ECE 2012.

P54
Identification and functional characterization of CDC73 gene mutations in HPT-JT
families
Valerio Pazienza1, Annamaria la Torre2, Massimiliano Chetta3, Dieter Kotzot4,
Klaus Kapelari5, Dalhia Alabdulrazzaq6, Kusiel Perlman6, Etienne Sochett6, DavidEC Cole7, Fabio Pellegrini8,9, Geoﬀrey N Hendy10, Alfredo Scillitani12, Vito
Guarnieri11 1: Gastroenterology, 2: Laboratory of Oncology, 8: Unit of
Biostatistics, 11: Medical Genetics and 12: Endocrinology, IRCCS “Casa Sollievodella Soﬀerenza”, San Giovanni Rotondo (FG), Italy; 3: Department of Molecular
Biology, Molecular Stamping (FBK), Povo (TN), Italy; 4: Division of Human
Genetics, Department of Medical Genetics, Molecular and Clinical Pharmacology
and 5: Clinical Department of Pediatrics, Innsbruck Medical University, Innsbruck,

Austria; 6: Division of Endocrinology, the Hospital for Sick Children, Toronto ON,
Canada and 7: Departments of Laboratory Medicine and Pathobiology, Medicine
and Genetics, University of Toronto, ON, Canada; 9: Laboratory of Clinical
Epidemiology of Diabetes and Chronic Diseases, Consorzio Mario Negri Sud,
Santa Maria Imbaro, Italy; 10: Calcium Research Laboratory and Hormones andCancer Research Unit, Royal Victoria Hospital, Montreal, QC, Canada
Hyperparathyroidism Jaw-Tumour (HPT-JT) syndrome is characterized by primary
hyperparathyroidism (PHPT), including parathyroid carcinoma in ~15% of cases,
and maxillary/mandible ossifying fibromas. Inactivating mutations of the CDC73/
HRPT2 gene cause HPT-JT, but are also a major determinant in sporadic
parathyroid carcinoma. The CDC73 gene is rarely inactivated in the atypical or
typical parathyroid adenomas seen in sporadic or familial isolated PHPT. Here, wereport the molecular analysis of the CDC73/HRPT2 gene in aﬀected patients ofthree HPT-JT families. We identified 4 CDC73 mutations: 3 germline (c.
679_680delAG, p.Val85_Val86del, and p.Glu81_Pro84del), and 1 somatic(p.Arg77Pro). Three of the mutations are within the 76-92 region designated as anucleolar localization signal sequence while the 125-139 region was previously
identified as the nuclear localization signal sequence. Constructs encoding Flagtagged wild-type (WT) and the three mutant (delVV, delENIP, R77P) CDC73/
parafibromin proteins were transiently transfected in HEK293 cells, and whole cell
expression, nuclear localization, and cell viability/proliferation assessed. All threemutant proteins were expressed at greatly reduced levels relative to WT, and theproteasome inhibitor MG132 was ineﬀective in restoring the mutant protein levels
to those of WT. Indirect immunofluorescence of HEK293 cells transfected with
Flag-tagged WT and mutant constructs demonstrated that WT was absent in thecytoplasm but localized to the nucleus with punctate staining indicating
concentration in nucleolae. In contrast, neither the delVV nor the R77P mutants
were found in the nucleus but were present in the cytoplasm. Cells expressing thedelENIP mutant demonstrated both cytoplasmic and some nuclear staining. Thus,
all mutants exhibited mislocalization in comparison to WT. Cells transfected withany of the three mutant parafibromin constructs demonstrated higher values
relative to WT in the MTT viability assay at 48 and 72 h after transfection. In
conclusion, we report the identification of three novel CDC73 mutations in HPT-JT
families. The mislocalization and loss of cellular growth control of the mutantsemphasizes the importance of nuclear/nucleolar location for normal tumour
suppressor actions of the CDC73/parafibromin protein.

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